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Cockcroft-Gault equation
MDRD Equation
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The Cockcroft-Gault equation allows the creatinine clearance to
be estimated from the serum creatinine in a patient with a stable
-/+%*%#-+!5+//%!-*+%')#)#%!)#!*+/%2)(#+!%!4%&&%!-(*$(*+%3!-*+%')#)#%!&)+*)-%!+5!
serum creatinine:
NKF's KDOQI
+'>8! clinical practice guidelines recommend the
Modification(140
of -Diet
age) xinlean
Renal Disease
body weight [kg]
CCr (mL/min) =
(MDRD) Study equation
Cr [mg/dL] tox 72estimate GFR
!
T#B%/'+*#%'),%!?!/%!X_`_G!
This formula takes into account the increase in creatinine
GFR, in mL/min
production per 1.73 weight,
with increasing m2 = 175 andxthe
SCr (exp[-1.154])
decline X
in creatinine
production with age. For women, multiplication by 0.85 is
required
Age to account for smaller
(exp[-0.203]) X (0.742muscle massxcompared
if female) to men.
(1.21 if black)
!
The equation is not adjusted for body surface area. Therefore to
! compare normal values, the calculation should be adjusted for
body
w surface area. Normalization for body surface increases the
ww.kidney.org/professionals/KLS/gfr_calculator.cfm
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accuracy of this equation, particularly among those with
nephron.com/mdrd/default.html
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decreased renal function.
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The commonly utilized estimation equations are less accurate in individuals
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with normal GFR, children, elderly patients, specific ethnic groups, pregnant
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Common Causes of Glomerular Proteinuria
Cause Renal Manifestation Clinical Presentation Laboratory/Imaging
Diabetes mellitus type 1/type 2 Ranging from microalbuminuria to nephrotic Polyuria, polydipsia, nocturia, Fasting plasma glucose 126 mg/dL (7.0
range proteinuria; most common etiology of weight loss mmol/L). Increased HbA1c.
end-stage renal disease in the US
Hypertension Microalbuminuria Often asymptomatic (excluding Other possible signs of hypertensive
hypertensive crisis)! injury
Crescentic glomerulonephritis *Proteinuria with an active urinary sediment and Sign or symptoms of uremia Increased creatinine and BUN levels.
decreased GFR Hypertension. ANCA and anti-GBM
antibodies
Multiple myeloma SCr is increased in 50% of patients15; urine Pallor, radiculopathy, peripheral Monoclonal protein in serum and/or
protein is not detected on urine dipstick; neuropathy, bone pain in the back protein electrophoresis, lytic lesions
sulfosalicylic acid test and UPCR detect or chest is present in 60% of and fractures on x-ray, hypercalcemia
proteinuria patients27
Light chain deposition disease Most commonly associated with multiple Related to renal, cardiac, or Tissue deposition of kappa light chains,
myeloma; in rare cases it is occurs with hepatic involvement urinary light chain excretion
lymphoma
Primary amyloidosis Nephrotic syndrome with or without renal Peripheral neuropathy, Amyloid deposition on biopsy;
insufficiency macroglossia, hepatomegaly evidence of a clonal plasma cell
proliferative disorder
HIV nephropathy Nephrotic syndrome, slowly progressive renal More common in African- HIV positive
dysfunction American patients; edema
Immunoglobulin A nephropathy From urine abnormalities to nephritic syndrome Hematuria Renal immunoglobulin A deposition;
active urine sediment
Minimal change disease, FSGS Nephrotic syndrome Edema, anasarca, foamy urine Hypercholesterinemia,
membranous glomerulonephritis hypoalbuminemia, proteinuria;
diagnostic renal biopsy findings
Streptococcal glomerulonephritis Ranging from microscopic hematuria to acute Recurrent episodes of hematuria Kidney biopsy shows proliferative
nephritic syndrome glomerulonephritis
Other forms of glomerulonephritis, Proteinuria with or without an active urinary Depending on underlying disease ANA, complement C3 and C4, VDRL,
infectious or systemic diseases sediment (red blood cell casts, dysmorphic hepatitis serology, cryoglobulins
erythrocytes)!
!
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< Proteineplasmatiche
Proteine plasmatiche
<#"#$)3')'6(,-$"&1%"C'%'#:)
nella sindrome
nella sindromenefrosica nefrosica
E%!$*('+)#1*)%!%/!5)!&($*%!5+)!K3S!7!5+0)#)&-+!/%!&)#5*(4+!#+0*(&)-%!%#-.+!&+!'1'')!7/)!%/'*)!
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&)+*)-(!#+/!$%2)+#'+!-(#!&)#5*(4+!#+0*(&)-%G!
< transferrina !
< transferrina
<< albumina
albumina < transcortina
< transcortina !
<< !1
!1 globuline
globuline
< TGB,
< TGB, < T4
< T4
>> !2
!2 ee " globuline
globuline
< vitamin D-binding protein
< vitamin D-binding protein!
Immunoglobuline
Immunoglobuline Complemento
Complemento
<< IgG
IgG
< fattore B B !
+/- >> IgA, < fattore
+/- IgA, IgM,
IgM,IgEIgE < C3, C4bp
< proteine di trasporto < C3, C4bp !
< proteine di trasporto < C1q, C2, C8,C8,
Ci Ci
dei metalli
metalli (Fe, < C1q, C2,
dei (Fe,Cu,
Cu,Zn)
Zn) < C4
< eritropoietina < C4 !
< eritropoietina >/- C1s, C4, inibitore di C1
>/- C1s, C4, inibitore di C1
!
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$%2)+#'+!4%!$(&&(#(!%#-.+!$*+,%/+*+!/B1#%!&1//B%/'*%8!H+*!+&+4$)(3!#+)!$%2)+#')!)#!-1)!-B?!
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$%'(/(7)%3!&)!.%!1#%!&)'1%2)(#+!5)!'6(,7$%(/'"!-.+!$*+,%/+!&1//%!*)512)(#+!5+//%!
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$*+,%/+#'+4+#'+8!"#!:1+&')!$%2)+#')!/B1&(!5+)!5)1*+')-)!#(#!-(4$(*'%!7*(&&)!$*(6/+4)8!
b+)!$%2)+#')!-(#!$*+,%/+#2%!5+//%!*)512)(#+!5+//%!$*+&&)(#+!(#-(')-%3!/%!&)'1%2)(#+!?!
)#,+-+!:1+//%!5)!)$(,(/+4)%3!+!/B%''),%2)(#+!5+)!&)&'+4)!5)!-(4$+#&(!&(5)(<*)'+#'),)!?!1#%!
