Skip to main content
SpringerLink
Log in

Ischämische Nephropathie und Nierenarterienstenose

Ischemic renal disease and renal artery stenosis

  • Schwerpunkt
  • Published:
Der Internist Aims and scope Submit manuscript

Zusammenfassung

Eine hämodynamisch wirksame Nierenarterienstenose kann sich klinisch unterschiedlich manifestieren: Bei unilateraler Stenose kommt es zu einer renovaskulären Hypertonie, bei bilateraler Stenose bzw. bei stenosierter Einzelniere oder Transplantatniere zusätzlich zu einer ischämischen Nephropathie mit Niereninsuffizienz und zum akuten Lungenödem. Die häufigste Ursache ist eine Arteriosklerose der ostiumnahen Aorta und Nierenarterie, seltener findet sich eine fibromuskuläre Dysplasie (unterschiedliche Formen). Kausal oft angestrebte revaskularisierende Verfahren – die Stentangioplastie oder seltener chirurgische Verfahren – erreichen im Hinblick auf die Wiedereröffnung des Lumens eine hohe primäre technische Erfolgsrate. Insbesondere die katheterbasierten Interventionen werden bei der arteriosklerotisch verursachten Stenosierung jedoch gegenwärtig nur mit Zurückhaltung eingesetzt, da die funktionellen Langzeitergebnisse bezüglich Hypertonie und Nierenfunktionsstörung wenig überzeugend sind. Im Einzelfall kann es aber notwendig und vertretbar sein, ein revaskularisierendes Verfahren einzusetzen, z. B. bei sonst therapierefraktärer Hypertonie, bei progredientem Nierenversagen oder bei anders nicht zu beherrschenden Überwässerungszuständen.

Abstract

Severe renal artery stenosis may cause renovascular hypertension; in case of bilateral narrowing or in a stenotic solitary or transplant kidney, renal insufficiency (ischemic renal disease) or rarely pulmonary flash edema may occur. In most cases arteriosclerotic disease is the underlying cause; less prevalent are the various manifestations of fibromuscular disease. Renal artery stenosis may be treated by revasularization, using either percutaneous (balloon angioplasty, stenting) or rarely open surgical procedures, both with excellent primary patency rates. However, randomized trials of renal artery angioplasty or stenting in patients with arteriosclerotic lesions have failed to demonstrate a longer-term benefit with regard to hypertension control and renal dysfunction over medical management alone. Careful patient selection is essential to maximize the potential benefit (e.g., in patients with refractory hypertension, progressive renal failure or recurrent pulmonary flash edema).

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1

Literatur

  1. Antopolsky M, Simanovsky N, Stalnikowicz R et al (2012) Renal infarction in the ED: 10-year experience and review of the literature. Am J Emerg Med 30:1055–1060

    Article  PubMed  Google Scholar 

  2. Appel RG, Bleyer AJ, Reavis S, Hansen KJ (1995) Renovascular disease in older patients beginning renal replacement therapy. Kidney Int 48:171–176

    Article  CAS  PubMed  Google Scholar 

  3. Baboolal K, Evans C, Moore RH (1998) Incidence of end-stage renal disease in medically treated patients with severe bilateral atherosclerotic renovascular disease. Am J Kidney Dis 31:971–977

    Article  CAS  PubMed  Google Scholar 

  4. Bax L, Woittiez AJ, Kouwenberg HJ et al (2009) Stent placement in patients with atherosclerotic renal artery stenosis and impaired renal function: a randomized trial. Ann Intern Med 150:840–848

    Article  PubMed  Google Scholar 

  5. Bloch MJ, Trost DW, Pickering TG et al (1999) Prevention of recurrent pulmonary edema in patients with bilateral renovascular disease through renal artery stent placement. Am J Hypertens 12:1–7

    Article  CAS  PubMed  Google Scholar 

  6. Caps MT, Zierler RE, Polissar NL et al (1998) Risk of atrophy in kidneys with atherosclerotic renal artery stenosis. Kidney Int 53:735–742

    Article  CAS  PubMed  Google Scholar 

  7. Cooper CJ, Murphy TP, Cutlip DE et al (2014) Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med 370:13–22

  8. Dorros G, Jaff M, Mathiak L et al (1998) Four-year follow-up of Palmaz-Schatz-stent revascularization as treatment for atherosclerotic renal artery stenosis. Circulation 98:642–647

    Article  CAS  PubMed  Google Scholar 

  9. Dworkin LD, Cooper CJ (2009) Clinical practice. Renal artery stenosis. N Engl J Med 361:1972–1978

  10. ESH/ESC (2013) Guidelines for the management of arterial hypertension. J Hypertens 31:1281–1357

  11. Fatica RA, Port FK, Young EW (2001) Incidence trends and mortality in end-stage renal disease attributed to renovascular disease in the United States. Am J Kidney Dis 37:1184–1190

    Article  CAS  PubMed  Google Scholar 

  12. Farmer CKT, Cook GJR, Blake GM et al (1999) Individual kidney function in atherosclerotic nephropathy is not related to the presence of renal artery stenosis. Nephrol Dial Transplant 14:2880–2884

    Article  CAS  PubMed  Google Scholar 

  13. Gloviczki ML, Glockner JF, Crane JA et al (2011) Blood oxygen level-dependent magnetic resonance imaging identifies cortical hypoxia in severe renovascular disease. Hypertension 58:1066–1072

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  14. Gray BH, Olin JW, Childs MB et al (2002) Clinical benefit of renal artery angioplasty with stenting for the control of recurrent and refractory congestive heart failure. Vasc Med 7:275–279

