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NEFROPATIA ISCHEMICA
Stenoza aterosclerotica AR HTARV , NEF ISCH
Boala caracterizata prin reducerea semnificativa a ratei FG
consecutiv unei stenozari hemodinamic semnificative
(>75%) a arterei renale (in cazul rinichiului solitar) sau a
ambelor AR (daca exista ambii rinichi)
PREVALENTA NEF ISCH putin cunoscuta; arteriografic:
14-42% (coasociere cu boala vasculara periferica); 11-23%
(la pac cu coronarografie)
CLINICA
3 SITUATII:
Asimptomatic clinic
IR
HTA + ateroscleroza sistemica (claudicatie /
cardiopatie ischemica / ICC)
Profilul caracteristic: B, >60 ani, fumator, dislipidemic,
hipertensiv +/- flash EPA
Renal abnormalities
Unexplained renal failure in patients aged >50 years
Elevation in plasma creatinine level after the initiation of ACE-I or AIIRB therapy (> 30% increase in serum creatinine)
Asymmetrical kidneys on imaging
NEFROANGIOSCLEROZA HT
DEFINITIE
afectare renala care poate fi iniiat, perpetuat sau
accelerat ca o consecin a unor componente ale PA
(sistolica, diastolica, presiunea pulsului, variabilitatea
PA).
INCIDENTA
Systolic (mmHg)
Diastolic (mmHg)
Optimal
< 120
< 80
Normal
120-129
80-84
High normal
130-139
85-89
Grade 1 (mild)
140-159
90-99
Grade 2 (moderate)
150-179
100-109
Grade 3 (severe)
180
100
140
< 90
Hypertension
Mecanisme patogenice
nefroangiscleroza benigna
Autoreglare aberanta
Pierderea capacitatii de autoreglare a fluxului sanguin renal la nivelul arteriolei
aferente conduce la transmiterea presiunii crescute catre glomerulii ramasi
neprotejati, avand drept consecinta hiperfiltrarea , hipertrofia glomerulara si in
final GSFS
Mecanisme protrombotice
interventia factorilor genetici modulatori ai trombozei in producerea sclerozei
vasculare.
Sindrom dismetabolic
Blood pressure 130/85 mm Hg;
Low high-density lipoprotein cholesterol: < 1.0 mmol/L (40 mg/dL) in men; <
1.2 mmol/L (46 mg/dL) in women;
High triglycerides: > 1/7 mmol/L (150 mg/dL);
Altered fasting glucose: 5.6-6.9 mmol/L (102-125 mg/dL); and
Abdominal obesity: waist circumference > 102 cm in men; > 88 cm in women.
3. Hipertensiune arterial:
Leziunile tubulo-interstiiale
atrofie tubular,
fibroz interstiial
infiltrat inflamator cu macrofage i limfocite
Clinic
Reflect afectarea visceral multipl, caracteristic
acestui sindrom.
1. Stare general alterat, paloare tegumentar, scdere
ponderal important.
2. Encefalopatia hipertensiv; Se nsoete de modificri ale
FO de gradul IV i III.
3. Cardiopatia hipertensiv
4. Manifestrile renale constau n proteinurie variabil
neselectiv (ntre 0,4 - 20 g/24 ore), hematurie
microscopic sau macroscopic, degradare a funcie
renale care poate fi acut oliguric, subacut sau cronic.
Paraclinic
1. Modificrile hematologice sunt complexe: anemie de tip
microangiopatic (cu schizocite i fragilitate crescut a
hematiilor), trombocitopenie. VSH este crescut.
2. Modificrile electrolitice constau n hipokalemie,
hiponatremie i alcaloz pasager, prin creterea
compensatorie a reteniei de bicarbonai.
3. Explorrile renale: sumarul de urin asociaz
proteinurie dozabil cu hematurie i leucociturie,
cilindri hialini, granuloi, hematici sau leucocitari.
Valorile produilor de retenie azotat cresc rapid, pe
msura scderii concomitente a fluxului plasmatic renal
i a filtratului glomerular.
4. Dozarea hormonal relev creteri importante ale
reninei, angiotensinei i aldosteronului plasmatic.
5. Puncia biopsie, practicat numai dup scderea valorilor
tensionale, relev tabloul histologic specific HTAM.
TRATAMENT
Tratamentul de urgen
scderea rapid a valorilor presiunii arteriale, folosind
medicaie administrat pe cale parenteral.
La pacienii cu encefalopatie hipertensiv valorile
presionale vor fi sczute lent, n 24 ore i la nivele de
minimum 170/100mmHg.
Se folosesc, n ordinea eficienei, nitroprusiatul de sodiu,
diazoxidul, hidralazina, diuretice de ans.
Tratamentul de ntreinere
Va include o schem de 2-4 antihipertensive, asociate
astfel nct s se obin o scdere a presiunii arteriale la
valori normale (<120/80mmHg) dup 2-3 luni, alegnd
IEC de prim intenie.
HTA agravat
de
apariia la primipare;
instalarea n ultimul trimestru al sarcinii;
retrocedarea postpartum;
lipsa repetrii la sarcina ulterioar.