Diagnosi
-$*0(&1(*2")3(%%51*3(,+'%%'*&G!%//(*%3!)!5)1*+')-)!5+,(#(!+&&+*+!)4$)+7%')!-(#!-%1'+/%!+!
$*+,)%!+&$%#&)(#+!$/%&4%')-%!($$(*'1#%8!L1+&')!$%2)+#')!.%##(!6%&&)!/),+//)!5)!MbH8)
Ipoalbuminemia
Perdita di albumina Ridotta
con le urine Edema Ritenzione di sodio
pressione oncotica
Soppressione della
sintesi epatica di albumina
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'+#5+!%5!%14+#'%*+!/%!&)#'+&)!5)!%$(/)$($*('+)#+!5)!')$(!hE_E!+!*%//+#'%!)/!-%'%6(/)&4(!
5+//+!E_E3!5+'+*4)#%#5(!1#!%&&+''(!6,$"#(,$&(*'-$8!M#-.+!/%!&)#'+&)!5+)!0%''(*)!5+//%!
Sindrome Nefrosica
Proteinuria > 3.5 g nelle 24 ore, accompagnata da edema,
-(%71/%2)(#+!%14+#'%3!4+#'*+!,+#7(#(!$+*&)!-(#!/+!1*)#+!)!0%''(*)!)#)6)'(*)!0)&)(/(7)-)!
ipoalbuminemia (<2,5 g/dl), iperlipidemia and lipiduria.
5+//%!-%&-%'%!-(%71/%'),%3!-(#!-(#&+71+#'+!&'%'(!6,$#,$/C$#'-$8
Perdita di IgG e di Proteinuria Perdita della globulina
complemento legante il colecalciferolo
Trombosi
Embolia Polmonare Instabilit cardiovascolare
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MCD 76% 20% 20%
GSF 8% 15% 2%
GN membranosa 7% 40% 39%
MPGN 4% 7% --
altre 5% 18% 39%
Nefropatia diabetica
Amiloidosi renale
Cause rare
glomerulopatia fibrillare malattia da deposito di catene leggere
pre-eclampsia forme post-infettive e para-infettive
neoplasie (in genere MCD) malattie sistemiche (LES, altre
collagenopatie, vasculiti)
GN eredofamiliari (sindrome di Alport, nail-patella sindrome)
Reazioni allergiche (farmaci, veleni, punture di insetti, antigeni inalati)
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A modification of the RIFLE criteria has been proposed by the Acute Kidney Injury
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Network. The AKIN proposed both diagnostic criteria for ARF and a staging
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!
* Modified from RIFLE (Risk, Injury, Failure, Loss, and End-stage kidney disease) criteria. The staging system
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Ipoperfusione renale
SI NO
!
Diagnosi differenziale della Insufficienza Renale Acuta
pre-renale renale
(funzionale)! (organica ischemica)!
La risoluzione della ostruzione provoca rapida ripresa della funzione renale, eccetto
che nel caso in cui la ostruzione sia stata molto protratta ed abbia provocato danni
irreversibili al parenchma renale (danno ischemico da compressione operato dalla
sovradistensione della pelvi e dei bacinetti)!
!
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O)#'(4)!
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Ipertensione glomerulare
Nel diabetico si verifica, fin dallinizio della malattia, prima che insorga la
microalbuminuria, un aumento del GFR. Il fenomeno, che si associa ad
ipertrofia dei glomeruli ed aumento del volume dei reni, pi evidente nel
diabete tipo 1.
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GN Membranoproliferativa
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segmentale Cvasculiti
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< H%2)+#')!(6+&)!
< \(%71/($%')+!
< k1#2)(#+!*+#%/+!5+'+*)(*%'%!
< `+#+!$)--(/(!Y$+*-.[!)#5)-%'),(!5)!$%'(/(7)%!-*(#)-%!)**+,+*&)6)/+Z!
< V14(*)!*+#%/)!Y*)&-.)(!5)!)#&++5)#7Z!
< H%2)+#')!#(#!5)&$(&')!%!-(($+*%*+!
< "#0+2)(#)!*+#%/)!(!$+*)*+#%/)!
< h%&-1/)')!-(#!41/')$/)!%#+1*)&4)!)#'*%*+#%/)!
>9 `%$/(,1%$*(+,'#')*$*)6,$%'+(,"#'7()
< `%$/(,1%$*(+,'#()/(/C,"*$0")
< `%$/(,1%$*(+,'#()")%(0'$*')/'*'/()
Glomerulonefrite membranosa
< `%$/(,1%$0-%(,$0')+$-"%()0(&/(*#"%()
`%$/(,1%$*(+,'#()/(/C,"*$0")
La glomerulonefrite membranosa una malattia immunologica
anticorpo-mediata nella quale gli immunocomplessi si localizzano sul
a&(*5)&-+!:1%&)!&+4$*+!-(4+!1#%!&)#5*(4+!#+0*(&)-%3!(!-(41#:1+!-%1&%!1#%!
versante sottoepiteliale del capillare glomerulare, tra la membrana
$*('+)#1*)%!7*%,+8!H1N!+&&+*+!$*+&+#'+!+4%'1*)%3!4%!4%)!5)!7*%5(!)4$(*'%#'+G!
basale ed il podocita.
1#B+4%'1*)%!&+*)%!-)!-(#&+#'+!7)>!5)!+&-/15+*+!/%!^b!4+46*%#(&%8!!
!
Nel primo stadio anche a maggior Tuttavia, pur in assenza di evidenti
ingrandimento le pareti capillari depositi al microscopio ottico, !
non presentano evidenti aspetti di l'immuno-fluorescenza
ispessimento o evidenti depositi caratterizzata da depositi
sottoepiteliali. fluorescenti diffusi lungo la
membrana basale, con aspetto
finemente granulare o simil-
lineare.
!
_+-(*&(!
L)g*)#(,2$)3(')6"2'(*#')7")'*-$*#,$)"),(/'00'$*()06$*#"*(")#+/!7)*(!5)!1#!%##(U1#!
%##(!+!4+22(C!:1+&'%!?!1#%!$*(,%!5+//%!&+-(#5%*)+'>!5+//%!4%/%'')%G!*)4(&&(!/(!&')4(/(!D!
%#-.+!)#%,,+*')'%4+#'+!D!&+!#+!,%!%#-.+!/%!4%/%'')%8!
