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Antihypertensive Therapie bei CKD-Stadium 5

Rolle von Reservemedikamenten

Antihypertensive treatment in stage 5 CKD

Role of second line antihypertensive drugs

Zusammenfassung

Mehr als 50 % der Dialysepatienten sind hypertensiv. Probleme in der antihypertensiven Therapie bei terminaler Niereninsuffizienz stellen sich durch stark erhöhte Gefäßsteifigkeit und tonische Aktivierung des sympathischen Nervensystems. Zielblutdruckwerte liegen für jüngere Patienten unter 140/90 mm Hg vor und unter 130/80 mm Hg nach Hämodialyse (HD), bei älteren Patienten können höhere systolische Werte toleriert werden. Diastolische Werte unter 70 mm Hg sollten nicht angestrebt werden. Eine antihypertensive Therapie beeinflusst die Prognose bei hypertensiven Dialysepatienten günstig. ACE(„angiotensin-converting enzyme“)-Inhibitoren und Angiotensinrezeptorantagonisten sowie Kalziumantagonisten erscheinen vorteilhaft. Reservemedikamente wie direkte Vasodilatatoren und zentral wirksame Antisympathotonika bewirken zwar eine deutliche Blutdrucksenkung, beeinflussen aber die kardiovaskuläre Prognose nicht günstig. Wesentlich ist eine diätetische Kochsalzrestriktion. Eine adäquate Volumenkontrolle gelingt unter Verzicht auf zu hohe Ultrafiltrationsraten mit allmählicher Reduktion des Trockengewichts, ggf. häufigerer Dialysefrequenz und v. a. genügend langer HD.

Abstract

More than 50% of dialysis patients suffer from arterial hypertension. Problems of antihypertensive treatment in terminal kidney failure arise due to excessively increased vascular stiffness and a tonic activation of the sympathetic nerve system. The target blood pressure values for younger patients are < 140/90 mm Hg before dialysis and < 130/80 mm Hg after hemodialysis and for older patients with comorbidities higher systolic values may be tolerated. Diastolic blood pressure values < 70 mm Hg should not be strived for. Antihypertensive treatment favorably influences the prognosis of hypertensive dialysis patients. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor antagonists and calcium channel blockers appear to be advantageous. Reserve antihypertensive medications, such as direct vasodilators and centrally acting sympatholytic drugs, effect a clear lowering of blood pressure but do not favorably influence the cardiovascular prognosis. Of utmost importance is a dietary salt restriction. An adequate volume control is achieved without excessive ultrafiltration rates, with gradual reduction of the dry weight, more frequent dialysis when applicable and especially sufficiently long duration of hemodialysis.

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Correspondence to Martin Hausberg.

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Hermann Haller, Hannover

Joachim Hoyer, Marburg

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Hausberg, M. Antihypertensive Therapie bei CKD-Stadium 5. Nephrologie 17, 215–220 (2022). https://doi.org/10.1007/s11560-022-00587-6

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  • DOI: https://doi.org/10.1007/s11560-022-00587-6

Schlüsselwörter

  • Niereninsuffizienz
  • Hypertonie
  • RAAS-Blocker
  • Kalziumantagonisten
  • Gefäßsteifigkeit

Keywords

  • Renal insufficiency
  • Hypertension
  • RAAS blockers
  • Calcium channel blockers
  • Vascular stiffness