Tratament igieno-dietetic
Tratamentul medicamentos:
1 tratamentul anti-HTA se va aplica la tensiuni peste 17/11cmHg
Dopegyt, Aldomet 250-1000mg/24h;
Hidrazinoftalazinele 25-100mg/24h;
Clonidina 0,1-0,3mg;
Antagonitii de Ca (nu nainte de spt 20!)
Prozosin (Minipress);
Diazoxidul 300mg i.v. n marile urgene
2 medicaia diuretic - numai n situaii speciale (IC, EPA, eclampsie)
3 medicaia
antiadezivo-agregant
i
anticoagulant
(controversat):
Aspririna, Dipiridamol, Prostaciclina, Heparina etc
4 medicaia sedativ (barbiturice, benzodiazepine)
Tratamentul convulsiilor
Sulfatul de magneziu 4g i.v. n bolus + 5g i.m. profund, doz
repetat n funcie de evoluie la 4-5 ore interval
Monitorizarea = verificarea ROT, a diurezei i a respiraiei !
Fenobarbitalul 0,10g i.m. la 2-4h
Amital sodic 0,25g i.v. lent
Diazepam 20mg i.v. lent
Mialgin 100mg i.m.
Diabetic nephropathy
DN is the leading cause of CKD in the industrialised world.
One of the most significant long-term complications in terms of morbidity
and mortality for individual patients with diabetes.
Diabetes is responsible for 30-40% of all end-stage renal disease (ESRD)
cases in the United States.
Although both type 1 diabetes mellitus (IDDM) and type 2 diabetes mellitus
(noninsulin-dependent diabetes mellitus [NIDDM]) lead to ESRD, the
great majority of patients are those with NIDDM.
The glomeruli and kidneys are typically normal or increased in size initially,
thus distinguishing DN from most other forms of chronic renal insufficiency,
wherein renal size is reduced (except renal amyloidosis and polycystic
kidney disease).
DN = Diabetic Renal Disease - which progresses through five predictable stages.
Definition
A microvascular complication of diabetes
marked by albuminuria and a deteriorating
course from normal renal function to ESRD.
Natural History
Pathology
Expansion of mesangial matrix with diffuse
and nodular glomerulosclerosis
(Kimmelstiel-Wilson nodules)
Thickening of glomerular and tubular BM
Arteriosclerosis and hyalinosis of afferent
and efferent arterioles
Tubulointerstitial fibrosis
Pathogenesis
Exposure to the diabetic milieu
Hyperglycemia
DIAGNOSIS/SCREENING
TREATMENT
Glycemic control
Hypertension control
Dietary protein restriction
RAS blockade- IECA/ ARBs
BARDOXOLONE ??!!
HD i DPCA
hidro-electrolitic i acido-bazic:
severe;
necorectabile prin mijloacele terapeutice conservatoare;
Insuficiena renal cronic cu simptomatologie intens sau
cu risc vital:
pericardit;
insuficien cardic rezistent la terapia clasic;
malnutriie;
tulburri neurologice.
Contraindicaiile HD
Relative:
Vrsta naintat (peste 75 ani);
Boli cu deficiene funcionale severe ale altor organe
(insuficien cardic cu disfuncie sistolic sever,
insuficien hepatic, insuficien respiratorie etc);
capital vascular deficitar.
Absolute:
IRC asociat cu cancer cu metastaze/generalizat sau
cu prognostic de supravieuire <1 an;
bolile psihice majore;
alergia la heparin.
Contraindicaiile DPCA
Absolute:
Rezecii mezenterice ntinse;
Tumori abdominale mari;
Ileus;
Obezitate extrema;
Comunicri pleuroperitoneale largi
nnascute/dobndite;
Intervenii chirurgicale cu
deschiderea peritoneului
posterior;
Enterostomii;
Cisto-/ureterostomii;
Insuficien respiratorie;
Cecitate;
Bolnavi sub 18 ani, fr
aparintori care s i asume
responsabilitatea terapiei;
Psihoze, demen, retardare
mintal,
Paralizii, osteo-artropatii cu
deficit funcional al minilormpiedicnd efectuarea
schimburilor.
Contraindicaiile DPCA
Relative:
Cicatrici ntinse ale peretelui abdominal;
Hernii;
Radioterapie pe abdomen n antecedente;
Discopatii lombare;
Drenaj post-operator al cavitii abdominale;
Sarcina avansat;
Polichistoz renal cu dimensiuni foarte mari ale
rinichilor;
Diverticuloza colonic.
RENAL TRANSPLANTATION
AN OVERVIEW
Kidney Donor
Living related.
Cadaveric (Brain-dead)
Beating and non-beating heart.
Blood relative.
Highly motivated.
ABO blood group-compatible.
HLA-identical or haploidentical with
negative cross-match.
Excellent medical condition with normal
renal function.
A Final CM is mandatory
Age
HLA matching
Delayed graft function
Ischemia time.
Number of acute rejection episodes.
Native kidney disease.
Ethnicity.
Others
outweight the
Examples
Calcineurin inhibitors
Cyclosporine
Tacrolimus (FK506)
Calcinurin-independent agents
Sirolimus (rapamycin)
Glucocorticoids
Antimetabolites