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Kardiovaskuläre Kalzifikationen bei chronischer Niereninsuffizienz

Cardiovascular calcifications in chronic kidney disease

  • Leitthema
  • Published:
Der Nephrologe Aims and scope

Zusammenfassung

Chronische Nierenerkrankungen sind weiterhin weltweit auf dem Vormarsch. Damit einhergehende lebenslimitierende kardiovaskuläre Kalzifikationen entstehen aus einem komplexen Zusammenspiel an Promotoren (Kalzium, Phosphat, Parathormon) und Inhibitoren (Magnesium, Matrix-Gla-Protein, Pyrophosphat, Fetuin-A), Calciproteinpartikeln und Apoptosekörperchen. Im Rahmen des Geschehens wandeln sich verschiedene Zelltypen der Gefäßwand in Zellen mit knochenähnlichen Eigenschaften und Markern um. Die extrazelluläre Matrix wird umgebaut, und ist hier erst ein Kalziumphosphatkristall ausgefallen, triggert dies die Anlagerung von weiteren und größeren Kristallen. Verkalkungen können intimal im Rahmen von Atherosklerose sowie medial im Rahmen von Arteriosklerose auftreten. Oftmals finden sich bei chronisch niereninsuffizienten Patienten beide Formen. Eine weitere Manifestation sind valvuläre Kalzifikationen, welche ebenfalls vermehrt bei niereninsuffizienten Patienten auftreten. Nachgewiesen werden bestehende Verkalkungen am empfindlichsten mittels Computertomographie. Prädiktiv kann das Kalzifizierungshemmungspotenzial im Serum mittels T50-Assay ermittelt werden. Bestehende Therapien sind nach wie vor unzureichend. Ansätze liegen in der Normalisierung des Kalzium-Phosphat-Produkts, der Therapie eines sekundären Hyperparathyreoidismus, und – bisher noch experimentell – der Gabe von Vitamin K, Pyrophosphat, Inositolphosphaten und Natriumthiosulfat.

Abstract

The incidence of chronic kidney disease (CKD) is still increasing worldwide. Life-limiting cardiovascular calcifications associated with CKD result from a complex interplay between calcification promotors (calcium, phosphate, parathyroid hormone) and inhibitors (magnesium, matrix Gla protein, pyrophosphate, fetuin A), calciprotein particles and apoptotic bodies. In the process of calcification various cell types of the vascular wall transdifferentiate into cells with bone-like characteristics and markers. In addition, the extracellular matrix is rearranged and once a single calcium phosphate crystal precipitates further crystal growth and accumulation are triggered. Calcifications occur in the intimal (atherosclerosis) or the medial (arteriosclerosis) layer of vessels. Both forms can often be detected in CKD patients. A further manifestation is valvular calcification, which is also frequent in CKD patients. The most sensitive method to visualize calcifications is computed tomography. A more recent predictive method is the T50 assay, which assesses the calcification inhibitory potential of serum. Existing therapeutic methods are still insufficient. The approaches range from normalization of the calcium phosphate product and treatment of secondary hyperparathyroidism to experimental approaches including the administration of vitamin K, pyrophosphate, inositol phosphates and sodium thiosulfate.

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  1. Abteilung für Nieren- und Hochdruckkrankheiten, rheumatologische und immunologische Erkrankungen, Universitätsklinikum der RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland

    N. Kaesler, R. Kramann & J. Floege

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Kaesler, N., Kramann, R. & Floege, J. Kardiovaskuläre Kalzifikationen bei chronischer Niereninsuffizienz. Nephrologe 15, 277–284 (2020). https://doi.org/10.1007/s11560-020-00429-3

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