L’insufficienza renale cronica (IRC) è una condizione patologica caratterizzata dalla perdita irregolare della funzione renale che richiede un trattamento sostitutivo rappresentato dalla dialisi o dal trapianto del rene. Con il termine malattia renale cronica (MRC) si indica invece ogni condizione patologica caratterizzata da fenomeni infiammatori o sclerotici che interessano i reni, che possono, nel tempo, provocare una riduzione della funzione renale avendo una naturale tendenza verso l’insufficienza renale cronica. La riduzione della funzione renale conseguente alla MRC si associa ad un corteo di segni e sintomi clinici racchiusi nel termine generico uremia.
Fisiopatologia
Il rene ha capacità di adattamento eccezionali; in effetti l’uremia (aumento dell’azotemia e della creatininemia) si manifesta quando la filtrazione glomerulare è inferiore al 30%. L’uremia diventa molto grave quando la filtrazione glomerulare è del 10% e lo stadio terminale è raggiunto con una filtrazione glomerulare del 5%. In questa situazione, i nefroni che rimangono dovrebbero teoricamente potere filtrare l’acqua e i differenti soluti ( azoto, creatinina, sodio, potassio, fosforo) ad un tasso 20 volte superiore alla norma per poter mantenere l’equilibrio interno. L’aumento di queste diverse sostanze nel sangue dipenderà dalla capacità dei nefroni rimanenti di aumentare la filtrzione glomerulare e dall’equilibrio tra la funzione glomerulare e tubolare.
Sintomi
Podromi:l’insufficienza renale può rimanere asintomatica per anni e rivelarsi con :
Stanchezza
Dimagrimento
Impotenza nell’uomo
Perdita di libido nella donna
La nicturia può essere un segno precoce
Periodo di stasi:
Manifestazioni cutanee: la pelle si decolora o prende un colore caffè-latte. Prurito a volte insopportabile
Manifestazioni neurologiche: depressione, polinevrite, confusione, agitazione, coma uremico
Disturbi neuro-muscolari: crampi muscolari, parestesie agli arti inferiori, fascicolazione muscolare, crisi di tetania
Disturbi digestivi: alito fetido con odore di urina, nausea, vomito, stomatite, esofagite, gastrite, colite, emorragia gastrointestinale
Disturbi ossei:dolori ossei, fratture patologiche per osteomalacia.
Quali sono le cause dell´IRC?
L´IRC è causata da una serie di condizioni e malattie che colpiscono i reni. Alcune di queste sono presenti alla nascita (malformazioni dei reni o delle vie urinarie), altre invece, iniziano più tardi durante l’infanzia (glomerulopatie). Talvolta, l’IRC può essere secondaria ad una patologia sistemica, ovvero che interessa diversi organi tra cui i reni (vasculite). Non tutte le patologie renali causano IRC, e non tutti i bambini con IRC progrediscono agli stadi successivi con la stessa rapidità.
Terapia dietetica e farmacologica
La terapia conservativa deve mirare soprattutto a ridurre l’apporto proteico per limitare la produzione giornaliera di cataboliti azotati. E’ preferibile iniziare la dieta ipoazotata in epoca molto precoce allo scopo di ritardare il peggioramento progressivo della funzione renale. Infatti, un sovraccarico proteico determina uno stato di ipefiltrazione glomerulare che, sebbene rappresenti un meccanismo di compenso per eliminare le scorie azotate, accelera la perdita dei nefroni residui.
L’altro cardine della terapia conservativa è rappresentato da interventi farmacologici mirati a ridurre l’iperfiltrazione glomerulare. Questo si può ottenere con l’impiego di farmaci che inibiscono il sistema renina-angiotensina quali gli ACE-inibitori e/o gli antagonosti recettoriali dell’angiotesina. L’associazione dei due farmaci sembra essere più efficace.
Emodialisi
Le metodiche dialitiche sono rappresentate dall’emodialisi extracorporea e dalla dialisi peritoneale. Nell’emodialisi si effettuano sedute periodiche depurative nelle quali il sangue del paziente circola attraverso un circuito extracorporeo comprendente un filtro di dialisi. L’obiettivo di ogni seduta dialitica è infatti quello di eliminare le scorie e l’acqua accumulatesi nell’organismo durante il tempo intercorso dall’ultima seduta.
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