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Interventionelle Therapie einer atherosklerotischen Nierenarterienstenose

Pro und kontra

Interventional treatment of atherosclerotic renal artery stenosis

Pros and cons

Zusammenfassung

Eine hämodynamisch wirksame atherosklerotisch bedingte Nierenarterienstenose einer oder beider Nierenhauptarterien (in seltenen Fällen auch eine stenosierte größere Segmentarterie) mit einer Lumeneinengung von mindestens 70 % kann zu unterschiedlichen Erkrankungen führen: bei unilateraler Stenose zu einer renovaskulären Hypertonie, bei bilateraler Stenose (bzw. bei funktioneller oder tatsächlicher Einzelniere mit Stenosierung) auch zu einer oft progredienten Niereninsuffizienz (ischämische Nephropathie) und/oder zum akuten Lungenödem („pulmonary flash edema“). Kausal früher oft angestrebte revaskularisierende Verfahren (Angioplastie mit und ohne Stentapplikation, seltener gefäßchirurgische Revaskularisation) erreichen eine Wiedereröffnungsrate von über 90 %. Allerdings bleiben nach den Ergebnissen randomisierter Studien bei den katheterbasierten Interventionen die erhofften funktionellen Auswirkungen, etwa eine verbesserte Blutdruckeinstellung oder eine Nierenfunktionsverbesserung und eine verringerte Gesamtsterblichkeit, hinter den Erwartungen zurück, sodass einer optimalen medikamentösen Therapie meist der Vorzug gegeben wird. Patienten mit kritischer Stenosierung und stärker ausgeprägten klinischen Komplikationen wie rezidivierendem Lungenödem oder progredientem Nierenversagen können von einer solchen Maßnahme profitieren. Im Einzelfall kann es daher vertretbar und im Sinne einer Ultima ratio auch medizinisch notwendig sein, ein revaskularisierendes Verfahren einzusetzen. Die sorgfältige Auswahl hierfür geeigneter Patienten ist für den klinischen Erfolg ausschlaggebend.

Abstract

A hemodynamically acting atherosclerotic renal artery stenosis of one or both main renal arteries (in rare cases also stenosis of a larger segment artery) with a lumen narrowing of at least 70%, can lead to a variety of diseases. In the case of unilateral stenosis it can lead to renovascular hypertension, in bilateral stenosis (or in a functional or actual solitary kidney with stenosis) also frequently to progressive renal insufficiency (ischemic kidney disease) and/or to acute lung edema (pulmonary flash edema). Previously often attempted causal revascularization procedures (angioplasty with and without stent placing, more rarely surgical revascularization) achieve a patency rate of over 90%; however, according to the results of randomized studies, the desired functional effects of catheter-based interventions, such as improved blood pressure adjustment or improved renal function and reduced overall survival, fell short of the expectations, so that an optimized pharmaceutical treatment is mostly prioritized. Patients with a critical stenosis and strongly pronounced clinical complications, such as recurrent pulmonary edema and progressive kidney failure, can benefit from such measures. Therefore, in individual cases it can be justifiable and also medically necessary in the sense of a last resort, to instigate a revascularization procedure. The meticulous selection of patients suitable for this procedure is essential for clinical success.

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Abb. 1

Abbreviations

ASTRAL:

Angioplasty and STent for Renal Artery Lesions (1)

CORAL:

The Cardiovascular Outcomes in Renal Atherosclerotic Lesions (2)

DRASTIC:

Dutch Renal Artery STenosis Intervention Cooperative Study Group (3)

EMMA:

Essai Multicentrique Medicaments vs Angioplastie Study Group (4)

SNRASCG:

Scottish and Newcastle Renal Artery Stenosis Collaborative Group (5)

STAR:

STent Placement in Patients With Atherosclerotic Renal Artery Stenosis and Impaired Renal Function Trial (6)

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Correspondence to Tomas Lenz.

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T. Lenz gibt an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden vom Autor keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Hermann Haller, Hannover

Joachim Hoyer, Marburg

Dieser Beitrag ist Herrn Prof. Dr. Karl-Ludwig Schulte, Berlin, langjähriger ehemaliger Präsident der Deutschen Gesellschaft für Angiologie und Deutschlands Nestor der interventionellen Therapie der Nierenarterienstenose, gewidmet.

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Lenz, T. Interventionelle Therapie einer atherosklerotischen Nierenarterienstenose. Nephrologie 17, 221–232 (2022). https://doi.org/10.1007/s11560-022-00583-w

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Schlüsselwörter

  • Ischämische Nephropathie
  • Rezidivierendes Lungenödem
  • Angioplastie
  • Stents
  • Gefäßchirurgische Revaskularisation

Keywords

  • Ischemic nephropathy
  • Recurrent pulmonary edema
  • Angioplasty
  • Stents
  • Surgical revascularization