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Diagnostik und Therapie der diabetischen Nephropathie

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Zusammenfassung

In Deutschland haben bereits 36% aller neuen chronischen Dialysepatienten ursächlich eine diabetische Nephropathie als renale Grunderkrankung. Die meisten dieser Patienten sind Typ-2-Diabetiker. Insgesamt verursacht die überhöhte Morbidität und Mortalität dieser Patienten eine erhebliche Kostenbelastung für das deutsche Gesundheitswesen.

Ziel sollte es daher sein, die diabetische Nephropathie sehr früh zu erkennen, da Interventionen in einem sehr frühen Stadium den größten therapeutischen Effekt haben. Eine beginnende Nephropathie ist durch den Nachweis einer Mikroalbuminurie zu diagnostizieren (30–300 mg Albumin/g Kreatinin im Spontanurin). Diese Untersuchung sollte jährlich erfolgen (bei Typ-2-Diabetikern sofort nach Diagnosestellung des Diabetes, bei Typ-1-Diabetikern beginnend nach 5 Jahren). Der Nachweis einer Proteinurie mit dem Standardteststreifen (Albuminurie >300 mg/g Kreatinin) zeigt eine manifeste Nephropathie an, in deren Verlauf es zur progredienten Einschränkung der Nierenfunktion kommt. Wichtige beeinflussbare Kofaktoren für die Progression sind: arterielle Hypertonie, Blutzuckereinstellung, Rauchen und Fettstoffwechselstörungen.

Eine Einstellung der Diabetiker auf niedrig normale Blutdruckwerte (<130/80 mmHg ohne Proteinurie, <125/75 mmHg mit Proteinurie) auf der Basis von ACE-Hemmern (bewiesen für Typ-1-Diabetiker) oder Angiotensinrezeptorblockern (bewiesen für Typ-2-Diabetiker) sollte erfolgen. Kombinationstherapien (günstig mit Diuretika, Betablockern und Non-Diyhydropyridincalciumantagonisten) sind häufig erforderlich. Durch frühe therapeutische Maßnahmen ist das Stadium der Mikroalbuminurie in vielen Fällen rückgängig zu machen.

Bei fortschreitender Niereninsuffizienz sind besondere Therapiemaßnahmen sinnvoll (Knochelstoffwechsel, Anämie, Azidose, Meiden von nephrotoxischen Medikamenten). Eine frühzeitige Einleitung der Nierenersatztherapie bei Diabetikern (bei etwa einer GFR <15 ml/min) verkürzt stationäre Aufenthalte und vermindert die Ein- und Zweijahresmortalität. Neben Hämodialyse und Peritonealdialyse ist v. a. eine frühe Nierentransplantation und bei Typ-1-Diabetikern in Einzelfällen auch eine kombinierte Nieren-/Pankreastransplantation sinnvoll.

Abstract

In Germany, 36% of all new chronic dialysis patients have diabetic nephropathy as the causative renal disease. The majority of these patients are type 2 diabetics. The excessive morbidity and mortality of these patients represent a considerable cost factor for the German health care system.

The goal should thus be to recognize diabetic nephropathy very early since intervention during the early stage has the greatest therapeutic effect. Incipient nephropathy can be diagnosed by evidence of microalbuminuria (30–300 mg albumin/g creatinine in spontaneous urine). This test should be performed annually (in type 2 diabetics immediately following diagnosis of the diabetes and in type 1 diabetics commencing after 5 years). Evidence for proteinuria on the standard test strip (albuminuria >300 mg/g creatinine) indicates manifest nephropathy and leads during its course to progressive impairment of renal function. Important influenceable cofactors for progression are arterial hypertension, blood sugar management, smoking, and dyslipidosis.

The diabetic patient should be kept at low normal blood pressure levels (<130/80 mmHg without proteinuria and <125/75 mmHg with proteinuria) with ACE inhibitors (proven for type 1 diabetics) or angiotensin receptor blockers (proven for type 2 diabetics). Combination therapies (beneficial with diuretics, beta blockers, and non-dihydropyridine calcium antagonists) are frequently necessary. Early therapeutic intervention can in many cases reverse the stage of microalbuminuria.

Special therapeutic measures are judicious for progressive renal insufficiency (osseous metabolism, anemia, acidosis, avoidance of nephrotoxic medications). Timely initiation of renal replacement therapy in diabetics (GFR at approximately <15 ml/min) shortens hospital stay and reduces the 1- and 2-year mortality rates. In addition to hemodialysis and peritoneal dialysis, early kidney transplantation in particular is appropriate and in individual cases in type 1 diabetics combined kidney and pancreas transplantation.

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Authors and Affiliations

  1. Klinik für Nephrologie, Medizinische Fakultät, Otto-von-Guericke-Universität, Leipziger Straße 44, 39120, Magdeburg

    E. Wrenger

  2. Klinik für Nephrologie, Medizinische Fakultät, Otto-von-Guericke-Universität, Magdeburg

    E. Wrenger & K. H. Neumann

  3. Klinik für Endokrinologie und Stoffwechselkrankheiten, Medizinische Fakultät, Otto-von-Guericke-Universität, Magdeburg

    H. Lehnert

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  1. E. Wrenger
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Wrenger, E., Neumann, K.H. & Lehnert, H. Diagnostik und Therapie der diabetischen Nephropathie. Urologe [A] 42, 269–286 (2003). https://doi.org/10.1007/s00120-002-0292-1

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