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Dtsch Med Wochenschr 2004; 129(19): 1075-1081
DOI: 10.1055/s-2004-824850
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Nephrologie/Transplantationsmedizin
© Georg Thieme Verlag Stuttgart · New York

Vaskuläre Stenosen nach Nierentransplantation mit Einfluss auf Blutdruck und Nierenfunktion

Vascular stenosis after kidney transplantation with influence on blood pressure and renal functionA. Voiculescu1 , M. Schmitz1 , W. Sandmann2 , U. Mödder3 , B. Grabensee1
  • 1Klinik für Nephrologie und Rheumatologie
  • 2Klinik für Gefäßchirurgie und Nierentransplantation
  • 3Institut für diagnostische Radiologie
  • 4Heinrich Heine Universität, Düsseldorf
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Publication History

eingereicht: 4.9.2003

akzeptiert: 15.1.2004

Publication Date:
22 July 2004 (online)

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Zusammenfassung:

Meist heilbare Ursachen der arteriellen Hypertonie nach Nierentransplantation (NTX) und Einschränkung der Nierenfunktion bis hin zur Dialysepflichtigkeit sind Stenosen der Arterien mit einer Diameterreduktion von > 70 %, die die Transplantatperfusion beinträchtigen. Atherosklerotische Verschlusserkrankungen des Spenders oder des Empfängers sind in erster Linie für die Stenosen verantwortlich, gefolgt von Gefäßläsionen, die während der Entnahme oder der NTX entstehen. Insofern unterscheidet man Stenosen der Transplantatarterie selbst (TRAS) und Stenosen der aorto-iliacalen Strombahn proximal der Transplantatarterie (Prox-TRAS). Die Inzidenz von TRAS liegt bei 1,5 - 12 %, die von Prox-TRAS bei 1,5 - 2,4 %. Leitsymptome für beide Lokalisationen sind eine meist schwer einstellbare Hypertonie und/oder eine Nierenfunktionsverschlechterung bis hin zur Dialysepflichtigkeit, insbesondere unter ACE-Hemmer bzw. AT-1-Blockern. Bei Prox-TRAS werden vom Patienten nur in ca. 50 % der Fälle Symptome der peripheren arteriellen Verschlusserkrankung angegeben.

Als Screening-Untersuchung und zur Verlaufskontrolle hat sich die farbkodierte Duplex-Sonographie bewährt. Die MR-Angiographie (MRA) weist verfahrens-assoziierte Ungenauigkeiten auf. Der diagnostische Goldstandard ist weiterhin die intraarterielle digitale Subtraktionsangiographie (ia DSA) auch unter Berücksichtigung der kontrastmittel induzierten Nephrotoxizität.

Bei progredienter Stenose drohen unkontrollierbare Hypertonie und Transplantatverlust. Somit stellt die Beseitigung der Stenose die kausale Therapie dar, wobei das therapeutische Spektrum von interventionellen Methoden mittels perkutaner Angioplastie ohne (PTA) und mit Stent (PTAS) bis zu verschiedenen operativen Verfahren reicht. Die Auswahl der Therapieform hängt von der Art, Lokalisation und Morphologie der Stenose und von der Verfügbarkeit der Methoden ab.

Die Ergebnisse der operativen Behandlung sind gegenüber der PTA in bisherigen klinischen Beobachtungen günstiger. Über Verläufe nach PTAS sind bisher nur wenige Berichte mit kleinen Patientenzahlen vorhanden. Eine gelungene Intervention/Operation führt fast immer zu einer Besserung der Hypertonie und Verbesserung/Stabilisierung der Nierenfunktion.

Summary

Vascular stenoses > 70 % with influence on the kidney transplant perfusion are potentially curable causes for posttransplant hypertension and deterioration of kidney function including requirement of dialysis. Two locations of stenosis can be differentiated: stenosis of the transplant renal artery (TRAS) and stenosis proximal to the kidney graft (Prox-TRAS). Causes of TRAS and Prox-TRAS are mainly due to atherosclerosis of the donor or recipient, trauma to donor or recipient vessels during organ harvesting and transplantation. The incidence of TRAS varies from 1,5 - 12 %, and from 1,5 - 2,4 % for Prox-TRAS. The most frequent clinical presentation is severe hypertension with or without graft dysfunction, which is even more pronounced under treatment with ACE-inhibitors/AT-1-blockers. Patients with Prox-TRAS complain in only 50 % about symptoms of peripheral arterial occlusive disease.

According to our experience, colour coded Doppler sonography (CDS) is a very sensitive and useful tool for detection and follow-up of TRAS and Prox-TRAS. MR-angiography is also sensitive but exaggerates the degree of obstruction. Although selective angiography remains gold standard, the injection of contrast material may further deteriorate kidney function.

Progressive stenosis bears the risk of uncontrollable hypertension and loss of graft function, therefore invasive treatment for removal of stenosis is indicated. Percutaneous transluminal balloon angioplasty without (PTA) and with sent (PTAS) deployment as well as surgical techniques are treatment options and are applied depending on the type, morphology and localisation of the stenosis. Results after surgery are better as compared to PTA. Comparison to PTAS is not yet possible, due to very few data obtained until today. Technically successful management of the stenosis results nearly always in improvement of hypertension and of renal function.

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Dr. Adina Voiculescu

Klinik für Nephrologie und Rheumatologie, Heinrich-Heine-Universität

Moorenstraße 5

40225 Düsseldorf

Phone: 0211/8117726

Fax: 0211/8117722

Email: voicules@uni-duesseldorf.de

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