Fisiopatologia e diagnosi della sindrome cardio-renale: stato dell’arte e prospettive future

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Pubblicato il 31 ottobre 2013

Fisiopatologia e diagnosi della sindrome cardio-renale

Pathophysiology of Cardio-renal Syndrome

Fisiopatologia e diagnosi della sindrome cardio-renale: stato dell’arte e prospettive future

Pathophysiology and Diagnosis of Cardio-renal Syndrome: Actual Picture and Future Prospectives

Luca Di Lullo¹, Fulvio Floccari², Antonio De Pascalis³, Annibale Marinelli ⁴, Vincenzo Barbera¹, Alberto Santoboni¹, Moreno Malaguti², Alessandro Balducci⁵, Domenico Russo⁶, Rodolfo Rivera⁷, Antonio Gorini⁸, Claudio Ronco⁹

(1) UOC Nefrologia e Dialisi, Ospedale “L. Parodi, Delfino”, Colleferro
(2) UOC Nefrologia e Dialisi, Ospedale “San Paolo”, Civitavecchia
(3) UOC Nefrologia, Dialisi e Trapianto, Ospedale “V. Fazzi”, Lecce
(4) UOC Nefrologia e Dialisi “Ospedali Riuniti”, Anzio
(5) UOC Nefrologia e Dialisi, Azienda Ospedaliera “San Giovanni, Addolorata”, Roma
(6) Dipartimento di Nefrologia, Università degli Studi Federico II, Napoli
(7) Divisione di Nefrologia, Ospedale “San Gerardo”, Monza
(8) Consultant Nephrologist, Roma
(9) International Renal Research Institute, Ospedale “San Bortolo”, Vicenza
A cura del Gruppo di Studio di Cardionefrologia dellaSocietà Italiana di Nefrologia

Abstract

Con il termine di Sindrome Cardio-Renale (SCR) vengono evidenziate le strette correlazioni clinico-patologiche tra malattia renale ed interessamento cardiovascolare. La classificazione più recente permette di individuare cinque tipologie di sindrome cardio-renale, delle quali le SCR di Tipo I e di Tipo II riconoscono come primum movens lo scompenso cardiaco (acuto o cronico), mentre la SCR di Tipo III e la SCR di Tipo IV riconoscono come causa iniziale un danno di tipo renale. La SCR di Tipo V è, invece, correlata ad un ampio spettro di patologie secondarie (in primis collagenopatie).

La diagnosi di SCR si basa sia su dosaggi di laboratorio, sia su tecniche, come quelle ultrasonografiche, di diagnostica per immagini di I° livello. Oltre ai consueti dosaggi dei parametri di funzionalità renale e cardiaca, diversi nuovi biomarcatori sono stati testati per valutare il grado di funzionalità renale e cardiaca.

L’ecografia renale e l’ecocardiografia trans-toracica sono in grado di integrare le informazioni ottenute con il dosaggio dei parametri di laboratorio ed offrire un quadro di natura non solo funzionale, ma anche di tipo anatomico del coinvolgimento renale e cardiaco.

Abstract

The cardio–renal syndrome (CRS) indicates how close the relationship is between heart and kidney during failure of these organs. At present, the classification of the syndrome includes five types of CRS: types I and II which are strictly related to initial heart failure (both acute and chronic), types III and IV which include initial kidney failure, and type V which includes several systemic diseases. Many pathophysiological pathways have been described illustrating how heart and kidney disease are involved in clinical conditions.

The diagnosis of CRS is based on both blood tests and ultrasound imaging. Several biomarkers indicating levels of heart and kidney function have emerged over the last few decades which can be used to predict kidney failure in patients with acute or chronic heart disease. Kidney injury biomarkers have also to be tested, especially those indicating glomerular and tubular damage.

Renal ultrasound and trans-thoracic echocardiography can provide further information on heart and kidney failure in patients with cardio-renal syndrome at any stage.

Tabella 1. Classificazione delle Sindromi Cardio-Renali.

Tipo	Denominazione	Descrizione	Esempio
1	Cardiorenale acuta	Insufficienza cardiaca acuta che conduce ad IRA	Sindrome coronarica acuta che porta ad scompenso cardiaco acuto ed insufficienza renale
2	Cardiorenale cronica	Scompenso cardiaco cronico che conduce ad insufficienza renale	Scompenso cardiaco cronico
3	Nefrocardiaca acuta	IRA che conduce ad insufficienza cardiaca acuta	Cardiomiopatia uremica secondaria ad IRA
4	Nefrocardiaca cronica	IRC che conduce ad insufficienza cardiaca	Ipertrofia ventricolare sinistra e scompenso cardiaco diastolico secondari ad insufficienza renale
5	Secondaria	Patologie sistemiche che comportano insufficienza cardiaca ed insufficienza renale	Shock settico, vasculiti, diabete mellito

Tabella 2. Principali cause di insufficienza renale acuta in grado di causare la SCR di tipo 3.

