Der Internist

, 50:42

Hypertonie bei Patienten mit Nierenarterienstenosen

Schwerpunkt: Arterielle, therapierefraktäre und sekundäre Hypertonie

Zusammenfassung

Patienten mit schwer einstellbarer Hypertonie sowie mit Atherosklerose der Koronargefäße und Aorta weisen häufig eine Nierenarterienstenose (NAST) auf. Daher ist in dieser Patientengruppe eine Screeningdiagnostik mit Duplex-Sonographie, CT- oder MR-Angiographie indiziert. Voraussetzung für die Entscheidung zur invasiven Behandlung ist aber der Beweis, dass die vorhandene Einengung der Nierenarterie auch tatsächlich für Hypertonie und/oder Nierenfunktionseinschränkung verantwortlich ist. Die hämodynamische Wirksamkeit wird im Zweifel mit einer i.a.-Druckmessung nachgewiesen. Andererseits weisen diese Patienten meist eine multifaktorielle Hypertonie auf, die aus einer Kombination aus primärer oder renoparenchymatöser Hypertonie mit einer renovaskulären Komponente bestehen. Dies erklärt u. a., warum auch nach Beseitigung von hochgradigen Stenosen eine Heilung der Hypertonie ausbleibt. Außerdem führen mögliche Komplikationen bei einer Intervention, wie Embolien und Niereninfarkte, zu einem Ausbleiben des Therapieerfolgs. Ein genaues Abwägen zwischen dem zu erwartenden Erfolg einer invasiven Therapie und den Risiken für den individuellen Patienten ist von großer Bedeutung, zumal noch keine ausreichende Evidenz für einer Verringerung der Mortalität durch eine Beseitigung der NAST besteht. Dagegen besteht Konsens, dass immer eine gute Blutdruckeinstellung und optimale Therapie von Risikofaktoren angestrebt werden sollte.

Schlüsselwörter

Nierenarterienstenose Renovaskuläre Hypertonie Niereninsuffizienz Dopplersonographie 

Hypertension in patients with renal artery stenosis

Abstract

Renal artery stenosis (RAS) is often present in patients with severe hypertension and atherosclerotic vascular disease. In this setting it is important to screen patients for renovascular disease, e.g. with Duplex-ultrasound, CT- or MR-angiography. The challenge of treating these patients is to find the evidence proving that the RAS is responsible for hypertension and/or renal dysfunction. Measurement of the intra-arterial pressure gradient is necessary in order to determine hemodynamic relevance. On the other side, in these patients hypertension is often of primary and/or renoparenchymatous origin and is aggravated by a renovascular disease. This explains why hypertension cannot be cured even if a high grade stenosis has been removed. In addition, thromb- and cholesterol-embolic material is often mobilized during an invasive procedure and leads to renaparenchymatous ischemia which sustains hypertension after intervention. An individual evaluation of profit versus risk is important for the decision for or against an invasive procedure, especially since there is no sufficient evidence for a decrease of mortality after interventions of RAS. The optimal conservative treatment, including the treatment of atherosclerotic risk factors is recommended.

Keywords

Renal artery stenosis Renovascular hypertension Renal insufficiency Doppler-ultrasound 

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Copyright information

© Springer Medizin Verlag 2008

Authors and Affiliations

  1. 1.Klinik für NephrologieUniversitätsklinikum DüsseldorfDüsseldorfDeutschland

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