Zusammenfassung
Die in den letzten Jahrzehnten schnell steigende Zahl der Menschen mit Diabetes zeigt auf, wie wenig bisher für die Prävention dieser Stoffwechselerkrankung getan wurde. Auch die Inzidenz und Prävalenz der diabetischen Nephropathie nehmen nach einer Phase der Stagnation wieder zu. Zu niedrige und zu hohe glomeruläre Filtrationsraten sind als signifikantes kardiorenales Risiko anzusehen. Mit der Einführung neuer hochwirksamer Stoffgruppen wird die früher übliche zeitige Umstellung auf Insulin bei diabetischen Spätschäden nach und nach verdrängt. Inhibitoren des Angiotensinkonversionsenzyms (ACE) und Sartane senken den Blut- und intraglomerulären Druck und wirken dadurch gleichzeitig antihypertensiv und antiproteinurisch. Die SGLT-2-Inhibitoren (SGLT: Natrium-Glukose-Kotransporter) sind inzwischen der Goldstandard für alle Nephropathien. Dabei sollte die SGLT-2-Inhibitor-Therapie möglichst frühzeitig begonnen werden, um gute Langzeiteffekte zu erzielen. Mit diesen Substanzen können auch bei Herz- und Niereninsuffizienz noch gute Effekte erzielt werden, die Therapie darf jedoch bei einer eGFR (geschätzte glomeruläre Filtationsrate) von < 25 ml/min und 1,73 m2 (Dapagliflozin) oder < 20 ml/min und 1,73 m2 (Empagliflozin) nicht mehr begonnen werden. Andererseits sollte sie bei einer eGFR von 20 ml/min und 1,73 m2 noch nicht beendet werden, da kardiorenale Vorteile auch unter bereits hochgradig eingeschränkter Nierenfunktion nachweisbar sind. Mineralokortikoidrezeptorantagonisten wie Finerenon wirken ebenfalls kardiorenal protektiv. Die EASD (europäische Diabetesgesellschaft) und die ESC (europäische Gesellschaft für Kardiologie) empfehlen in ihrer gemeinsamen Leitlinie GLP-1-Rezeptor-Agonisten (GLP: glukagonähnliches Peptid) und SGLT-2-Hemmer als Erstlinientherapie für die Stoffwechseleinstellung bei Menschen mit Typ-2-Diabetes mit einem hohen Risiko für atherosklerotische Komplikationen.
Abstract
The rapidly increasing number of people with diabetes in recent decades shows how little has been done to prevent this metabolic disease. The incidence and prevalence of diabetic nephropathy is also increasing again after a period of stagnation. Glomerular filtration rates that are too low or too high must be regarded as a significant cardiorenal risk. With the introduction of new, highly effective groups of drugs, the previously common practice of switching to insulin for late diabetic damage will gradually be replaced. Angiotensin-converting enzyme (ACE) inhibitors and sartans reduce blood and intraglomerular pressure and, thus, have an antihypertensive and antiproteinuric effect at the same time. The sodium–glucose cotransporter 2 inhibitors (SGLT2i) are now the gold standard for all nephropathies. SGLT2i therapy should be started as early as possible in order to achieve good long-term effects. Good effects can still be achieved with these drugs for cardiac and renal insufficiency, but therapy should no longer be started if the estimated glomerular filtration rate (eGFR) is < 25 ml/min and 1.73 m2 (dapagliflozin) or < 20 ml/min and 1.73 m2 (empagliflozin). On the other hand, it should not yet be discontinued at an eGFR of 20 ml/min and 1.73 m2, as cardiorenal benefits are also detectable in patients with already severely impaired renal function. Mineralocorticoid receptor antagonists such as finerenone also have cardiorenal protective effects. In their joint guideline, the European Association for the Study of Diabetes (EASD) and the European Society of Cardiology (ESC) recommend glucagon-like peptide‑1 (GLP 1) receptor agonists and SGLT2i as first-line therapy for metabolic control in people with type 2 diabetes with a high risk of atherosclerotic complications.
