Bestimmung der Nierenfunktion im Alter – Was ist zu beachten?

Zusammenfassung

Eine eingeschränkte Nierenfunktion hat eine hohe Prävalenz im Kollektiv der Älteren und ist zudem ein unabhängiger Risikofaktor für kardiovaskuläre Ereignisse. Die Leitlinien der KDIGO-Organisation (KDIGO: Kidney Disease: Improving Global Outcomes) definiert eine errechnete oder gemessene glomeruläre Filtrationsrate (GFR) von weniger als 60 ml/min/1,73 m² als eine eingeschränkte Nierenfunktion (altersunabhängig). Goldstandardverfahren zur Bestimmung der Nierenfunktion sind z.B. die Inulin- oder Iohexolclearance. In der klinischen Praxis wird die Nierenfunktion jedoch nicht direkt gemessen, sondern vielmehr über endogene Biomarker und mittels mathematischer Formeln abgeschätzt. Beruhend auf Untersuchungen an einer gesunden, hauptsächlich kaukasischen US-amerikanischen Kohorte wurde eine jährliche, altersabhängige Abnahme der glomerulären Filtrationsrate (GFR) von ca. 0,75 ml/min/1,73 m² beobachtet. Die aktuellen KDIGO-Guidelines teilen die Stadien der chronischen Niereninsuffizienz beruhend auf der „estimated glomerular filtration rate“ (eGFR) und dem Ausmaß der Albuminurie ein. Eine exakte Einteilung der Stadien hat insbesondere im Hinblick auf die Dosisanpassung einer Pharmakotherapie eine praktische klinische Relevanz. Weiterhin hat die Stadieneinteilung auch eine prognostische Relevanz. Die Bestimmung der Nierenfunktion ist bei älteren und vor allem bei hoch betagten Menschen (> 80 Jahren) nicht trivial – einerseits aufgrund einer möglichen „physiologischen“ Abnahme der Nierenfunktion im Alter und andererseits aufgrund nicht gut evaluierter Messparameter. Sowohl die MDRD- (Modification of Diet in Renal Diseases) als auch die CKD-EPI-Formel (CKD-EPI: Chronic Kidney Disease Epidemiology Collaboration) benutzen standardmäßig das Serumkreatinin als Biomarker. Beide Formeln sind jedoch im Kollektiv der älteren Patienten entweder gar nicht (MDRD) oder nur an einer kleinen Personenzahl validiert. Die Bestimmung des Cystatin C (muskelmasseunabhängiger Biomarker) zur Abschätzung der Nierenfunktion scheint beim älteren Menschen Vorteile zu haben. Seit dem Jahr 2012 stehen uns durch die Ergebnisse der Berliner Initiative Studie (BIS) erstmals Daten zur Abschätzung der Nierenfunktion beim hochbetagten Menschen zur Verfügung.

Summary

Impaired renal function is associated with an increased risk of adverse outcomes, including cardiovascular events, development of end-stage renal disease and death. Furthermore, the prevalence of chronic kidney disease (CKD) increases with advancing age. The Kidney Disease: Improving Global Outcomes (KDIGO) Guidelines define a glomerular filtration rate (GFR) less than 60 ml/min/1.73 m² as chronic kidney disease (independently from age). Gold standards for the determination of renal function are e.g. inulin or iohexol clearance, but this is impractical for large-scale application. In everyday clinical practice, mostly creatinine-based equations to estimate GFR (eGFR) were used. Estimation of GFR is essential for the evaluation of patients with CKD, to classify into stages according to the level of GFR and to prevent further complications, e.g. correct dosage of drugs cleared by the kidney so as to avoid potential drug toxicity. When focusing on elderly population, it must be taken into account that there is a physiological decrease of GFR from 0.75–1.0 ml/min/year. Therefore, determination of kidney function in very elderly people (> 80 years) is not trivial because of the physiological decrease of GFR and, on the other hand, current equations to estimate glomerular filtration rate (GFR) are not validated and may misclassify elderly persons in terms of their stage of chronic kidney disease. Both used formulas, Modification of Diet in Renal Diseases (MDRD) and Chronic Kidney Disease Epidemiology Collaboration, (CKD-EPI) are based on serum creatinine or cystatin C and were not validated in elderly patients. Measurements of cystatin C to estimate the GFR in elderly or very elderly people might be superior. Since 2012, for the first time we have data from the Berlin Initiative Study (BIS) to estimate GFR in elderly and very elderly people.

Key words

cystatin C - BIS - CKD-EPI - MDRD - chronic kidney disease

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