Akutes Nierenversagen und Vaskulitis: Wann dran denken und was tun ?

 

 Buy Article Permissions and Reprints

Zusammenfassung

Die Nierenbeteiligung ist bei systemischen Autoimmunerkrankungen wie z.B. der ANCA-Vaskulitis häufig. Das akute Nierenversagen (ANV) limitiert die Prognose des Patienten und muss rechtzeitig erkannt werden. Das ANV verläuft jedoch symptomarm und daher stehen häufig zunächst extra-renale Krankheitssymptome im Vordergrund. Zur Beurteilung einer Nierenbeteiligung sind die Retentionsparameter, vor allem aber die Urinanalyse von Bedeutung. Die Nierenbiopsie ist das Verfahren der Wahl zur Bestätigung der Diagnose. Die Behandlung muss auf die Krankheitsschwere der ANCA-Vaskulitis abgestimmt sein und in Fällen mit schwerem Organversagen müssen extrakorporale Verfahren wie die Plasmapherese erwogen werden. Die immunsuppressive Erhaltungstherapie is notwendig um Rezidive zu verhindern und die Patienten müssen engmaschig überwacht werden, um renale Krankheitsaktivität frührzeitig zu erkennen.

Abstract

Renal involvement in systemic autoimmune diseases such as ANCA-vasculitis is common. Acute kidney injury (AKI) limits the prognosis of the patient and needs to be detected early. However, AKI is in early phases clinically inapparent and at first contact with the patient, extra-renal symptoms may dominate the clinical presentation. Serum-Creatinine and urinary analysis provide useful information on the extent of renal involvement. A renal biopsy should confirm the diagnosis. Treatment needs to be adapted to the extent of ANCA-vasculitis and in cases with severe organ failure plasmapheresis should be performed. Maintenance immunosuppressive is necessary to prevent relapses and the patients should be monitored closely to detect renal flares early.