    Article  PubMed  Google Scholar 

  15. Hansen KJ, Cherr GS, Craven TE et al (2000) Management of ischemic nephropathy: dialysis-free survival after surgical repair. J Vasc Surg 32:472–481

  16. Hansen KJ, Edwards MS, Craven TE et al (2002) Prevalence of renovascular disease in the elderly: a population-based study. J Vasc Surg 36:443–451

  17. Harden PN, MacLeod MJ, Rodger RSC et al (1997) Effect of renal artery stenting on progression of renovascular renal failure. Lancet 349:1133–1136

    Article  CAS  PubMed  Google Scholar 

  18. Hill GS (2008) Hypertensive nephrosclerosis. Curr Opin Nephrol Hypertens 17:266–270

    Article  PubMed  Google Scholar 

  19. Higashi Y, Sasaki S, Nakagawa K et al (2002) Endothelial function and oxidative stress in renovascular hypertension. N Engl J Med 346:1954–1962

  20. Jacobson HR (1988) Ischemic renal disease: an overlooked clinical entity? Kidney Int 34:729–743

    Article  CAS  PubMed  Google Scholar 

  21. Jung O, Gechter JL, Wunder C et al (2013) Resistant hypertension? Assessment of adherence by toxicological urine analysis. J Hypertens 31:766–774

  22. Lerman L, Textor SC (2002) Pathophysiology of ischemic nephropathy. Urol Clin North Am 28:793–803

    Article  Google Scholar 

  23. Losito A, Selvi A, Jeffrey S et al (2000) ACE gene polymorphism and survival in atherosclerotic renal disease. Am J Kidney Dis 35:211–215

    Article  CAS  PubMed  Google Scholar 

  24. Mailloux LU, Bellucci AG, Mossey RT et al (1988) Predictors of survival in patients undergoing dialysis. Am J Med 84:855–862

    Article  CAS  PubMed  Google Scholar 

  25. McLaughlin K, Jardine AG, Moss JG (2000) Renal artery stenosis. Br Med J 320:1124–1127

    Article  Google Scholar 

  26. Missouris CG, Buckenham T, Cappuccio FP, MacGregor GA (1994) Renal artery stenosis: a common and important problem in patients with peripheral vascular disease. Am J Med 96:10–14

    Article  CAS  PubMed  Google Scholar 

  27. Olin JW, Melia M, Young JR et al (1990) Prevalence of atherosclerotic renal artery stenosis in patients with atherosclerosis elsewhere. Am J Med 88(Suppl I):46N–51N

    Article  CAS  PubMed  Google Scholar 

  28. O’Neil EA, Hansen KJ, Canzanello VJ et al (1992) Prevalence of ischemic nephropathy in patients with renal insufficiency. Am Surg 58:485–490

    Google Scholar 

  29. o A (2006–2007) Quasi-Niere-Bericht. http://www.bundesverband-niere.de/bundesverband/quasi-niere/jahresberichte.html

  30. Rimmer JM, Gennari FJ (1993) Atherosclerotic renovascular disease and progressive renal failure. Ann Intern Med 118:712–719

    Article  CAS  PubMed  Google Scholar 

  31. Rundback JH, Jacobs JM (1996) Percutaneous renal artery stent placement for hypertension and azotemia: a pilot study. Am J Kidney Dis 28:214–219

    Article  CAS  PubMed  Google Scholar 

  32. Radermacher J, Chavan A, Bleck J et al (2001) Use of Doppler ultrasonography to predict the outcome of therapy for renal-artery stenosis. N Engl J Med 344:410–417

  33. Safian RD, Textor SC (2001) Renal-artery stenosis. N Engl J Med 344:431–442

  34. Slovut DP, Olin JW (2004) Fibromuscular dysplasia. N Engl J Med 350:1862–1871

  35. Textor SC, Misra S, Oderich GS (2013) Percutaneous revascularization for ischemic nephropathy: the past, present, and future. Kidney Int 83:28–40

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  36. Tuttle KR (2001) Ischemic nephropathy. Curr Opin Nephrol Hypertens 10:167–173

    Article  CAS  PubMed  Google Scholar 

  37. The ASTRAL Investigators (2009) Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med 361:1953–1962

  38. Tollefson DEJ, Ernst CB (1991) Natural history of atherosclerotic renal artery stenosis associated with aortic disease. J Vasc Surg 14:327–331

  39. Ampting JM van, Penne EL, Beek FJ et al (2003) Prevalence of atherosclerotic renal artery stenosis in patients starting dialysis. Nephrol Dial Transplant 18:1147–1151

    Article  PubMed  Google Scholar 

  40. Zeller T, Müller C, Frank U et al (2003) Stent angioplasty of severe atherosclerotic ostial renal artery stenosis in patients with diabetes mellitus and nephrosclerosis. Catheter Cardiovasc Interv 58:510–515

    Article  PubMed  Google Scholar 

  41. Zierler RE, Bergelin RO, Isaacson JA et al (1994) Natural history of atherosclerotic renal artery stenosis: a prospective study with duplex ultrasonography. J Vasc Surg 19:250–258

Download references

Danksagung

Der Autor dankt Herrn Prof. Dr. Schulte, Gefäßzentrum Berlin, für die Überlassung des Bildes.

Einhaltung ethischer Richtlinien

Interessenkonflikt. T. Lenz gibt an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

Author information

Authors and Affiliations

  1. KfH-Nierenzentrum, Maxstr. 48, 67059, Ludwigshafen, Deutschland

    T. Lenz

Authors
  1. T. Lenz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to T. Lenz.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lenz, T. Ischämische Nephropathie und Nierenarterienstenose. Internist 56, 248–254 (2015). https://doi.org/10.1007/s00108-014-3573-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00108-014-3573-z

Schlüsselwörter

Keywords

Search

Navigation