L)g*)#(,2$)3(')6"2'(*#')07'%166")1*)a1"3,$)-,$*'-$)3')*(+,$0')-.()*$*)6,$&,(3'0-()
7(,0$)%5'*01++'-'(*2"),(*"%()#(,/'*"%(9)
L)g*)#(,2$)3(')6"2'(*#')7")'*-$*#,$)"3)'*01++'-'(*2"),(*"%()#(,/'*"%(9)
O)--(4+!1#!'+*2(!5+)!$%2)+#')!,%!)#!*+4)&&)(#+!&$(#'%#+%3!&)!'+#5+!%!#(#!'*%''%*+!&16)'(!
/%!4%/%'')%3!$*($*)(!#+//B+,+#'1%/)'>!-.+!&)!'*%'')!5)!1#%!0(*4%!&+-(#5%*)%!/%!-1)!(*)7)#+!
&)%!5%!*)-+*-%*+8!L1+//(!-.+!#(#!4%#-%3!$+*N3!?!/%!'+*%$)%!-(#!M\a<"!+!&%*'%#)3!4)*%'%!%!
*)51**+!/%!$*('+)#1*)%8!O+!+#'*(!51+!%##)!#(#!&)!('')+#+!*+4)&&)(#+!Y(!)#!-%&(!5)!0(*4+!
%77*+&&),+Z!&)!$1N!$+#&%*+!5)!'*%''%*+!)/!$%2)+#'+!-(#!&'+*()5)!+5!)441#(&($$*+&&(*)C!
(77)!&)!1')/)22%!4(/'(!)/!*)'1g)4%6!YX%6V.+*%Z3!%#')-(*$(!4(#(-/(#%/+!%#')<\_IP!-.+!&)!
&'%!*),+/%#5(!$)1''(&'(!+00)-%-+8!
O"%"##'")")%(0'$*')/'*'/()
M#-.+!:1+&'(!?!1#!:1%5*(!#(#!$*(/)0+*%'),(3!+!&)!,+5+!#+)!6%46)#)G!$1N!+&&+*+!%&&(-)%'%!
%!/+1-+4)+!+!/)#0(4)!+!&)!$*+&+#'%!-(#!4%77)(*+!0*+:1+#2%!#+7/)!%'($)-)!)4$(*'%#')8!
V)$)-%4+#'+3!)/!6%46)#(!&)!$*+&+#'%!7(#0)(3!+5+4%'(&(!+!,)+#+!*)-(,+*%'(8!_1*%#'+!
:1+&'(!$*)4(!+$)&(5)(!#+0*(&)-(!%-1'(3!&$+&&(!,)+#+!)4$)+7%'%!1#%!'+*%$)%!+g!)1,%#')61&!
-(#!1#(!&'+*()5+3!5($(5)-.[!)/!6%46)#(!,%!)#!*+4)&&)(#+8!H1*'*($$(3!$+*N3!&(/(!)/!IPR!
5+)!6%46)#)!71%*)&-+G!)!*+&'%#')!%,*%##(!*+-)5),+8!M/-1#)!$%2)+#')3!5($(!1#!-+*'(!#14+*(!
5)!*+-)5),+!D!&$+&&(!&-%'+#%'+!5%!+$)&(5)!)#0+''),)!<3!%#5*>!5+0)#)'),%4+#'+!)#!*+4)&&)(#+8!
97#)!*+-)5),%!$1N!+&&+*+!'*%''%'%!+00)-%-+4+#'+!-(#!7/1-(-(*')-()5)3!5%!:1)!/B)5+%!
'*%5)2)(#%/+!-.+!:1+&'%!0(*4%!5)!^b!&)%!&1!6%&+!)441#(/(7)-%8!\.)%*%4+#'+3!5($(!1#!
$+*)(5(!5)!-%*)-(!+!5)!4%#'+#)4+#'(3!&)!'+#'%!5)!*)51**+!)/!5(&%77)(!0)#(!%//%!&(&$+#&)(#+8!
X(/')!6%46)#)3!%//%!&(&$+#&)(#+!5+//(!&'+*()5+3!*)4%#7(#(!/)6+*)!5%!$*('+)#1*)%!+!
,),*%##(!6+#)&&)4(!0)#(!%5!1#%!+,+#'1%/+!&1--+&&),%!*+-)5),%!D!-(4+!&)!5)-+,%3!:1%&)!
&+4$*+!&-%'+#%'%!5%!)#0+2)(#)8!T#!-+*'(!#14+*(!5)!6%46)#)3!$+*N3!5),+#'%!&'+*()5(<
5)$+#5+#'+8!"#!:1+&'(!-%&(3!$+*!+,)'%*+!5)!+--+5+*+!-(#!/(!&'+*()5+!)#!1#!(*7%#)&4(!)#!
-*+&-)'%3!&)!1')/)22%#(!7/)!)441#(&($$*+&&(*)!-(4+!&'+*()5<&$%*)#7!%7+#'&8!a&)&'(#(!$()!)!
$%2)+#')!0#(,$'3$L,(0'0#(*#'G!7+#+*%/4+#'+!/%!&'+*()5(<*+&)&'+#2%!&)!4%#)0+&'%!%5!)#)2)(!
'+*%$)%3!4%!+&)&'(#(!%#-.+!-%&)!5)!&'+*()5(<*+&)&'+#2%!%-:1)&)'%!)#!-(*&(!5)!'+*%$)%8!"#!
:1+&')!-%&)3!)/!SPR!5+)!6%46)#)!&(#(!)#!*+%/'>!%00+''!5%!1#%!6"#$%$&'")&(*(#'-"!-.+!
-(/$)&-+!)/!*+#+8!k)#(*%!#+!&(#(!&'%'+!)5+#')0)-%'+!WI3!+5!?!$(&&)6)/+!-.+!%#-.+!)/!*+&'%#'+!
SPR!5)!$%2)+#')!&'+*()5(<*+&)&'+#')!$(&&%#(!+&&+*+3!)#!01'1*(3!)#-/1&)!)#!:1+&'(!7*1$$(8!"/!
'*)77+*3!%#-.+!$+*!)!$%2)+#')!-(#!4%/%'')%!7+#+')-%3!&+46*%!-(41#:1+!+&&+*+!
1#B)#0+2)(#+3!(!-(41#:1+!1#%!#(g%!$%'(7+#%!-.+3!#+/!6%46)#(!-(#!-)'(&-.+/+'*(!
$(5(-)'%*)(!7+#+')-%4+#'+!5+0)-)'%*)(3!?!)#!7*%5(!5)!5+'+*4)#%*+!/B)#)2)(!5+/!5%##(8!!
L1%#5(!)/!6%46)#(!&,)/1$$%!
