Fattori di rischio per insufficienza renale acuta nella VL umana (Brasile)

Le alterazioni renali da Leishmania sono state ben documentate in studi animali sperimentali e sono costituite da modificazioni interstiziali e glomerulari. Ma sono stati pubblicati pochi studi sulla funzione renale nella VL. Il meccanismo patofisiologico principale attraverso cui la VL colpisce i reni comprende probabilmente la patologia da immunocomplessi, come avviene in altre parassitosi come la malaria e la schistosomiasi. La maggior parte dei pazienti presenta una glomerulonefrite proliferativa ed una nefrite interstiziale. Le possibili cause di danno renale acuto nella VL sono la tossicità farmacologica, le infezioni intercorrenti, le anomalie emodinamiche e la leishmaniosi stessa.

Scopo di questo studio è stato di investigare la prevalenza, le manifestazioni cliniche ed i fattori di rischio associati ad insufficienza renale acuta nei pazienti affetti da VL.I soggetti sono stati trattati con iniezioni endovenose di Glucantime® (AnM, 20 mg/kg/die per 20-40 giorni) e, nei casi gravi, di amfotericina B (AmB, dose totale 7-20 mg/kg fino a 20 giorni); ai pazienti con infezioni secondarie sono stati somministrati antibiotici. Sono stati inclusi 224 soggetti (età 36 ± 15 anni, range 15-84) di cui il 76,8% erano maschi.

L'insufficienza renale acuta (IRA) è stata osservata in 76 pazienti (33,9%) di cui l'85,5% erano maschi e 26 (34,2%) avevano una creatininemia superiore a 1,4 mg/dl al momento dell'accesso in ospedale; 39 soggetti (51,3%) hanno sviluppato IRA entro una media di 10 giorni dall'inizio della terapia con AmB, 7 (9,2%) con AnM e 4 (5,3%) per altre cause. I pazienti in IRA rispetto a quelli non-IRA hanno mostrato livelli superiori di BUN, creatininemia, kaliemia, bilirubinemia diretta ed indiretta e WBC; mentre livelli inferiori di natriemia, bicarbonatemia, pCO2, albuminemia, piastrinemia e tempo di protrombina. I fattori chiaramente associati ad IRA sono risultati il genere maschile, l'età avanzata, l'ittero e la somministrazione di AmB. Questo farmaco nefrotossico in Brasile è la seconda scelta nei casi di VL. È stata osservata un'associazione significativa tra il suo utilizzo e l'IRA nei pazienti che non avevano risposto all'AnM: l'IRA è stata osservata in 39 soggetti trattati con AmB (l'82,9% dei trattati col farmaco, ovvero il 17,4% di tutti i soggetti). Il 20,9% ha ricevuto AnM e AmB; tutti i pazienti trattati con AmB avevano le creatininemia normale all'ammissione; la somministrazione di AnM è stata associata con una minore incidenza di IRA (AmB: 39 pazienti IRA [51,3%], 8 non-IRA [5,4%]; AnM: 37 IRA [48,7%], 140 non-ira [94,6%]). La mortalità totale è risultata del 13,3% (30 soggetti), significativamente più alta nei pazienti IRA (23 [30,2%]) rispetto ai non-IRA (7 [3,1%]). I fattori di rischio di morte sono risultati la somministrazione di AmB, l'oliguria, l'ittero e la dispnea.

Il coinvolgimento renale nella VL è considerato raro e si presenta con ematuria, proteinuria od alterazioni della funzionalità renale. In letteratura esistono scarse informazioni sull'associazione IRA – VL. Uno studio ha rilevato alterazioni renali in solo 1 paziente su 11 (11%) considerando la creatininemia > 1,4 mg/dl. Il presente studio ha rilevato un'incidenza superiore di IRA (33,9%) nei pazienti con diagnosi di VL accertata. In uno studio recente le alterazioni renali (creatininemia > 1,3 mg/dl) sono state riscontrate nel 26,2% di 57 pazienti con VL. In un altro lavoro è stata riscontrata una diminuzione di GFR nel 28% di 50 soggetti e la causa è stata attribuita alla perdita di liquidi, alla contrazione del volume ed alla patologia glomerulare immunomediata.

HCO3 e pCO2 sono risultati inferiori nei pazienti IRA, suggerendo un'alta incidenza di acidosi metabolica probabilmente secondaria alla disfunzione renale. Uno dei dati salienti emersi dallo studio è la forte associazione tra AmB (non liposomiale) ed IRA: i pazienti trattati con AmB hanno un rischio 18 volte superiore di andare in IRA. Questo è emerso anche in altri lavori con percentuali dei pazienti trattati con AmB ed andati incontro ad IRA che oscillano intorno all'80%.

(Risk factors for acute kidney injury in visceral leishmaniasis (Kala-Azar) – Oliveira MJ, Silva Júnior GB, Abreu KL, Rocha NA, Garcia AV, Franco LF, Mota RM, Libório AB, Daher EF – Am J Trop Med Hyg. 2010;82(3):449-53 [abstract])

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Ultima modifica: 22 giugno 2010 @ 20:17 10''

11 commenti a “Fattori di rischio per insufficienza renale acuta nella VL umana (Brasile)”  

  1. 1 Laura

    Tutte le caratteristiche che dovrebbe avere il farmaco per la cura della Leismania sono rappresentate da quelle del farmaco momeopatico unitario, cioè al simillimum del paziente!
    e’ ora di finirla di proporre sempre come una unica e valida opzione terapeutica quella tradizionale e solo per puri interessi economici!!!!!!!!!!!!!!!!!!!!!!
    Per non parlare del vaccino per la Leismania!

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