Prototypical Condition
Contrast-induced AKI	Post-inflammatory GN
Drug-induced AKI	Rhabdomyolysis
Major surgery	Acute pyelonephritis
Cardiac surgery	Post-obstructive uropathy

Tabella 3. Fattori di rischio individuali per lo sviluppo di SCR di tipo 3.

Risk Modifying Factors
Age	Congestive heart failure
Sex	Pulmonary disease
Coronary artery disease	Chronic kidney disease
Hypertension	Systemic vascular disease
Hypercholesterolemia	Systemic immune disease
Diabetes mellitus	Infection/sepsis

Tabella 4. Fattori di rischio e correlazioni diagnostico-terapeutiche in corso di SCR di tipo 5 sepsi-correlata.

Caratteristiche del paziente	Percorso Terapeutico
Evento scatenante e risposta immunitaria	Rianimazione Effetto della volemia sull’edema dei tessuti e sull’ ipertensione venosa renale Sindrome compartimentale addominale Rimaneggiamento delle proteine del glicocalice
Patologia di base (cardiaca e renale)	Ricerca del focus patologico primitivo Impiego di mezzo di contrasto
Risposte fisiologiche Vasodilatazione periferica Risposta ormonale compensatoria Aumentata permeabilità vascolare Disfunzione mitocondriale ed ipossia tissutale Riempimento cardiaco Ipoperfusione renale	Dosaggio dei farmaci Antibiotici Sedativi Vasopressori ed inotropi
	Terapia di supporto Liquidi Inotropi, vasopressori
	Terapie specifiche Ventilazione meccanica Chirurgia Terapia sostitutiva della funzione renale

Tabella 5. Diagnosi differenziale tra SCR di tipo 5 ad evoluzione acuta e SCR di tipo 5 ad evoluzione cronica.

Caratteristiche	SCR-5 Acuta (Sepsi)	SCR-5 Cronica (Cirrosi)
Tempo necessario per il deficit organo/tessuto specifico	Breve: da ore a giorni	Prolungato: da settimane a mesi
Funzionalità d’organo (cuore/rene)	Si può sovrapporre ad una preesistente patologia renale e/o cardiaca	Cuore e rene mettono in atto risposte adattative che falliscono nel lungo periodo
Sequenza temporale nel coinvolgimento di cuore e rene	L’interessamento cardio-renale è simultaneo ovvero differisce di poche ore	La disfunzione di uno dei due organi precede nettamente quella dell’altro
Patologia di base	Si tratta di una patologia sistemica che conduce allo sviluppo di una SCR-5	Si possono verificare alcuni eventi clinici in grado di far precipitare acutamente un quadro cronico (ad es, un sanguinamento del tratto gastrointestinale può far precipitare una condizione di sindrome epato-renale)
Fisiopatologia	Effetti diretti a carico di cuore e rene	Fallimento a lungo termine dei meccanismi adattativi
Percorsi fisiopatologici	Determinati dalla patologia di base	Determinati dai processi adattativi
Reversibilità del quadro clinico	Possibile in caso di controllo del processo settico ed adeguato supporto degli organi coinvolti	Limitata finchè non si arriva alla sostituzione dell’organo interessata dalla patologia scatenante la SCR-5 (ad es, trapianto di fegato)

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pubblicata il 31 ottobre 2013
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Parole chiave: Biomarcatori, Ecocardiografia, Ecografia renale, Insufficienza cardiaca, Insufficienza renale acuta, Malattia renale cronica, Sindrome cardio-renale

Key words: Acute kidney injury, Biomarkers, Cardio – Renal Syndrome, Chronic Kidney Disease, Echocardiography, Heart failure, Kidney Ultrasound

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Fisiopatologia e diagnosi della sindrome cardio-renale: stato dell’arte e prospettive future

Fisiopatologia e diagnosi della sindrome cardio-renale

Pathophysiology of Cardio-renal Syndrome

Fisiopatologia e diagnosi della sindrome cardio-renale: stato dell’arte e prospettive future

Pathophysiology and Diagnosis of Cardio-renal Syndrome: Actual Picture and Future Prospectives

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