Hypertonietherapie bei Nierenerkrankungen

ZUSAMMENFASSUNG

Die arterielle Hypertonie bei Patienten mit einer chronischen Nierenerkrankung (CKD: „chronic kidney disease“) ist häufig schlecht kontrolliert und der wichtigste modifizierbare Risikofaktor, der zur Progression der CKD beiträgt. Dieser Beitrag gibt einen Überblick über die aktuelle Diagnostik und Therapie der arteriellen Hypertonie in den verschiedenen CKD-Stadien, inklusive für Patienten mit Nierenersatztherapie und für Patienten nach einer Nierentransplantation. Die Diagnose und die Therapieüberwachung der Blutdruckwerte sollte bei allen CKD-Stadien ohne Nierenersatztherapie und bei Nierentransplantation primär mittels ambulanter Blutdruckmessung (ABDM) erfolgen. Bei allen CKD-Patienten empfiehlt die europäische Hypertonie-Leitlinie aus dem Jahr 2023 einen Zielblutdruck von < 140/90 mmHg (Praxisblutdruck) anzustreben. Insbesondere bei jüngeren Patienten mit Albuminurie und/oder Diabetes erscheint ein Blutdruckziel von < 130/80 mmHg vorteilhaft. In den CKD-Stadien 1–3 werden in erster Linie ACE-Inhibitoren (ACE: „angiotensin converting enzyme“) beziehungsweise Angiotensin-II-Rezeptor-Blocker (ACEi/ARB), Dihydropyridin-Kalzium-Antagonisten (CCB: „calcium channel blocker“) und Thiaziddiuretika eingesetzt. Als Reservemedikament ist Spironolacton zu bevorzugen. Die renale Denervation rückt als zusätzliche antihypertensive Option zunehmend in den Vordergrund. Die Gabe und das Erreichen der Maximaldosis von ACEi/ARB und MRA kann in fortgeschrittenen CKD-Stadien durch kaliumsenkende Ionenaustauscher ermöglicht werden. Bei hochgradig reduzierter Nierenfunktion (CKD-Stadien 4 und 5 ohne Nierensatztherapie) ist statt einem Thiaziddiuretikum der Einsatz eines Schleifendiuretikums ratsam. Bei Patienten mit Nierenersatztherapie sind Grundpfeiler der Therapie das Erreichen des Trockengewichts, eine effektive Dialysedosis und eine Kochsalzrestriktion. Medikamentös sind, im Gegensatz zu anderen CKD-Subgruppen, Betablocker und Kalziumantagonisten bevorzugte Medikamente. Patienten nach einer Nierentransplantation haben aufgrund vaskulärer Vorerkrankungen und unter Glukokortikoiden und Calcineurininhibitoren häufig einen schlecht kontrollierten Blutdruck. Kalziumantagonisten sind als Erstlinientherapie bei Hypertonie nach einer Nierentransplantation in Bezug auf die Blutdrucksenkung und das Transplantatüberleben wirksam.

Publication History

Article published online:
19 April 2024

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