Nefroangiosclerosi
Table of Contents
Definizione
Si definisce nefroangiosclerosi la sclerosi (cioè dalla sostituzione di zone più o meno estese di tessuto renale da parte di tessuto connettivo) arteriolare dei reni, rapidamente progressiva associata ad ipertensione arteriosa diastolica permanente (140 mm Hg o più) ed edema papillare.
Eziologia
Ipertensione arteriosa di qualsiasi origine. La causa esatta del peggioramento dell’ipertensione è sconosciuta, ma è probabilmente renale. L’aumento della pressione e della vasocostrizione provocano lesioni endoteliali delle arteriole renali, trombosi piastriniche, depositi di fibrina; l’ischemia renale si aggrava e causa in circolo vizioso, che tende ad aumentare e a peggiorare la sindrome ischemica renale.
Anatomia patologia
Nella nefroangiosclerosi i reni sono di volume diminuito, pallidi, ischemici, con petecchie emorragiche. Al microscopio, si constata una necrosi fibrinoide delle pareti arteriolari, senza reazione infiammatoria. Questa necrosi fibrinoide può estendersi fino all’ ansa afferente del glomerulo e anche al glomerulo (glomerulonefrite necrotizzante); lascia cicatrici fibrose, concentriche “a bulbo di cipolla”, chiamate anche arteriolite iperplastica.
Sintomi
La nefroangiosclerosi è più frequente nell’uomo che nella donna, tra i 45-50 anni. Può sopraggiungere durante un’ ipertensione arteriosa secondaria, essenziale o di origine renale. Si osserva più raramente in un soggetto normoteso. Il malato accusa:
- Stanchezza
- Cefalee violente
- Lipotimia
- Perdite di coscienza
- Disturbi della vista (encefalopatia ipertensiva)
- Nausea
- Disturbi cardiaci (dispnea, palpitazioni, angor).
La pressione arteriosa diastolica è pari o superiore a 140 mmHg; la pressione sistolica supera spesso i 200 mmHg. L’esame del fondo dell’occhio rivela una retinopatia avanzata (stadio III o IV) con edema papillare. Sono presenti segni più o meno rari insufficienza cardiaca coronarica. Raramente si sviluppano insufficienza renale acuta con oligo-anuria.
Esami di laboratorio
Le urine presentano una proteinuria generalmente elevata, ematuria microscopica e a volte cilindri ematici e cerei; la velocità di sedimentazione accelerata pure in presenza di qualsiasi infezione. L’ azotemia e creatininemia sono aumentate. I tassi di renina e aldosterone sono molto aumentati.
Prognosi
La prognosi è negativa senza terapia. Vi possono essere gravi ripercussioni entro alcune settimane o mesi a causa di complicazioni cerebrovascolari, insufficienza cardiaca, infarto del miocardio, più raramente insufficienza renale. La nefroangiosclerosi è un’ urgenza medica da trattare precocemente per ridurre la mortalità e la frequenza delle complicazioni.
Diagnosi
Si basa sull’esistenza di un’ ipertensione diastolica stabile, associata a insufficienza renale progressiva e a retinopatia avanzata.
Terapia
Comporta al momento della diagnosi una fase ospedaliera seguita da una terapia ambulatoriale regolare rigorosamente controllata.
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