&'+*()5(<5)$+#5+#2%!(!&'+*()5(<
Per definizione nella *+&)&'+#2%!5($(!1#!-)-/(!5)!Q!
glomerulonefrite a lesioni minime i 4+&)3!'*%5)2)(#%/4+#'+!&)!?!
glomeruli appaiono sostanzialmente
normali &+4$*+!0%''%!/%!6)($&)%!*+#%/+8!
M//%!6)($&)%3!%//+!,(/'+!&)!
*)&-(#'*%,%!1#!:1%5*(!%!/+&)(#)!
4)#)4+3!4%!&($*%''1''(!#+)!
$%2)+#')!*+&)&'+#')!&)!*+$+*'%,%!
)#,+-+!-(#!1#%!-+*'%!0*+:1+#2%!
Al ME, la membrana basale ha
un decorso tortuoso e si
1#(!&'%'(!5)!7/(4+*1/(&-/+*(&)!
apprezza la "fusione" completa 0(-%/+!&+74+#'%*)%8!
dei pedicelli.
E%!^b!4+46*%#(&%!+!/%!
7/(4+*1/(&-/+*(&)!0(-%/+!
&+74+#'%*)%3!$*)4%!*)'+#1'+!$%'(/(7)+!#+''%4+#'+!5)&')#'+3!&+46*%#(!(77)!+&&+*+!51+!
+#')'>!&'*+''%4+#'+!1#)'+3!+!)/!*)&-(#'*(!5+//B1#%!(!5+//B%/'*%!)#!1#!5%'(!$%2)+#'+!
5)$+#5+*+66+!+&&+#2)%/4+#'+!5%/!4(4+#'(!)#!-1)!&)!,%!%!0%*+!/%!6)($&)%3!+!/%!
7/(4+*1/(&-/+*(&)!0(-%/+!&+74+#'%/+!*%$$*+&+#'+*+66+!1#%!0%&+!5)!5%##(!$)F!%,%#2%'%8!
L1)3!,(/+#5(3!&)!*)'(*#%!%/!5)&-(*&(!)#)2)%/+!&1//B)4$(*'%#2%!5+//%!:1('%!*+&)51%!5)!
$(5(-)')8!!
b+)!$%2)+#')!&'+*()5(<*+&)&'+#')!&)!1')/)22%#(!)#!7+#+*+!-)-/(&$(*)#%3!*)'1g)4%6!(!
-)-/(0(&0%4)5+3!-(#!'1'')!)!$*(6/+4)!5)!7*%,+!'(&&)-)'>!)44%7)#%6)/)8!H1*'*($$(3!$+*N3!&(/(!
1#%!$)--(/%!$%*'+!5)!:1+&')!$%2)+#')!('')+#+!/%!*+4)&&)(#+!-(#!/B)441#(&($$*+&&(*+G!
5B%/'*%!$%*'+3!-(4+!&)!5)-+,%3!:1+&')!&(#(!#+//%!4%77)(*!$%*'+!5+)!-%&)!:1%5*)!7+#+')-)!
4)&-(#(&-)1')8!L1)#5)3!/%!7+&')(#+!5)!:1+&')!$%2)+#')!?!5)00)-)/+!+!$*)#-)$%/4+#'+!
0)#%/)22%'%!%//%!/)4)'%2)(#+!5+//%!$*('+)#1*)%3!(6)+''),(!-.+!&)!$1N!*%77)1#7+*+!D!%!,(/'+!
%#-.+!)#!4(5(!4(/'(!&(55)&0%-+#'+!D!-(#!7/)!M\a<"!+5!)!&%*'%#)8!
"#!%/-1#)!-%&)3!/%!4%/%'')%!%!/+&)(#)!4)#)4+!?!-(#7+#)'%!+!&)!$*+&+#'%!:1)#5)!7)>!%//%!
#%&-)'%G!)#!:1+&')!-%&)!)!6%46)#)!$(&&(#(!*)&1/'%*+!$(&)'),)!%//(!&-*++#)#7!$+*!
/B)$(')*()5)&4(!-(#7+#)'(!$()-.[3!%!-%1&%!5+//%!$*('+)#1*)%3!$+*5(#(!/%!Vq^8!!
_+-(*&(!
E%!4%/%'')%!.%!#+//%!4%77)(*!$%*'+!5+)!-%&)!5+-(*&(!6+#)7#(!+!$1N!+&&+*+!-(#'*(//%'%!
-(4$/+'%4+#'+!-(#!7/)!&'+*()5)8!EB)5+%!-.+!&)%!1#%!$%'(/(7)%!&1!6%&+!)441#(/(7)-%!
-(#'*%&'%!-(#!/B%&&+#2%!5+/!*)&-(#'*(!5)!)441#(-(4$/+&&)!%/!/),+//(!*+#%/+G!
$*(6%6)/4+#'+!&)%4(!5)!0*(#'+!%!'%#'+!4%/%'')+!5),+*&+!%--(41#%'+!5%/!:1%5*(!
#+0*(&)-(8!M/-1#+!5)!:1+&'+!0(*4+!$('*+66+*(!+00+''),%4+#'+!+&&+*+!-%*%''+*)22%'+!5%!
0+#(4+#)!)#0)%44%'(*)!Y-.+!4%7%*)!&)!&,)/1$$%#(!)#!-%&(!5)!)#0+2)(#)Z8!"#!&(&'%#2%3!$()3!?!
$*(6%6)/+!-.+!4(/'+!5)!:1+&'+!0(*4+!&)%#(!&+4$/)-+4+#'+!/B+&'*+4)22%2)(#+!5+/!
0+#(4+#(!$%*%0)&)(/(7)-(!5+//%!$*('+)#1*)%!#+/!6%46)#(!)#!-(*&(!5)!0+66*+3!'%#'(!$)F!-.+!
)!6%46)#)!&(#(!&(77+'')!-.+!5)!$+*!&[!'+#5(#(!%!&,)/1$$%*+!*)&$(&'+!-)'(-.)#)-.+!
+&(*6)'%#')!%5!($+*%!5+//B)441#)'>!)##%'%C!&+!:1+&'(!&)!*),+/%!%66%&'%#2%!)##(-1(!#+/!
6%46)#(!@&%#(A3!#+/!6%46)#(!-(#!5)0+'')!7+#+')-)!5+/!-)'(&-.+/+'*(!$(5(-)'%*)(!)/!5%##(!
-.+!&)!5+'+*4)#%!)#!:1+&'%!&)'1%2)(#+!#(#!$1N!$)F!+&&+*+!*)$%*%'(!+00)-%-+4+#'+8!
