Optimierung des kardiovaskulären Risikos bei Nierenpatienten – Die Rolle von Lipiden

Patienten mit chronischer und terminaler Niereninsuffizienz haben ein exzessives kardiovaskuläres Morbiditäts- und Mortalitätsrisiko. Durch die lipidmodulierende Therapie, insbesondere durch den Einsatz von CSE-Hemmern, konnte die kardiovaskuläre Morbidität und Mortalität bei Patienten ohne chronische Niereninsuffizienz (CKD: Chronic Kidney Disease) in den letzten Jahren signifikant gesenkt werden. Im Gegensatz dazu zeigt die Therapie mit CSE-Hemmern bei CKD-Patienten eine geringere Wirksamkeit im Hinblick auf die Verminderung der kardiovaskulären Morbidität. Auch die Progression der Niereninsuffizienz ist hier nur teilweise zu beeinflussen. Unter zunehmenden urämischen Bedingungen entwickeln CKD-Patienten eine komplexe Lipid-Stoffwechsel-Störung, die aktuell nur zum Teil verstanden ist. Die therapeutische Ausrichtung auf eine Absenkung der LDL-Plasma-Konzentration scheint aufgrund der komplexen metabolischen Lipidveränderungen bei Niereninsuffizienz im Gegensatz zur nierengesunden Population nicht zielführend zu sein. Aus dieser Konsequenz ergibt sich bei Patienten mit CKD und Dialysepflichtigkeit (ESRD: End-Stage Renal Disease) die Notwendigkeit, die therapeutischen Ziele weg von einem reinen quantitativen hin zu einem qualitativen Ansatz zu verschieben.

Patients with chronic and end-stage kidney disease have an excessive cardiovascular morbidity and mortality risk. In the last decades, lipid-modulating therapy using statins successfully reduced cardiovascular events in patients without renal disease. In contrast, statin therapy in patients with chronic kidney disease is less effective in reducing cardiovascular morbidity and mortality compared to patients without kidney disease. Furthermore, the progression of renal insufficiency could not be influenced. Patients with chronic renal disease develop a complex lipid disturbance that is not fully understood so far. The therapeutic aim of quantitative modulation of lipoprotein plasma concentration, which is the main concept in renal healthy subjects, seems not to be sufficient in chronic and end-stage renal disease patients. In the future, new therapeutic options have to be developed aiming on the functional status of the different lipoproteins more than on the quantitative concentrations.

Key words

cardiovascular risk - kidney disease - lipids - therapy

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