Insufficienza renale acuta (IRA)
Definizione
L’insufficienza renale acuta (IRA) è una sindrome caratterizzata dalla riduzione rapidamente progressiva, sovente transitoria, della funzione escretrice renale, che compromette il mantenimento dell’equilibrio necessario al funzionamento normale dell’organismo.
Eziologia
Dal punto di vista eziopatogenico con il termine di IRA si descrivono tre diverse situazioni: IRA prerenale, IRA postrenale e IRA organica.
IRA prerenale
- riduzione della perfusione renale causata da condizioni patologiche che determinano una riduzione della perfusione renale; la ridotta perfusione renale da ipovolemia è il momento patogenetico principale e può dipendere da perdita di sangue in toto per emorragie, perdita di plasma per ustioni o perdita di tipo di composti da acqua e sali come nelle disidratazioni gravi.
Sintomatologia
Il sintomo principale dell’ IRA prerenale è l’oliguria (< a 400 ml/die), associata all’ emissione di urina ad alto peso specifico (> a 1020) e iperosmotiche. Lo stato di ipovolemia da disidratazione perdita di sangue o plasma si manifesta clinicamente con:
- Ipotensione ortostatica
- Tachicardia
- Secchezza delle mucose e della cute.
Nelle condizioni di disidratazione si associano frequentemente alterazioni elettrolitiche quali iponatriemia caratterizzata da sintomi neurologici (cefalea, vomito, sonnolenza) per passaggio di acqua libera nel compartimento intracellulare del SNC o in alternativa ipernatriemia (disidratazione ipertonica) causa di sete intensa.
IRA organica o intrinseca
- è causata da alterazioni di uno o più componenti del parenchima renale (glomeruli, tubuli,vasi, interstizio); l’ IRA organica complica frequentemente la sepsi (20- 50% dei casi a seconda della gravità del quadro clinico) o il decorso post-operatorio (20- 25% di tutti i casi di IRA in ambiente ospedaliero). La terza causa più comune di IRA organica è quella associata alla nefropatia acuta da mezzo di contrasto iodato. Diversi farmaci o sostanze esogene possono determinare un deterioramento della funzione renale per un’azione nefrotossica diretta sul tubulo renale.
Sintomatologia
L’esordio clinico dell’IRA organica può venire con l’oliguria, emissione di 100-200 ml di urine brunastre che sono a basso peso specifico a (1010) e ad alto contenuto di sodio (> 40 mEq/1). L’azoturia e la creatininuria sono anch’esse notevolmente ridotte.
Anuria completa si può avere nei casi di IRA associata a glomerulonefrite rapidamente progressiva, vasculite renale, necrosi corticale bilaterale. Lo studio del sedimento urinario può orientare verso la patologia responsabile.
IRA postrenale
- è associata a malattie delle vie escretrici urinarie, caratterizzate da ostacolo meccanico al deflusso delle urine; l’ostruzione delle vie urinarie può stabilirsi per cause diverse, quali calcolosi renale (specialmente nei soggetti con un rene unico) e le neoplasie del tratto urinario o della piccola pelvi. Nei maschi anziani assume particolare importanza l’ipertrofia prostatica.
Sintomatologia
L’IRA postrenale può avere un esordio brusco o subdolo a seconda della rapidità con la quale si instaura l’ostruzione. Un’ ostruzione rapida e completa comporta un’anuria con ingrandimento dei reni che possono essere percepiti alla palpazione bimanuale delle logge renali. La diagnosi di IRA postrenale si basa sulla dimostrazione dell’ostruzione urinaria.
Il 75% dell’ insufficienza renale (IRA) è secondaria a Necrosi tubulare acuta.
Esami di laboratorio
Urine:
- Normali o con anomalie minori nell’insufficienza prerenale; patologiche nelle forme renali e post-renali;
Sangue:
- Aumento rapido dell’azotemia e della creatinina;
- Sodio: la natriemia può essere normale, diminuita nel caso di iperidratazione, nella fase diuretica con perdite di sodio elevate o aumentata in caso di disidratazione extracellulare;
- Potassio: la kaliemia può aumentare rapidamente, soprattutto in caso di acidosi ed arrivare ad un livello minaccioso per la vita del malato;
- Calcio: ridotto fosforo e solfati aumentati;
- Magnesio: generalmente aumentato.
Prognosi
Dipende dall’eziologia dell’insufficienza renale, le necrosi tubulari nefrotossiche hanno una migliore prognosi di quelle ischemiche. L’insufficienza renale acuta prerenale o postrenale è reversibile se si riesce a stabilire l’irrorazione del rene o a rimuovere l’ostacolo delle vie urinarie. La morte può sopraggiungere per iperidratazione , insufficienza cardiaca, edema polmonare, ipertensione, encefalopatia, crisi convulsive, iperpotassiemia e arresto cardiaco.
Terapia
IRA postrenale: la terapia è fondamentalmente finalizzata a rimuovere l’ostacolo, perlopiù con interventi chirurgici sia palliativi sia definitivi o con manovre endoscopiche. Quando l’IRA è molto grave e le condizioni generali del paziente sono compromesse si può ricorrere alcune sessioni di emodialisi con lo scopo di migliorare le alterazioni biochimiche e metaboliche connesse con l’IRA e preparare così il paziente al successivo intervento chirurgico.
IRA prerenale: tende in genere a regredire spontaneamente quando migliorano le condizioni di perfusione renale. La terapia deve mirare a ristabilire un efficace apporto ematico al rene contrastando la causa iniziale dell’IRA.
IRA organica: la terapia dell’ IRA organica prevede misure conservative e sostitutive. La terapia conservativa deve essere mirata a correggere le alterazioni biochimiche e metaboliche e a prevenire le complicanze, soprattutto di tipo infettivo. Pertanto vanno controllate attentamente l’equilibrio idro-elettrolitico e il catabolismo azotato.
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