`%$/(,1%$0-%(,$0')+$-"%()0(&/(*#"%()
non
L1+&'(!?!1#!:1%5*(!$*(/)0+*%'),(!-.+!&)!,+*)0)-%!:1%#5(!&)!?!%,1'%!/%!4(*'+!5+/!QP<SPR!
5+)!$(5(-)')8!O)!5+&-*),+,%#(!-/%&&)-%4+#'+!0(*4+!$*)4)'),+!+!0(*4+!&+-(#5%*)+8!E%!
5+0)#)2)(#+!5)!0(*4+!@$*)4)'),+A!5+*),%!5%/!0%''(!-.+!#+//+!6)($&)+!&)!+*%#(!*)&-(#'*%')!)#!
%/-1#)!-%&)!"7X!%!/),+//(!7/(4+*1/%*+G!)#!&+71)'(3!&)!-%$e!!-.+!:1+//+!"7X!&)!'*(,%,%#(!#+//%!
4+46*%#%!7/(4+*1/%*+!&+4$/)-+4+#'+!%!-%1&%!5)!0+#(4+#)!5)!'*%$$)#73!+!#(#!%!-%1&%!5)!
1#B)441#(*+%''),)'>!&$+-)0)-%8!L1)#5)3!&)!?!)$(')22%'%!/%!$*+&+#2%!5)!1#!0%''(*+!
$+*4+%6)/)22%#'+!)#!-)*-(/(3!+!-)!&(#(!/%,(*)!-.+!#+!5+&-*),(#(!/%!$*+&+#2%8!\(41#:1+!
&')%#(!/+!-(&+3!?!4(/'(!$*(6%6)/+!-.+!/%!5+0)#)2)(#+!5)!7/(4+*1/(&-/+*(&)!0(-%/+!
&+74+#'%/+!&)%!&+4$/)-+4+#'+!,%/)5%!-(4+!5+&-*)2)(#+!%#%'(4($%'(/(7)-%3!+!-.+!/+!
+#')'>!#(&(/(7)-.+!-.+!&)!+&$*)4(#(!'*%4)'+!:1+&'(!')$(!5)!/+&)(#+!&)%#(!)#!*+%/'>!
4(/'+$/)-)8!T#!%/'*(!%&$+''(!)4$(*'%#'+!?!-.+!:1+&')!$%2)+#')3!&+!'*%$)%#'%')3!*+-)5),%#(!
#+/!KPR!5+)!-%&)G!1#%!5)%7#(&)!5)!^OkO3!:1)#5)3!?!4(/'(!)4$+7#%'),%!$+*-.[!&)!*)&-.)%!5)!
+&&+*+!+&-/1&)!5%//%!$(&&)6)/)'>!5)!+00+''1%*+!)/!'*%$)%#'(8!!
M#-.+!)#!:1+&'(!-%&(!/%!-(#(&-+#2%!5+//+!$%'(/(7)+!7+#+')-.+!.%!4(/'(!-%46)%'(!)/!
#(&'*(!4(5(!5)!,+5+*+!:1+&'%!$%'(/(7)%8!"#!+00+'')3!&)!?!,)&'(!-.+!)!6%46)#)!-(#!%/'+*%2)(#)!
7+#+')-.+!&(#(!:1+//)!-.+!5($(!)/!'*%$)%#'(!#(#!*+-)5),%#(3!)#!:1%#'(!)/!5)0+''(!&%*+66+!
)#'*)#&+-(!%//B(*7%#(!+&$)%#'%'(C!$%*%//+/%4+#'+3!:1+//)!-.+!'+#5(#(!%!$+*5+*+!)/!
'*%$)%#'(!&(#(!:1+//)!)#!-1)!#(#!-B?!1#!5)0+''(!7+#+')-(!%//%!6%&+3!+!D!71%*5%!-%&(!D!:1+//)!
-.+!.%##(!1#%!:1%/-.+!*)&$(&'%!%//%!'+*%$)%!)441#(&($$*+&&),%3!%!&177+*)*+!)/!*1(/(!5)!
-)'(-.)#+!+!)#0)%44%2)(#+!#+//%!$%'(7+#+&)!5)!:1+&'+!0(*4+8!!
"#!&+71)'(3!-)!&)%4(!%--(*')!-.+!1#%!:1('%!5+)!$%2)+#')!-(#!%/'+*%2)(#)!7+#+')-.+!$+*5+!
-(41#:1+!)/!'*%$)%#'(8!L1+&'(3!$+*-.[!)#!%/-1#)!5)!:1+&')!-%&)!/%!$*('+)#%!-(#,(/'%!?!
'('%/4+#'+!4%#-%#'+3!#(#!&)#'+')22%'%!Y5+/+2)(#)!'('%/)3!41'%2)(#)!&'($Z!+!:1)#5)!)/!
&)&'+4%!)441#)'%*)(!5+/!6%46)#(!#(#!*)-(#(&-+!-(4+!&+/0!:1+//%!&'+&&%!$*('+)#%!
$*+&+#'+!#+)!$(5(-)')!5+/!*+#+!'*%$)%#'%'(8!
Condizioni morbose che possono provocare una
a&)&'+!$()!)/!a1"3,$)0(-$*3",'$3!:1+//(!$)F!0*+:1+#'+3!-.+!)/!-/%&&)-(!-%&(!5)!0a1'%'C,'$)
#,")/"00")+'%#,"*#()()/"00")3")+'%#,",(Q)
GSF secondaria
Infezioni virali (HIV, epatite B)! M!$%*'+!/+!)#0+2)(#)!5%!l"h!+!
Farmaci (eroina, analgesici) lqh3!)#0%'')3!$+*!'1''+!/+!%/'*+!
,(-)!5)!:1+&'(!+/+#-(3!/%!-)0*%!?!
Neoplasie (linfomi, altre neoplasie)
$*($*)(!:1+&'(!&:1)/)6*)(!'*%!
Malattie congenite renali (oligonefronia, 4%&&%!0)/'*%#'+!+!4%&&%!5%!
ipoplasia segmentaria) 0)/'*%*+8!L1+&'(!7+#+*%!1#%!
Ridotta massa nefronica (agenesia renale &)'1%2)(#+!5)!)$+*0)/'*%2)(#+!
unilaterale)!
Uropatia ostruttiva
Reflusso vescico-ureterale
Obesit grave
Trapianto renale
-.+!-%1&%!5%##(!7/(4+*1/%*+!+!:1)#5)!$*('+)#1*)%8!
H+*!:1%#'(!*)71%*5%!/Bl"h3!+&)&'+!1#!:1%5*(!$%*')-(/%*+!-.+!&)!&,)/1$$%!#+)!$%2)+#')!l"hw3!