• Literaturverzeichnis

• 1 Couser WG. Basic and translational concepts of immune-mediated glomerular diseases. J Am Soc Nephrol 2012; 23: 381-399
  CrossrefPubMedGoogle Scholar
• 2 Comarmond C, Cacoub P. Granulomatosis with polyangiitis (Wegener): Clinical aspects and treatment. Autoimmun Rev 2014; 13: 1121-1125
  CrossrefPubMedGoogle Scholar
• 3 Kallenberg CGM. The diagnosis and classification of microscopic polyangiitis. J Autoimmun 2014; 48–49: 90-93
  PubMedGoogle Scholar
• 4 Sinico RA, Di Toma L, Radice A. Renal involvement in anti-neutrophil cytoplasmic autoantibody associated vasculitis. Autoimmun rev 2013; 12: 477-482
  CrossrefPubMedGoogle Scholar
• 5 Leib ES, Restivo C, Paulus HE. Immunosuppressive and corticosteroid therapy of polyarteritis nodosa. Am J Med 1979; 67: 941-947
  PubMedGoogle Scholar
• 6 Slot MC, Tervaert JW, Franssen CF et al. Renal survival and prognostic factors in patients with PR3-ANCA associated vasculitis with renal involvement. Kidney Int 2003; 63: 670-677
  CrossrefPubMedGoogle Scholar
• 7 Wilde B, Van Paassen P, Witzke O et al. New pathophysiological insights and treatment of ANCA-associated vasculitis. Kidney Int 2011; 79: 599-612
  CrossrefPubMedGoogle Scholar
• 8 Hilhorst M, Wilde B, van Breda Vriesman P et al. Estimating renal survival using the ANCA-associated GN classification. J Am Soc Nephrol 2013; 24: 1371-1375
  CrossrefPubMedGoogle Scholar
• 9 Hilhorst M, Wilde B, van Paassen P et al. Improved outcome in anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis: a 30-year follow-up study. Nephrol Dial Transplant 2013; 28: 373-379
  CrossrefPubMedGoogle Scholar
• 10 Flossmann O, Berden A, de Groot K et al. Long-term patient survival in ANCA-associated vasculitis. Ann Rheum Dis 2011; 70: 488-494
  CrossrefPubMedGoogle Scholar
• 11 Hellmich B, Flossmann O, Gross WL et al. EULAR recommendations for conducting clinical studies and / or clinical trials in systemic vasculitis: focus on anti-neutrophil cytoplasm antibody-associated vasculitis. Ann Rheum Dis 2007; 66: 605-617
  CrossrefPubMedGoogle Scholar
• 12 Mukhtyar C, Flossmann O, Hellmich B et al. Outcomes from studies of antineutrophil cytoplasm antibody associated vasculitis: a systematic review by the European League Against Rheumatism systemic vasculitis task force. Ann Rheum Dis 2008; 67: 1004-1010
  CrossrefPubMedGoogle Scholar
• 13 Holle JU, Laudien M, Gross WL. Clinical manifestations and treatment of Wegener’s granulomatosis. Rheum Dis Clin North Am 2010; 36: 507-526
  CrossrefPubMedGoogle Scholar
• 14 Berden A, Goceroglu A, Jayne D et al. Diagnosis and management of ANCA associated vasculitis. BMJ 2012; 344: e26
  CrossrefPubMedGoogle Scholar
• 15 Tarzi R, Harper L. Small vessel vasculitides. Medicine 2014; 42: 138-145
  CrossrefPubMedGoogle Scholar
• 16 Bienholz A, Feldkamp T, Kribben A. Akutes Nierenver­sagen. Update 2013. Dtsch med Wochenschr 2013; 138: 1229-1232
  Article in Thieme ConnectPubMedGoogle Scholar
• 17 Khwaja A. KDIGO Clinical Practice Guidelines for Acute Kidney Injury. Nephron Clin Pract 2012; 120: c179-c184
  CrossrefPubMedGoogle Scholar
• 18 Segelmark M, Hellmark T. Autoimmune kidney diseases. Autoimmu rev 2010; 9: A366-A371
  PubMedGoogle Scholar
• 19 Hellmich B, Flossmann O, Gross WL et al. EULAR recommendations for conducting clinical studies and / or clinical trials in systemic vasculitis: focus on anti-neutrophil cytoplasm antibody-associated vasculitis. Ann Rheum Dis 2007; 66: 605-617
  CrossrefPubMedGoogle Scholar
• 20 Mukhtyar C, Guillevin L, Cid MC et al. EULAR recommendations for the management of primary small and medium vessel vasculitis. Ann Rheum Dis 2009; 68: 310-317
  CrossrefPubMedGoogle Scholar
• 21 Ntatsaki E, Carruthers D, Chakravarty K et al. BSR and BHPR guideline for the management of adults with ANCA-associated vasculitis. Rheumatology 2014; 53: 2306-2309
  CrossrefPubMedGoogle Scholar
• 22 de Groot K, Harper L, Jayne DRW et al. Pulse Versus Daily Oral Cyclophosphamide for Induction of Remission in Antineutrophil Cytoplasmic Antibody Associated Vasculitis. Ann Intern Med 2009; 150: 670-680
  CrossrefPubMedGoogle Scholar
• 23 Walsh M, Faurschou M, Berden A et al. Long-Term Follow-Up of Cyclophosphamide Compared with Azathioprine for Initial Maintenance Therapy in ANCA-Associated Vasculitis. Clin J Am Soc Nephrol 2014; 9: 1571-1576
  CrossrefPubMedGoogle Scholar
• 24 Jones RB, Cohen Tervaert JW, Hauser T et al. Rituximab versus Cyclophosphamide in ANCA-Associated Renal Vasculitis. N Engl J Med 2010; 363: 211-220
  CrossrefPubMedGoogle Scholar
• 25 Stone JH, Merkel PA, Spiera R et al. Rituximab versus Cyclophosphamide for ANCA-Associated Vasculitis. N Engl J Med 2010; 363: 221-232
  CrossrefPubMedGoogle Scholar
• 26 Jayne DRW, Gaskin G, Rasmussen N et al. Randomized Trial of Plasma Exchange or High-Dosage Methylprednisolone as Adjunctive Therapy for Severe Renal Vasculitis. J Am Soc Nephrol 2007; 18: 2180-2188
  CrossrefPubMedGoogle Scholar
• 27 Walsh M, Casian A, Flossmann O et al. Long-term follow-up of patients with severe ANCA-associated vasculitis comparing plasma exchange to intravenous methylprednisolone treatment is unclear. Kidney Int 2013; 84: 397-402
  CrossrefPubMedGoogle Scholar
• 28 Walsh M, Merkel PA, Peh CA et al. Plasma exchange and glucocorticoid dosing in the treatment of anti-neutrophil cytoplasm antibody associated vasculitis (PEXIVAS): protocol for a randomized controlled trial. Trials 2013; 14: 73
  CrossrefPubMedGoogle Scholar
• 29 Miloslavsky EM, Specks U, Merkel PA et al. Clinical outcomes of remission induction therapy for severe antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Rheum 2013; 65: 2441-2449
  CrossrefPubMedGoogle Scholar
• 30 Slot MC, Tervaert JWC, Boomsma MM et al. Positive classic antineutrophil cytoplasmic antibody (C-ANCA) titer at switch to azathioprine therapy associated with relapse in proteinase 3-related vasculitis. Arthritis Rheum 2004; 51: 269-273
  CrossrefPubMedGoogle Scholar
• 31 Jayne D, Rasmussen N, Andrassy K et al. A Randomized Trial of Maintenance Therapy for Vasculitis Associated with Antineutrophil Cytoplasmic Autoantibodies. N Engl J Med 2003; 349: 36-44
  CrossrefPubMedGoogle Scholar
• 32 Kemna MJ, Damoiseaux J, Austen J et al. ANCA as a Predictor of Relapse: Useful in Patients with Renal Involvement But Not in Patients with Nonrenal Disease. J Am Soc Nephrol 2014; pii: ASN.2013111233
  PubMedGoogle Scholar
• 33 Feldkamp T, Gäckler A, Herget-Rosenthal S et al. State of the Art – Akutes Nierenversagen. Kompendium Nephrologie 2010; 2: 6-16
  PubMedGoogle Scholar