Nierenbeteiligung bei Kollagenosen – Teil 2: Antiphospholipid-Syndrom, primäres Sjögren-Syndrom, systemische Sklerose

Zusammenfassung

Renale Manifestationen bei Antiphospholipid-Syndrom (APS), primärem Sjögren-Syndrom (pSS) und systemischer Sklerose (SSc) unterscheiden sich erheblich in Pathogenese, Histologie, klinischem Erscheinungsbild, Prognose und therapeutischer Konsequenz. Die Häufigkeit APS-assoziierter Nierenveränderungen wird mit 10–40% angegeben. Das APS kann sich an der Niere in Form von renaler Hypertonie, Thrombosen oder Stenosen der Nierenarterien, Niereninfarkten, Nierenvenenthrombose und intrarenaler Vaskulopathie (APS-Nephropathie) manifestieren. Gerade beim sekundären APS ist die Differenzialdiagnose zur Lupusnephritis mittels Nierenbiopsie wichtig, da das APS eine Antikoagulation und in der Regel keine Immunsuppression erfordert. Auch beim pSS werden renale Affektionen mit 20–40% relativ häufig beobachtet. Die typische und auch häufigste Manifestation ist die interstitielle Nephritis mit distal tubulärer Azidose Typ 1. Sie verläuft oft asymptomatisch, kann aber zu Hypokaliämie und Osteomalazie führen. Während interstitielle Nephritis und die seltenere Glomerulonephritis in der Regel gut auf eine Immunsuppression ansprechen, wird die distal-tubuläre Azidose durch Immunsuppression nur unzureichend beeinflusst. Bei SSc werden Nierenfunktionseinschränkungen und Proteinurie als Ausdruck einer renalen Affektion in bis zu 36% beobachtet. Diese histologisch durch sklerosierte Glomeruli, tubuläre Atrophie und interstitielle Fibrose charakterisierte und häufig multifaktorielle Nephropathie hat jedoch im Hinblick auf die Nierenfunktion eine gute Prognose. Deutlich seltener ist mit 4–11% die renale Krise, welche histologisch durch eine obstruktive Vaskulopathie und klinisch durch akzelerierte arterielle Hypertonie und progrediente Niereninsuffizienz gekennzeichnet ist. Risikofaktoren der renalen Krise bei SSc sind das Vorliegen einer diffus cutanen SSc, höheres Alter, männliches Geschlecht, Einnahme von Glukokortikoiden, Perikarderguss sowie der Nachweis von Antikörpern gegen RNA-Polymerase III. Die Therapie der hypertensiven renalen Krise besteht in einer Blutdrucksenkung um ca. 10% pro Tag unter Vermeidung längerer Perioden einer Hypotension bis in den Normbereich unter bevorzugtem Einsatz von ACE-Hemmern. Bei unzureichender Blutdrucksenkung unter ausdosiertem ACE-Hemmer kommen zusätzlich Alpha-Blocker, Kalziumantagonisten und Minoxidil zum Einsatz. Nützlich sind ferner die intravenöse Gabe von Prostacyclin zur Verbesserung der renalen Perfusion und die Anwendung des Endothelin-Rezeptor-Antagonisten Bosentan. Die Einführung von ACE-Hemmern hat zwar die Mortalität infolge einer renalen Krise erheblich reduziert, allerdings ist in 40–50% ein Fortschreiten zur terminalen Niereninsuffizienz zu erwarten.

Abstract

Renal manifestations in antiphospholipid syndrome (APS), primary Sjögrenʼs syndrome (pSS) and systemic sclerosis (SSc) differ from each other substantially with respect to pathogenesis, histology, clinical picture, prognosis and therapeutic consequences. The frequency of APS-associated renal affections ranges from 10 to 40%. APS can affect the kidney in the form of renal hypertension, thrombosis or stenosis of the renal artery, renal infarction, thrombosis of the renal vein and intrarenal vasculopathy (APS nephropathy). Especially in the case of secondary APS, the differential diagnosis of lupus nephritis by renal biopsy is important because APS requires anticoagulation, but generally no immunosuppression. In pSS, too, renal affections are relatively common (20–40%). The characteristic and most frequent manifestation is interstitial nephritis with distal tubular acidosis type 1. Distal tubular acidosis is often asymptomatic, but can result in hypokalaemia and osteomalacia. Whereas interstitial nephritis and the less frequent glomerulonephritis generally respond well to immunosuppression, the response of distal tubular acidosis to immunosuppression is insufficient. Decrease of renal function and proteinuria as a sign of renal affection are observed in up to 36% of patients with SSc. This type of nephropathy, often multifactorial in origin, is characterised by sclerosed glomeruli, tubular atrophy and interstitial fibrosis, and has a good prognosis with respect to renal function. Scleroderma renal crisis, which is characterised by obstructive vasculopathy, accelerated arterial hypertension and progressive renal failure, is substantially less frequent (4–11%). Risk factors for renal crisis in SSc involve the presence of diffuse cutaneous SSc, older age, male gender, glucocorticoid use, pericardial effusion and the presence of anti-RNA polymerase III antibodies. Therapy of hypertensive renal crisis aims to reduce the systolic blood pressure by 10% per day to the normal range, preferably with ACE inhibitors, while avoiding prolonged periods of hypotension. In the case of insufficient reduction of blood pressure despite ACE inhibitor therapy, alpha-blockers, calcium channel blockers and/or minoxidil are used in addition. Intravenous administration of prostacycline to improve renal perfusion and the use of the endothelin receptor antagonist bosentan are also useful. The availability of ACE inhibitors has resulted in a significant reduction of mortality due to renal crisis; however, a progression to end-stage renal disease is to be expected in 40–50%.

Schlüsselwörter

Kollagenosen - Nierenbeteiligung - Pathogenese - Therapie

Key words

connective tissue diseases - renal involvement - pathogenesis - therapy

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