-.)%4%'(!-(//%$&)#7!7/(4+*1/($%'.o8!O)!,+5+!&($*%''1''(!#+7/)!%0*(%4+*)-%#)!#+7/)!O'%')!
T#)')8!!
V+*%$)%!
H+*!/%!'+*%$)%3!?!#+-+&&%*)(!$*)4%!
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b+//+!0(*4+!5%!&:1)/)6*)(!'*%!4%&&%!
#+0*(#)-%!+!4%&&%!5%!0)/'*%*+!/%!
'+*%$)%!4)7/)(*+!?!:1+//%!-(#!M\a<"!(!
&%*'%#)-)8!b+//+!0(*4+!-.+!&)!
&(&$+''%#(!&1!6%&+!)441#(/(7)-%3!&)!
)4$)+7%#(!&'+*()5)!+5!
)441#(&($$*+&&(*)8!!
A9 ^$,/()!,$%'+(,"#'7()
)
< ^/(4+*1/($%')%!%!5+$(&)')!4+&%#7)%/)!5)!"7M!
Sindromi cliniche associate alle
< ^/(4+*1/(#+0*)'+!$*(/)0+*%'),%!+#5(-%$)//%*+!(!$(&'<)#0+''),%!
< ^/(4+*1/(#+0*)')!4+46*%#(<$*(/)0+*%'),+!
principali forme di glomerulonefrite
< ^/(4+*1/(#+0*)'+!$*(/)0+*%'),%!+g'*%-%$)//%*+!
!
!
Sindrome Sindrome Anomalie Ematuria
!
nefrosica nefritica urinarie isolata
Sindromi cliniche associate alle -/+
`%$/(,1%$*(+,'#()")3(6$0'#')/(0"*&'"%')3')R&S)
Malattia a lesioni minime +++++ - ++
principali
GN membranosaforme ++++ di glomerulonefrite
aB!/%!0(*4%!5)!7/(4+*1/(#+0*)'+!$*)4)'),%!$)F!-(41#+!5+/!4(#5(8!O)!$1N!$*+&+#'%*+!-(#!
+ ++ -/+
5),+*&)!:1%5*)3!4%!$)F!0*+:1+#'+4+#'+!-(#!%#(4%/)+!1*)#%*)+!)&(/%'+3!4+#'*+!)/!$%2)+#'+!
Sindrome Sindrome Anomalie Ematuria
GS focale e segmentale +++ + ++ -/+
nefrosica nefritica urinarie isolata
Malattia a lesioni
Nefropatia minime
ad IgA +++++
++ -
+++ ++
++++ -/+
++++
GN membranosa
GN membranoproliferativa ++++
+++ +
+++ ++
++++ -/+
-/+
7(5+!5)!61(#%!&%/1'+8!!
GS focale e segmentale +++ + ++ -/+
GN proliferativa endocapillare + ++++ ++++ ++
M#-.+!/B+4%'1*)%!*)-(**+#'+!D!&$+&&(!%&&(-)%'%!%!+$)&(5)!)#0+''),)!D!$1N!+&&+*+!1#%!0(*4%!
5)!$*+&+#'%2)(#+!-/)#)-%!%66%&'%#2%!')$)-%G!/B+4%'1*)%!5%!#+0*($%')%!%5!"7M!?!')$)-%4+#'+!
Nefropatia ad IgA ++ +++ ++++ ++++
0'*+",'*&'#'-"3!-)(?!&)#-*(#%!%5!1#!+$)&(5)(!5)!0%*)#7)'+!+!0+66*+!Y4+#'*+!:1+//%!$(&'<
GN a semilune + ++++ ++++ -
&'*+$'(-(--)-%!?!6$0#L+",'*&'#'-"Z8!!
GN membranoproliferativa +++ +++ ++++ -/+
!
GN proliferativa endocapillare + ++++ ++++ ++
V1''%,)%3!&)!-(#(&-(#(!%#-.+!+$,/()0(-$*3",'(G!+&&+!&)!$*+&+#'%#(!')$)-%4+#'+!)#!
$%2)+#')!-(#!5)0+'')!5+//B)441#)'>!41-(&%/+G!
< O"%"##'")-(%'"-")
< O$,C$)3');,$.*)
< U(##$-$%'#()1%-(,$0")
< !$,6$,")3')<-.$(*%('*Lh(*$-.3!-(&')'1)'(!5%!#+0*($%')%!%5!"7M3!%*'*%/7)+!+!
$(*$(*%!,%&-(/%*+G!&)!,+5+!4(/'(!&$+&&(!#+)!6%46)#)!+!#+7/)!%5(/+&-+#')8!V%/,(/'%!
$(&&(#(!+&&+*+!$*+&+#')!%#-.+!5)&'1*6)!7%&'*()#'+&')#%/)8!
!
H*+&+#'%2)(#+!\/)#)-%!
Modalit di presentazione clinica
I pazienti affetti da nefropatia ad IgA si presentano di solito con una di queste
sindromi cliniche:
!
Il 40-50% dei pazienti presenta uno o pi episodi di ematuria macroscopica,
di solito in concomitanza con eventi febbrili o infezioni respiratorie.
Meno del 10% dei pazienti si presenta con un quadro clinico a tipo sindrome
nefritica acuta.
!
Decorso clinico
_+-(*&(!
V+*%$)%! Terapia
Studi recenti relativi al ruolo degli ACE inibitori e degli steroidi
b+)!-%&)!-(#!$*('+)#1*)%!&)!)4$)+7%#(!M\a<"!+!&%*'%#)3!&+!/%!$*('+)#1*)%!?!/)+,+8!O+!/%!
nella nefropatia ad IgA hanno modificato la trerapia della
Nefropatia ad IgA:
$*('+)#1*)%!?!4%77)(*+!5)!W7U5)+3!&)!1&%#(!7/)!&'+*()5)8!O+!&)!,%!(/'*+!)!K!73!&)!1')/)22%#(!7/)!
)441#(&($$*+&&(*)8!
Inibitori dellEnzima di Conversione dellAngiotensina/e o sartanici
Si sono dimostrati pi efficaci degli altri anti-ipertensivi nel !
ritardare la progressione verso linsufficienza renale e nel ridurre la
proteinuria, e vanno somministrati a tutti i pazienti, a prescindere dalla
presenza di ipertensione e dal grado di proteinuria. !
!
Se proteinuria> 1g/die:
Cicli di Steroidi
!
