Dtsch Med Wochenschr 2019; 144(24): 1714-1720
DOI: 10.1055/a-0887-0792
Klinischer Fortschritt
Nephrologie
© Georg Thieme Verlag KG Stuttgart · New York

Medikamentöse Therapie der Herzinsuffizienz mit reduzierter Ejektionsfraktion bei chronischer Nierenerkrankung

Pharmacologic treatment of heart failure with reduced ejection fraction in chronic kidney disease
Gunnar Henrik Heine
1   AGAPLESION MARKUS KRANKENHAUS, Medizinische Klinik II, Frankfurt am Main
,
Kyrill Sebastian Rogacev
2   Sana-HANSE-Klinikum, Wismar
3   MVZ Schwerin West GmbH
› Author Affiliations
Further Information

Publication History

Publication Date:
02 December 2019 (online)

Was ist neu?

Etablierte Therapiestrategien Auch wenn die Evidenz für den Einsatz von ACE-Hemmern, Angiotensin-Rezeptorblockern, Betablockern und Mineralokortikoid-Rezeptor-Antagonisten bei HFrEF-Patienten mit schwerer CKD begrenzt ist, macht die schlechte Prognose unbehandelter Patienten einen breiten Einsatz dieser Substanzen oft erforderlich. In den Leitlinien der European Society of Cardiology zur Herzinsuffizienz werden für den klinischen Alltag hilfreiche und konkrete Vorschläge zum Intervall von Laborkontrollen und zu Konsequenzen insbesondere von Hyperkaliämie und Kreatininanstieg unter RAAS-Inhibitoren vorgeschlagen.

Neue Therapiestrategien Neue Therapiestrategien zur Prognoseverbesserung von HFrEF-Patienten lassen sich in unterschiedlicher Weise auf CKD-Patienten übertragen: Der Einsatz von Sacubitril/Valsartan und SGLT-2-Inhibitoren ist bei mittelgradiger CKD (GFR ≥ 30 ml/min/1,73 m²), nicht jedoch bei höhergradiger CKD untersucht. Hingegen liegen für eine hochdosierte intravenöse Eisentherapie Daten aus der PIVOTAL-Studie vor, welche eine Prognoseverbesserung zumindest bei hinsichtlich der Herzfunktion unselektierten Patienten mit dialysepflichtiger CKD suggerieren.

Abstract

Medical management of patients with co-existing Heart Failure with reduced Ejection Fraction (HFrEF) and chronic kidney disease (CKD) poses a significant challenge to treating physicians. On the one hand, the traditional therapeutic strategies such as betablockers, angiotensin converting enzyme inhibiotors, angiotensin receptor blockers and mineralocorticoid receptor antagonists have been evaluated in clinical trials that broadly excluded patients with significant CKD. On the other hand, inhibition of the renin angiotensin aldosterone system can lead to worsening of renal function and hyperkalemia potentially causing harm. Consequently, the cornerstones of heart failure treatment are often not adequately employed in HFrEF patients with CKD, a fact which is in itself a risk factor for worse outcomes in this patient population. Notably, it has been shown that these established pharmacologic strategies can be safely administered when carefully monitored. Iron treatment in anemia in CKD is well established and outcome trials in HFrEF are underway. New therapeutic strategies are under current investigation. Sodium glucose transporter 2 inhibitors show promising results in HFrEF and in CKD trials. In addition, Sacubitril/Valsartan significantly reduced events in HFrEF and might reduce renal events in HFpEF.

 
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