Lo studio eseguito su una popolazione anziana affetta da scompenso cardiaco, ha consentito di individuare risultati significativi dal punto di vista statistico.
Il Test T a campioni appaiati ha individuato un differente andamento dei parametri ematochimici all’interno del gruppo che aveva sospeso il trattamento con diuretici dell’ansa (F-).
La riduzione significativa dei livelli ematici di creatinina e l’aumento della sua clearance indicano un miglioramento della funzione renale nel gruppo “F-“.
Gli altri risultati, pur non avendo raggiunto una significatività statistica, permettono di fare alcune considerazioni.
Rimanendo all’interno della popolazione che aveva sospeso la terapia con Furosemide, si evidenzia una riduzione dell’azotemia alla dimissione rispetto all’ingresso. Funzionalmente l’azotemia è indicativa dell’allerta dei recettori di volume conseguente all’ipovolemia e/o alla riduzione del volume effettivo circolante.
Una deplezione iatrogena del volume circolante effettivo è il meccanismo che sta alla base del peggioramento della funzionalità renale e dell’aumentata mortalità 133.
L’ipovolemia conseguente a riduzione della gittata cardiaca inizialmente stimola il RAAS cui consegue l’increzione di peptide natriuretico atriale, con conseguente aumento del riassorbimento di sodio che da’ ragione della ridotta escrezione sodica osservata negli stati di contrazione del volume 28. Ciò evidenzia l’attitudine del rene a ripristinare la volemia e l’equilibrio idroelettrolitico, a seguito della disidratazione eccessiva che fa seguito alla
49
somministrazione di alte dosi di diuretici là dove, com’è il caso dello scompenso, esiste già una riduzione del volume circolante effettivo.
Nell’ipovolemia di grado elevato, come spesso riscontrato nei pazienti in corso di terapia diuretica, la ritenzione di sodio è favorita dalla riduzione del GFR e dall’aumento del riassorbimento dello ione nel tubulo prossimale, nel tratto sottile dell’ansa di Henle per azione dell’angiotensina II e della noradrenalina e nelle porzioni distali del tubulo di pertinenza dell’aldosterone28. Quindi la riduzione dell’azotemia e della creatininemia potevano nel nostro caso ben essere ascritte a un miglioramento del volume effettivo circolante.
La riduzione del BNP, che attualmente è uno degli indici per valutare lo stato di “scompenso”, sta ad indicare una ridotta distensione della muscolatura parietale cardiaca ed una riduzione del precarico.
L’analisi dei risultati ottenuti con il Test T a campioni appaiati nei pazienti che potevano continuare terapia con diuretici dell’ansa (F+), evidenzia come la terapia con la Furosemide condizioni il perdurare dello stimolo ipovolemizzante a prescindere dai valori dell’escrezione frazionale del sodio, stabilmente intorno al 2%.
Alla dimissione si nota solo una non significativa riduzione della creatininemia, dell’azotemia, della PCR, del fibrinogeno e del D-dimero. La riduzione non significativa della PCR, del Fibrinogeno e del D-Dimero, che alla dimissione riguardava ambedue i gruppi, è ascrivibile ragionevolmente alla riduzione dello stato “reattivo” in ambedue i gruppi di pazienti.
I frammenti F1+2 e la generazione endogena di trombina mostravano un aumento in ambedue i gruppi di pazienti che, soprattutto per il caso della generazione endogena di trombina, potrebbero essere associati a un
recupero della totale competenza emostatica apparentemente compromessa a causa della congestione epatica. Le γGT infatti erano modestamente aumentate in ambedue i gruppi di pazienti.
I limiti di questo studio sono rappresentati dalla impossibilità di osservare i pazienti oltre i normali tempi di recupero e alcuni dati di laboratorio (clearance acqua libera ed escrezione frazionale del sodio) non si sottraggono a questo limite. Nei pazienti che erano stati sollevati dalla terapia diuretica per gli elevati livelli di potassiemia e per l’evidente ipoperfusione, anche la somministrazione di ACE inibitori, β-Bloccanti e Antialdosteronici doveva essere obbligatoriamente soppressa. In questi la sola idratazione e l’uso di nitroderivati ha consentito i risultati di cui diamo l’evidenza.
In questi pazienti al momento della dimissione o nei giorni immediatamente precedenti era possibile reintrodurre dosi adeguate di ACE inibitori, Antialdosteronici, β-Bloccanti e dosaggi modesti di diuretici dell’ansa, terapia che nei controlli successivi avrebbe permesso di apprezzare dal punto di vista clinico un compenso adeguato.
51
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