Riducono la perdita proteica nei soggetti che si presentano con grave
proteinuria, alcuni dati suggeriscono un effettivo vantaggio nel preservare
la funzione renale a lungo termine. !
Se proteinuria> 3g/die:
Cicli di Steroidi da soli o in associazione ad immunosoppressori
Gli immunosoppressori sono indicati soprattutto se vi
deterioramento della funzione renale.
GLOMERULONEFRITE PROLIFERATIVA
ENDOCAPILLARE
`%$/(,1%$*(+,'#()6,$%'+(,"#'7")(*3$-"6'%%",()
L1+&'%!0(*4%!?!$+*!-+*')!
%&$+'')!&)4)/!%//%!#+0*($%')%!%5!
"7M3!4%!)/!5+-(*&(!+!
/B+$)5+4)(/(7)%!&(#(!
-(4$/+'%4+#'+!5),+*&)8!L1+&'%!
?!/%!0(*4%!$*+-+5+#'+4+#'+!
#('%!-(#!)/!#(4+!5)!
&%$/(,1%$*(+,'#()6$0#L
0#,(6#$-$--'-")Y$(&'<
0%*)#7)')-%Z8!
EB%&$+''(!)&'(/(7)-(!?!
-%*%''+*)22%'(!5%!1#B)#'+#&%!
A forte ingrandimento evidente l'intensa$*(/)0+*%2)(#+!4+&%#7)%/+!+5!+#5('+/)%/+!%//B)#'+*#(!5+/!
ipercellularit glomerulare, in
cui sono riconoscibili numerose cellule infiammatorie endoluminali come
7/(4+*1/(3!-(#!)#0)/'*%2)(#+!5)!7*%#1/(-)')!+!-+//1/+!
i leucociti polimorfonucleati e cellule monocitarie.
4(#(#1-/+%'+3!*+&$(#&%6)/)!5+/!5%##(8!
M#-.+!/%!7/(4+*1/(#+0*)'+!$*(/)0+*%'),+!+#5(-%$)//%*+!&)!
$*+&+#'%!7+#+*%/4+#'+!-(#!1#B+4%'1*)%!)&(/%'%G!%!
5)00+*+#2%!5+//B+4%'1*)%!5+//%!#+0*($%')%!%5!"7M3!-.+!?!
')$)-%4+#'+!&)#0%*)#7)')-%3!:1+//%!5%!^Ha\!&)!$*+&+#'%!
7+#+*%/4+#'+!ALD)0(##'/"*(!5($(!/B+$)&(5)(!0%*)#7)')-(!
+5!?!:1)#5)!$(&'<0%*)#7)')-%8!L1+&'(3!$+*-.[!/%!^Ha\!?!
1#%!$%'(/(7)%!7/(4+*1/%*+!5%!5+$(&)'(!5)!'//1*$-$/6%(00'3!+!$+*-.[!:1+&'+!
4%-*(4(/+-(/+!&)!0(*4)#(!?!#+-+&&%*)(!-.+!&)!&,)/1$$)!-(4$/+'%4+#'+!/%!*)&$(&'%!
)441#)'%*)%!5+//B(&$)'+8!
L1+&'%3!$+*N3!?!/%!0(*4%!-(#-/%4%'%3!(*4%)!
%66%&'%#2%!*%*%!#+//B%46)'(!5+//%!4+5)-)#%!
7+#+*%/+!D!&+66+#+!%#-(*%!*+/%'),%4+#'+!
0*+:1+#'+!)#!%46)'(!$+5)%'*)-(8!\)N!-.+!&)!,+5+!
0*+:1+#'+4+#'+3!)#,+-+3!&(#(!/+!/'-,$(/"#1,'()
6$0#L'*+(##'7(9!H+*'%#'(3!/%!4(5%/)'>!5)!
$*+&+#'%2)(#+!5+//%!^Ha\!$1N!+&&+*+G!
<<'*3,$/()*(+,'#'-")"-1#"3!
$*+&+#'%2)(#+!%-1'%!-(#!6%46)#(!
(/)71*)-(3!-(#!+5+4%!5+/!,(/'(3!
4%-*(+4%'1*)%3!1#%!-+*'%!:1('%!5)!$*('+)#1*)%!+5!)$+*'+#&)(#+8!)
< S*$/"%'()1,'*",'()I/$3(0#")/'-,$(/"#1,'"3!'%/,(/'%!%#-.+!/)+,+!$*('+)#1*)%Z)
9/'*+!%//B)#0)/'*%2)(#+!
/+1-(-)'%*)%3!%#-.+!
/B%''),%2)(#+!4%&&),%!5+/!
-(4$/+4+#'(!%5!($+*%!
5+7/)!)441#(-(4$/+&&)!?!
1#!%&$+''(!
)4$(*'%#')&&)4(!#+/!
L'utilizzo di anticorpi monoclonali, 5%##(!7/(4+*1/%*+8!O+!
con metodo immunoistochimico, %#5)%4(!%!0%*+!
ha permesso di quantizzare meglio
l'entit e le caratteristiche delle 1#B)441#(0/1(*+&-+#2%!
cellule infiammatorie coinvolte nel $+*!)/!\K3!,+5)%4(!-.+!/+!
danno glomerulare. L'anticorpo 4+46*%#+!6%&%/)!&(#(!
contro l'antigene comune
leucocitario conferma la massiva
infiltrazione di queste cellule nel
flocculo glomerulare.
&')$%'+!5)!0*%2)(#+!-(4$/+4+#'%*+3!%!'+&')4(#)%*+!/%!4%&&),%!%''),%2)(#+!5+/!&)&'+4%!5+/!
-(4$/+4+#'(8!"#0%'')3!)#!:1+&'%!$%'(/(7)%!?!')$)-(!)/!*)&-(#'*(!5)!1#%!
'6$-$/6%(/(*#(/'"!5%!-(#&14(3!-.+!?!)#,+-+!%&&(/1'%4+#'+!%&&+#'+!#+//%!#+0*($%')%!
%5!"7M!Y+!:1)#5)!?!1#!61(#!-*)'+*)(!5)!5)&')#2)(#+Z8!"/!*)+#'*(!5+//%!-(4$/+4+#'+4)%!#+/!
*%#7+!#(*4%/+!'+&')4(#)%!/%!*+4)&&)(#+!5+//%!4%/%'')%8!!
a2)(/(7)%!+!$%'(7+#+&)!
L1+&'%!0(*4%!5)!7/(4+*1/(#+0*)'+!)441#(4+5)%'%!?!$+*!/(!$)F!&+-(#5%*)%!%!$*(-+&&)!
