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Fisiopatología de la insuficiencia renal aguda durante la sepsis

Regueira, T.; Andresen, M.; Mercado, M.; Downey, P.

Publicado en Med Intensiva. 2011;35:424-32. - vol.35 núm 07

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Resumen

La insuficiencia renal aguda (IRA) es un factor de riesgo independiente asociado a mayor mortalidad durante la sepsis. Definiciones de consenso recientes han permitido estandarizar los trabajos de investigación en el tema. La comprensión de la fisiopatología de la IRA durante la sepsis está limitada por la escasez de estudios histológicos y por la imposibilidad de medir los flujos microcirculatorios renales. Históricamente se ha considerado a la IRA séptica como una patología dependiente de la caída del flujo sanguíneo renal (FSR). Efectivamente, en las etapas precoces de la sepsis o en la sepsis acompañada de shock cardiogénico existe compromiso del FSR; sin embargo, estudios recientes han demostrado que en la sepsis reanimada, aquella en que característicamente se observa un gasto cardiaco normal o alto y vasodilatación sistémica, el FSR es normal o incluso aumentado y no existe evidencia histológica significativa de necrosis tubular. Otros factores, distintos al puramente hemodinámico, participan en la génesis de la IRA en la sepsis. Entre éstos están la apoptosis celular, los trastornos microcirculatorios glomerulares y medulares, los cambios celulares en respuestas a la cascada proinflamatoria propia de la sepsis, el estrés oxidativo, la disfunción mitocondrial y el daño a distancia inducido por ventilación mecánica, entre otros. En la actualidad, el tratamiento de la IRA en la sepsis es de soporte. En general, las terapias de reemplazo renal pueden ser clasificadas como intermitentes o continuas, y en las que buscan primariamente el reemplazo de la función renal deteriorada, frente a aquellas cuyo objetivo principal es lograr la estabilidad hemodinámica de los pacientes mediante la remoción de mediadores proinflamatorios.

Palabras clave Sepsis. Insuficiencia renal aguda. Flujo sanguíneo renal.

Introducción

Epidemiología La incidencia de insuficiencia renal aguda (IRA) en los pacientes críticos es variable según la definición utilizada y la población estudiada, pero oscila entre el 35 y el 50%¹. La sepsis y su forma más severa, el shock séptico, son las principales causas de IRA en las unidades de cuidados intensivos (UCI), correspondiéndoles hasta el 50% de los casos². La mortalidad de la sepsis sigue siendo alta, particularmente cuando se asocia a disfunción de órganos, como la IRA, donde alcanza valores del 20 al 35%, o en presencia de compromiso hemodinámico, con una mortalidad promedio del 60%. El desarrollo de IRA durante la sepsis es un factor de riesgo independiente asociado a mayor mortalidad²; de hecho, el estudio FRAMI, realizado en 43 UCI españolas, mostró que la aparición de IRA en paciente críticos se asocia en forma independiente a mayor mortalidad, con un OR de 2,51³. Definición Hasta hace poco no existía claridad en una definición de consenso para la IRA en la sepsis. Recientemente el grupo ADQI (Acute Dialysis Quality Initiative) propuso una clasificación diagnóstica de consenso que ha sido favorablemente recibida por los clínicos y ha permitido estandarizar los trabajos de investigación en el tema⁴, y dicha clasificación recibe el acrónimo de RIFLE (del inglés Risk, Injury, Failure, Loss, and End-stage Kidney failure) (Tabla 1). Los pacientes se clasifican de acuerdo a la pérdida de filtración glomerular (FG) (respecto al basal de cada paciente) y/o de flujo urinario (FU) normal en cinco categorías (eligiendo el criterio que arroje la peor...

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Regueira, T.^a; Andresen, M.^a; Mercado, M.^a; Downey, P.^b

^aDepartamento de Medicina Intensiva, Hospital Clínico Universidad Católica de Chile, Pontificia Universidad Católica de Chile, Santiago, Chile

^bDepartamento de Nefrología, Hospital Clínico Universidad Católica de Chile, Pontificia Universidad Católica de Chile, Santiago, Chile