Abbreviations
- ACE:
-
Angiotensinkonversionsenzym
- AKI:
-
Akute Nierenschädigung („acute kidney injury“)
- ASCVD:
-
Atherosklerotische kardiovaskuläre Erkrankung („atherosclerotic cardiovascular disease“)
- CKD:
-
Chronische Nierenerkrankung („chronic kidney disease“)
- CVD:
-
Kardiovaskuläre Erkrankung („cardiovascular disease“)
- CVOT:
-
Untersuchung des kardiovaskulären Ergebnisses („cardiovascular outcome trial“)
- DPP:
-
Dipeptidylpeptidase
- DTPA:
-
Diethylentriaminpentaessigsäure („diethylenetriamine-pentaacetic acid“)
- EASD:
-
Europäische Diabetesgesellschaft (European Association for the Study of Diabetes)
- eGFR:
-
Geschätzte („estimated“) glomeruläre Filtrationsrate
- eGFRCys :
-
Auf der Basis des Cystatin-C-Spiegels geschätzte GFR
- eGFRKrea :
-
Auf der Basis des Kreatininspiegels geschätzte GFR
- eGFRKrea+Cys :
-
Kombinierte geschätzte GFR, eGFR aus Cystatin C und Serumkreatinin
- ERA:
-
Endothelinrezeptorantagonist
- ESC:
-
Europäische Gesellschaft für Kardiologie (European Society of Cardiology)
- ESRD:
-
Terminales Nierenversagen („end-stage renal disease“)
- FS:
-
Fettsäure
- GFR:
-
Glomeruläre Filtrationsrate
- GIP:
-
Glukoseabhängiges insulinotropes Peptid (auch als gastroinhibitorisches Peptid bezeichnet)
- GLP:
-
Glukagonähnliches („glucagon-like“) Peptid 1
- GLP-1-RA:
-
GLP-1-Rezeptor-Agonisten
- HbA1c :
-
Glykohämoglobin
- HFpEF:
-
Herzinsuffizienz mit erhaltener Ejektionsfraktion („heart failure with preserved ejection fraction“)
- HHF:
-
Hypertensive Herzinsuffizienz
- KDIGO :
-
Kidney Disease: Improving Global Outcomes
- MACE:
-
Schwerwiegendes unerwünschtes kardiales Ereignis („major adverse cardiac event“)
- mGFR:
-
Direkt gemessene glomeruläre Filtrationsrate
- MRA:
-
Mineralokortikoidrezeptorantagonist
- NAFLD:
-
Nichtalkoholische Fettlebererkrankung („non-alcoholic fatty liver disease“)
- nsMRA:
-
Nichtsteroidaler Mineralokortikoidrezeptorantagonist
- PEP:
-
Primärer Endpunkt
- RAAS:
-
Renin-Angiotensin-Aldosteron-System
- RAAS‑I:
-
Inhibitor(en) des Renin-Angiotensin-Aldosteron-Systems
- RCT:
-
Randomisierte kontrollierte Studie („randomized controlled trial“)
- SEP:
-
Sekundärer Endpunkt
- SGLT‑2:
-
Natrium-Glukose-Kotransporter 2 („sodium glucose co-transporter 2“)
- SGLT-2‑I:
-
Inhibitor(en) des SGLT‑2
- T2D:
-
Typ-2-Diabetes
- UACR:
-
Albumin-Kreatinin-Verhältnis im Urin
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T.H. Lindner macht folgende Angaben: Vorträge: MSD, Sanofi, Boehringer-Ingelheim, Novo Nordisk, AstraZeneca. Advisory Boards: Vifor, Boehringer-Ingelheim. Des Weiteren Firmen-gesponserte Studien und Teilnahme an verschiedenen gesponserten multizentrischen Studien. W.A. Scherbaum gibt an, dass kein Interessenkonflikt besteht.
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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Lindner, T.H., Scherbaum, W.A. Diabetische Nephropathie 2023 – Beginn eines neuen Zeitalters. Diabetologie 20, 518–525 (2024). https://doi.org/10.1007/s11428-024-01201-0
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DOI: https://doi.org/10.1007/s11428-024-01201-0
Schlüsselwörter
- Diabetesische Nierenerkrankung
- Glomeruläre Filtrationsrate
- Inhibitoren des Natrium-Glukose-Kotransporters 2
- Mineralokortikoidrezeptorantagonisten
- Rezeptoragonisten des glukagonähnlichen Proteins