Akzelerierte Atherosklerose - Chronische Niereninsuffizienz ist ein etablierter kardiovaskulärer Risikofaktor

Patienten mit chronischer Niereninsuffizienz weisen eine vielfach erhöhte kardiovaskuläre Morbidität und Mortalität auf. Dieser akzelerierten Atherosklerose liegen unter anderem ein chronisch inflammatorischer Prozess, aber auch zahlreiche mit der Niereninsuffizienz assoziierte Faktoren (z.B. Proteinurie, gestörter Kalzium-Phosphat-Stoffwechsel, Anämie) zugrunde. Da bei vielen Patienten mit chronischer Niereninsuffizienz die koronare Herzkrankheit (KHK) asymptomatisch verläuft, sollte die Indikation zur Koronarangiografie bei Verdacht auf eine koronare Herzkrankheit großzügig gestellt werden. Zur Reduktion der kardiovaskulären Mortalität ist an erster Stelle ein Erhalt der Nierenfunktion zu nennen. Die Therapie der relevanten koronaren Herzerkrankung umfasst neben der medikamentösen Therapie die interventionelle Therapie mittels perkutaner Koronarangioplastie - auch mit Stent - oder die chirurgische Therapie mittels aortokoronarer Bypassoperation. Der Erfolg beider Verfahren hängt sowohl im Kurzzeit- als auch im Langzeitverlauf vom Ausmaß der Nierenfunktionseinschränkung ab. Mit zunehmender Niereninsuffizienz nimmt die postinterventionelle oder postoperative Überlebensrate signifikant ab. Zusammenfassend lässt sich feststellen, dass die Niereninsuffizienz ein eigenständiger kardiovaskulärer Risikofaktor ist.

Patients with end-stage renal disease suffer from increased cardiovascular death and morbidity. The increased gradient of cardiovascular risk is present even in mild renal dysfunction (GFR < 60 ml/min). Chronic inflammation is one of the major factors known to be associated with accelerated atherosclerosis in renal insufficency. Nevertheless, there are several uremia-related risk factors such as proteinuria, anemia, or disorders in calcium-phosphate metabolism (hyperparathyroidism) contributing to an increased cardiovascular mortality. In patients with impaired renal function there is a high incidence of asymptomatic coronary artery disease. Coronary angiography should be performed as frequent as done in patients with normal kidney function. To the treatment strategy of coronary artery disease in patients with impaired kidney function account medical therapy, percutaneous transluminal coronary angioplasty (PTCA/stent) or revascularization with coronary artery bypass surgery (CABG). For both interventional procedures the degree of impairment of kidney function is significantly associated with increased morbidity and mortality. To improve the poor prognosis of patients with any degree of renal insufficiency and coronary artery disease everything should be done to preserve kidney function at first and secondly to treat them as good as patients with normal kidney function and coronary artery disease.

end-stage renal disease - accelerated atherosclerosis - cardiovascular risc factor - percutaneous transluminal coronary angioplasty - coronary artery bypass

Literatur

• 1 Adler AI. et al. . Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64).  Kidney Int. 2003;  63 225-232
• 2 Aoki J. et al. . Five year clinical effect of coronary stenting and coronary artery bypass grafting in renal insufficient patients with multivessel coronary artery disease: insights from ARTS trial.  Eur Heart J. 2005;  26 1488-1493
• 3 Best PJM. et al. . The impact of renal insufficiency on clinical outcomes in patients undergoing percutaneous coronary interventions.  J Am Coll Cardiol. 2002;  39 1113-1139
• 4 Cooper WA. et al. . Impact of renal dysfunction on outcomes of coronary artery bypass surgery: result from the Society of Thoracic Surgeons National Adult Cardiac Database.  Circulation. 2006;  113 1063-1070
• 5 Dewey TM. et al. . Does coronary artery bypass graft surgery improve survival among patients with end-stage renal disease?.  Ann Thorac Surg. 2006;  81 591-598
• 6 Foley RN. et al. . Epidemiology of cardiovascular disease in chronic renal disease.  J Am Soc Nephrol. 1998;  9 S16-S23
• 7 Go AS. et al. . Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.  N Engl J Med. 2004;  351 1296-1305
• 8 Gupta R. et al. . The renal patient with coronary artery disease: Current concepts and dilemmas.  J Am Coll Cardiol. 2004;  44 1343-1353
• 9 Herzog CA. et al. . Comparative survival of dialysis patients in the United States after coronary angioplasty, coronary artery stenting, and coronary artery bypass surgery and impact of diabetes.  Circulation. 2002;  106 2207-2211
• 10 Hillege HL. et al. . Urinary albumin excretion predicts cardiovascular and non-cardiovascular mortality in general population.  Circulation. 2002;  106 1777-1782
• 11 Hillies GS. et al. . Renal function and outcome from coronary artery bypass grafting: impact on mortality after a 2.3-year follow-up.  Circulation. 2006;  113 1056-1062
• 12 Ketteler M. et al. . Association of low fetuin-A (AHSG) concentrations in serum with cardiovascular mortality in patients on dialysis: a cross-sectional study.  Lancet. 2003;  361 827-833
• 13 Lemos PA. et al. . Impact baseline renal function on mortality after percutaneous coronary intervention with sirolimus-eluting stents or bare metal stents.  Am J Cardiol. 2005;  95 167-172
• 14 Mann JFE. et al. . Renal insufficiency as a predictor of cardiovascular outcomes and the impact of ramipril. The HOPE randomized trial.  Ann Int Med. 2001;  134 629-636
• 15 Marco MP. et al. . Higher impact of mineral metabolism on cardiovascular mortality in a European hemodialysis population.  Kidney Int Suppl. 2003;  85 S111-S114
• 16 Sarafidis PA, Bakris GL. Level of kidney function determines cardiovascular fate after coronary bypass graft surgery.  Circulation. 2006;  113 1046-1047
• 17 Stigant C. et al. . Outcomes after percutaneous coronary interventions in patients with CKD: improved outcome in the stenting era.  Am J Kidney Dis. 2005;  45 1002-1009
• 18 Weiner DE. et al. . Effects of anemia and left ventricular hypertrophy on cardiovascular disease in patients with chronic kidney disease.  J Am Soc Nephrol. 2005;  16 3404-3410
• 19 Wright RS. et al. . Acute myocardial infarction and renal dysfunction.  Ann Intern Med. 2002;  137 563-570
• 20 Zimmermann J. et al. . Inflammation enhances cardiovascular risk and mortality in hemodialysis patients.  Kidney Int. 1999;  55 648-658

1 Heart Outcomes Prevention Evaluation

2 United Kingdom Prospective Diabetes Study

3 arterial revascularization therapy study

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