Zusammenfassung
Hintergrund
Der systemische Lupus erythematodes (SLE) ist eine autoimmune Systemerkrankung unklarer Ätiologie, die nahezu jedes Organsystem betreffen kann, wobei die Nierenbeteiligung (Lupusnephritis, LN) entscheidend für die Morbidität und Mortalität der Patienten ist. Dies wird zum einen durch die LN-bedingte Niereninsuffizienz sowie durch die notwendige starke immunsuppressive Therapie maßgeblich beeinflusst. Bis zu 50% der Patienten mit SLE haben bereits bei der Diagnosestellung klinische Zeichen einer Nierenbeteiligung. Im weiteren Krankheitsverlauf kommt es bei über 60% der Patienten mit SLE zu einer Nierenbeteiligung
Ergebnisse
Die Infiltration der Niere durch T-Zellen und Makrophagen (Mø; mononukleäre Zellen) ist neben der Ablagerung von Immunglobulinen ein wichtiges histomorphologisches Kennzeichen der LN und hat auch eine prognostische Bedeutung. Insbesondere die glomerulären Veränderungen korrelieren mit der klinischen Präsentation, dem Verlauf und dem Ansprechen der Therapie der LN. Die LN wird entsprechend dem histologischen Erscheinungsbild in 6 Klassen unterteilt [ISN (International Society of Nephrology)/RPS (Renal Pathology Society)-Klassifikation 2004]. Da sich die Therapie der LN an dieser Klassifikation orientiert, ist die Durchführung einer Nierenbiopsie bei Verdacht auf das Vorliegen einer LN notwendig. Basis der Therapie einer jeden LN ist die optimale Blutdruckeinstellung und die Blockade des Renin-Angiotensin-Systems als antiproteinurisch und wahrscheinlich immunmodulatorisch wirksame Komponente.
Schlussfolgerung
Abhängig vom Vorliegen der Klasse der LN erfolgt bei Klasse III, IV und V sowie ggf. auch bei Klasse II eine immunsuppressive Therapie. Bei Vorliegen einer LN Klasse I und VI besteht keine Indikation zur immunsuppressiven Therapie.
Abstract
Background
Systemic lupus erythematosus (SLE) is an autoimmune systemic disease of mainly unknown etiology with a variety of organ manifestations. Lupus nephritis (LN) is the main cause of morbidity and mortality for patients with SLE. Besides renal damage and failure the immunosuppressive treatment and relapses or flares of LN that are common (27–66 %) contribute to the morbidity and mortality of SLE. Up to 50 % of SLE patients present with renal involvement at the time of diagnosis while > 60 % develop a renal manifestation during the course of the disease.
Results
The intrarenal infiltration of T cells and macrophages as well as immunoglobulin deposits are the hallmark of histopathological findings in LN and show prognostic relevance. The histological changes, in particular the glomerular damage, correlate with presentation, course of disease and response to therapy in patients with LN. Histologically six different classes of LN have been described in the International Society of Nephrology and Renal Pathology Society (ISN-RPS) classification from 2004 and these classes lead to different treatment regimens. As the treatment of LN is dependent on the histological findings, a kidney biopsy should be done if renal involvement is expected. In all types of LN the basic therapy should include optimal blood pressure control.
Conclusion
Depending on the class of LN treatment will include immunosuppression, such as in types III, IV and V while types I, II and VI do not need immunosuppression. Moreover, for type V LN blockade of the renin-angiotensin system is most important.
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Einhaltung ethischer Richtlinien
Interessenkonflikt. J. Weinmann-Menke und D. Sollinger geben an, dass kein Interessenkonflikt besteht.
Die dargestellten Therapieoptionen beinhalten bereits publizierte Studienergebnisse (klinische Studien, Fallberichte) an Mensch und Tier, diese sind immer mit einer Referenz versehen.
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Weinmann-Menke, J., Sollinger, D. Immunsuppressive Therapie der Lupusnephritis. Nephrologe 10, 24–30 (2015). https://doi.org/10.1007/s11560-014-0906-9
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DOI: https://doi.org/10.1007/s11560-014-0906-9
Schlüsselwörter
- Systemischer Lupus erythematodes
- Nierenerkrankungen
- ISN/RPS-Klassifikation 2004
- Cyclophosphamid
- Mycophenolat-Mofetil (MMF)