Spezielle Aspekte der Hochdrucktherapie bei Niereninsuffizienz – Welche Therapie für welches Krankheitsbild?

Die Hauptursache einer terminalen Niereninsuffizienz in den Industrienationen sind sekundäre Nephropathien. Die Prävalenz der terminalen Niereninsuffizienz liegt in Europa bei ca. 1 pro Tausend Einwohner. Eine Niereninsuffizienz verursacht bzw. verschlechtert eine arterielle Hypertonie durch verschiedene Mechanismen, auf der anderen Seite trägt die arterielle Hypertonie erheblich zur Progression einer Niereninsuffizienz bei. Somit ist eine effektive antihypertensive Therapie entscheidend. Eine solide Evidenz für strengere Zielblutdruckwerte als < 140/90 mmHg existiert nur für Patienten mit einer relevanten Proteinurie, und dies auch nur im Hinblick auf renale Endpunkte.

ACE-Inhibitoren oder Angiotensin-Rezeptor-Blocker sind Antihypertensiva der ersten Wahl bei Patienten mit einer chronischen Nierenerkrankung, sofern eine relevante Proteinurie besteht. Diuretika sind meistens unverzichtbar. Bei eingeschränkter Nierenfunktion unterhalb ca. 30 ml/min sind Schleifendiuretika zu bevorzugen. Bei höhergradig eingeschränkter Nierenfunktion bedürfen RAS-Hemmstoffe und Diuretika engmaschiger Kontrolle von Elektrolyten und Retentionsparametern und des Volumenstatus. Begleitmedikationen wie NSAR oder Exsikkose können zum akuten Nierenversagen führen. Eine Doppelblockade des RAS wird im Allgemeinen nicht empfohlen und ist nur in besonderen Fällen (z. B. therapierefraktäre Proteinurie) unter engmaschiger Überwachung angezeigt. Viele Patienten benötigen als Teil einer Kombinationstherapie auch Substanzen, die nicht zu den Antihypertensiva der ersten Wahl zählen (zentral wirksame Sympathikolytika, direkte Vasodilatatoren, Alpha-Blocker).

The major causes of end-stage renal disease (ESRD) in the developed countries are secondary nephropathies (from diabetes and hypertension) – the prevelance of ESRD approximating 1 per 1000 habitants in Europe. Chronic renal disease causes and aggravates hypertension by various mechanisms, on the other hand hypertension is among the most important causes of renal disease progression. Effective antihypertensive therapy is therefore mandatory for patients with chronic renal disease. Target blood pressure is <140/90 mmHg. Lower values should be achieved in patients with significant proteinurie for the sake of renal endpoints.

In hypertensive patients with significant protenuria, ACE-inhibitors and angiotensin receptor blockers are the antihypertensives of first choice. Diuretics are in most cases necessary, in patients with advanced renal failure loop diuretics should be preferred. Particularly in patients with advanced renal failure receiving RAS-blockers and diuretics close surveillance of electrolytes, serum creatinine and hydration status is mandatory. Comedication with NSAR can cause acute renal failure in these patients. Dual blockade of the renin angiotensin system is suggested only under special circumstances such as treatment-refractory proteinuria and requires close monitoring. Many patients need an antihypertensive combination therapy comprising also second-line antihypertensives such as alpha-blockers, centrally-acting sympatholytics and direct vasodilator drugs.

Key words

Chronic renal failure - antihypertensives - RAS blockers - target blood pressure

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