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Der Orthopäde

, Volume 48, Issue 11, pp 927–935 | Cite as

Therapie rheumatischer Erkrankungen mit Niereninsuffizienz

  • S. M. WeinerEmail author
Leitthema

Zusammenfassung

Hintergrund

Patienten mit entzündlich-rheumatischen Erkrankungen weisen nicht selten eine eingeschränkte Nierenfunktion auf, mit hieraus resultierendem erhöhtem Risiko für medikamenteninduzierte Nebenwirkungen.

Methoden

Es wurde eine Literaturrecherche zur Therapie rheumatischer Erkrankungen bei Niereninsuffizienz durchgeführt, mit speziellem Fokus auf die medikamentöse Therapie und das perioperative Management.

Ergebnisse

Die Niereninsuffizienz potenziert das ohnehin bei rheumatischen Erkrankungen erhöhte kardiovaskuläre Risiko, führt zu einem beschleunigten Knochenmasseverlust und verschlechtert die Immunabwehr. Die perioperative kardiovaskuläre und infektiöse Komplikationsrate und das Risiko für ein akutes Nierenversagen sind erhöht. Gleichzeitig beeinflusst die eingeschränkte Nierenfunktion die Pharmakokinetik vieler bei entzündlich-rheumatischen Erkrankungen verwendeter Medikamente. Insbesondere Methotrexat ist aufgrund der Pharmakokinetik bei einer geschätzten glomerulären Filtrationsrate (eGFR) <45 ml/min kontraindiziert. Nichtsteroidale Antirheumatika (NSAR) und Coxibe sollten bei Niereninsuffizienz möglichst vermieden und – wenn erforderlich – nur mit Vorsicht für kurze Zeit und in niedrigster effektiver Dosis eingesetzt werden. In der Osteoporosetherapie sind Antiresorptiva bei schwergradiger Niereninsuffizienz mit einem erhöhten Risiko für eine adyname Knochenerkrankung verbunden und deren Einsatz deshalb umstritten.

Schlussfolgerung

Patienten mit rheumatischen Erkrankungen und Niereninsuffizienz bedürfen einer Anpassung der medikamentösen Therapie und eines speziellen perioperativen Managements, was im optimalen Falle durch eine enge interdisziplinäre Zusammenarbeit von internistischen Rheumatologen, Nephrologen und Orthopäden zu gewährleisten ist.

Schlüsselwörter

NSAR Glomeruläre Filtrationsrate Nieren Basismedikamente Rheuma 

Abkürzungen

ACE

„Angiotensin converting enzyme“

ANA

Antinukleäre Antikörper

ANCA

Antikörper gegen neutrophile Granulozyten

ASA

American Society of Anesthesiologists

AT

Angiotensin

AUC

„Area under the curve“

BMI

Body-Mass-Index

CCP

Zyklisches citrulliniertes Peptid

CKD-EPI

„Chronic Kidney Disease Epidemiology Collaboration“

COX

Cyclooxygenase

CYP

Cytochrom P

DMARD

„Disease-modifying anti-rheumatic drugs“

DXA

Dual-Röntgen-Absorptiometrie

eGFR

Geschätzten glomerulären Filtrationsrate

GFR

Glomerulären Filtrationsrate

HLA

„Human leukocyte antigen“

IgA

Immunglobulin A

IL

Interleukin

KDIGO

„Kidney Disease: Improving Global Outcomes“

LMW

„Low-molecular-weight“

NSAR

Nichtsteroidale Antirheumatika

PsA

Psoriasisarthritis

RA

Rheumatoide Arthritis

SLE

Systemischer Lupus erythematodes

SpA

Spondyloarthritis

TNF

„Tumor necrosis factor“

Treatment of rheumatic disease with renal insufficiency

Abstract

Background

Reduced renal function is not rare in patients with inflammatory rheumatic diseases and is associated with an increased risk of treatment-induced and perioperative adverse events.

Method

A literature search was carried out for the medical treatment and perioperative management of rheumatic disease in the presence of renal insufficiency.

Results

Patients with rheumatic disease and renal insufficiency have a higher risk of cardiovascular disease, bone loss and immunodeficiency than those without kidney disease. The perioperative rate of cardiovascular and infectious complications and the risk of acute kidney failure are elevated in these patients. The pharmacokinetics of many drugs used in rheumatology is influenced by the kidney function. Especially methotrexate is contraindicated in patients with an estimated glomerular filtration rate (eGFR) <45 ml/min. Nonsteroidal anti-inflammatory drugs (NSAIDS) and cyclooxygenase (COX)-2 inhibitors should not be used with renal insufficiency or only for a short term with the lowest effective dose. The treatment of osteoporosis with antiresorptive drugs may lead to adynamic bone disease in advanced kidney disease, and, therefore, the use of these drugs is controversial.

Conclusion

Medication should be modified in patients with rheumatic disease and kidney involvement according the grade of renal insufficiency. There is also a need for special perioperative management in these patients, with interdisciplinary cooperation of rheumatologists, nephrologists and orthopedic doctors.

Keywords

NSAIDS Glomerular filtration rate Kidneys DMARD Rheumatism 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

S.M. Weiner hat im Rahmen von Vorträgen Honorare der Firmen Abbott, AMGEN, BMS, MSD, Novartis, Pfizer und Roche erhalten.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2019

Authors and Affiliations

  1. 1.2. Medizinische Abteilung, Rheumatologie, Immunologie, Diabetologie, Endokrinologie, Hochdruckkrankheiten, Zentrum für Dialyse und NephrologieKrankenhaus der Barmherzigen Brüder und KfH-Nierenzentrum NordalleeTrierDeutschland

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