)#0+''),)8!E(!O'*+$'(-(--(!!<+4(/)')-(!5)!7*1$$(!M3!%7+#'+!5)!0%*)#7('(#&)//)')!+!
&-%*/%'')#%3!?!/B%7+#'+!'*%5)2)(#%/4+#'+!-.)%4%'(!)#!-%1&%3!4%!#(#!?!/B1#)-(!-.+!$1N!
-%1&%*+!1#%!$%'(/(7)%!5+/!7+#+*+G!&(#(!)#0%'')!-()#,(/')!%/'*)!6%''+*)!Y+&G!*)-]+''&)%+Z3!
,)*1&!+!$+*&)#(!$*('(2()8!E%!$%'(7+#+&)!?!%66%&'%#2%!&+4$/)-+G!5+'+*4)#%')!%#')7+#)!
6%''+*)-)U,)*%/)U$*('(2(%*)!Y$+*!+&+4$)(3!$+*!7/)!&'*+$'(-(--.)!&)!*)')+#+!+&&+*+!-()#,(/'%!
/%!0#,(6#$W'*"0'Z3!:1%#5(!$*+&+#')!)#!7*%#5)!:1%#')'>!)##+&-%#(!1#%!*)&$(&'%!
)441#)'%*)%!+&'*+4%4+#'+!,)(/+#'%3!&($*%''1''(!#+/!6%46)#(3!+!%!4%77)(*!*%7)(#+!
:1%#5(!#(#!,)+#+!)#'*%$*+&%!1#%!%5+71%'%!'+*%$)%!%#')6)(')-%8!H+*'%#'(3!-(/!4(#'%*+!
5+//%!*)&$(&'%!)441#)'%*)%!D!$*(-+&&(!-.+!*)-.)+5+!-)*-%!I!&+'')4%#+!D!&)!.%!/%!
0(*4%2)(#+!5)!1#%!7*%#5)&&)4%!:1%#')'>!5)!%#')-(*$)!-.+!,%##(!%!-(4$/+&&%*&)!-(#!
/B%#')7+#+!-.+!&)!'*(,%!&)%!/)6+*(!)#!-)*-(/(3!&)%!5+$(&)'%'(!&1//%!4+46*%#%!6%&%/+!
7/(4+*1/%*+!)#!*%7)(#+!5+//%!&1%!+/+,%'%!/)$(0)/)-)'>8!L1)#5)3!&)!0(*4%#(!
)441#(-(4$/+&&)!)#!&+5+!7/(4+*1/%*+3!+!:1+//)!-)*-(/%#')!,%##(!%!5+$(&)'%*&)!&1//%!
4+46*%#%!7/(4+*1/%*+!%!-%1&%!5+)!$*(-+&&)!5)!0)/'*%2)(#+8!M!:1+&'(!$1#'(3!)/!5%##(!
7/(4+*1/%*+!?!4+5)%'(!&)%!5%//%!-%&-%'%!-(4$/+4+#'%*+!Y%''),%'%!'*%4)'+!/%!,)%!-/%&&)-%!
%5!($+*%!5+7/)!)441#(-(4$/+&&)Z3!&)%!5%)!/+1-(-)')3!*)-.)%4%')!&1/!/1(7(!5%//+!
%#%0)/('(&&)#+!+!%''),%')!7*%2)+!%)!/(*(!*+-+''(*)!$+*!k-8!!
_+-(*&(!
aB!+&'*+4%4+#'+!)4$(*'%#'+!*)-(#(&-+*+!$*(#'%4+#'+!1#%!7/(4+*1/(#+0*)'+!$(&'<
)#0+''),%C!)#0%'')3!&+!#+)!6%46)#)!/%!$*(7#(&)!?!('')4%!D!-(#!*+4)&&)(#+!-(4$/+'%!(''+#1'%!
)#!7+#+*+!+#'*(!;!4+&)3!#+7/)!%51/')!%")6,$&*$0')i)6(&&'$,(G!)#!(/'*+!)/!SPR!5+)!-%&)!)/!
:1%5*(!-*(#)-)22%!-(#!$*(7*+&&),(!5+'+*)(*%4+#'(!5+//%!01#2)(#+!*+#%/+8!T#!)#5)-%'(*+!
5+//%!$(&&)6)/+!+,(/12)(#+!-*(#)-%!?!/%!$+*&)&'+#2%!5+//%!$*('+)#1*)%8!\.)%*%4+#'+3!
/B)#'*(512)(#+!5+//%!'+*%$)%!%#')6)(')-%!$+*!/+!0%*)#7('(#&)//)')!.%!*),(/12)(#%'(!/%!-/)#)-%!
5)!:1+&'+!0(*4+G!(77)!)!6%46)#)!,+#7(#(!'*%''%')!$*+-(-+4+#'+!:1%#5(!&,)/1$$%#(!1#%!
0%*)#7('(#&)//)'+3!%#-.+!&+4$/)-+!&1!6%&+!+4$)*)-%!&+#2%!+00+''1%*+!'%4$(#+!+5!
%#')6)(7*%44%8!H+*!:1+&'(3!)!6%46)#)!'+#5(#(!%!4(#'%*+!*)&$(&'+!)441#)'%*)+!4(/'(!
$)F!4(5+&'+!%!-%1&%!5+//%!$*+&+#2%!5)!4)#(*)!:1%#')'>!5)!%#')7+#+3!+!7/)!
)441#(-(4$/+&&)!&)!0(*4%#(3!4%!'*)/'01,")/$%#$)/'*$,(G!:1)#5)3!(77)7)(*#(!#(#!?!
-.+!/%!0*+:1+#2%!5+//+!7/(4+*1/(#+0*)')!$(&'<)#0+''),+!&)%!*+%/4+#'+!5)4)#1)'%8!\)N!-.+!?!
5)4)#1)'(!?!/%!+,(a1(*2")3(&%')(6'0$3')-$*-%"/"#'!-(#!4%-*(+4%'1*)%8!!
E%!5)%7#(&)!?!$)F!&+4$/)-+!5($(!1#!+$)&(5)(!5)!&-%*/%'')#%3!$+*-.[!)#!:1+&'(!-%&(!&(#(!
$*+,)&')!+&%4)!5+//+!1*)#+!%!51+!&+'')4%#+!5%//B+$)&(5)(3!+!:1)#5)!?!0%-)/+!)/!*)&-(#'*(!5)!
1#%!4(5+&'%!4)-*(+4%'1*)%8!
V+*%$)%!
aB!1#%!'+*%$)%!5)!&1$$(*'(3!$+*-.[!&(/)'%4+#'+!/%!4%/%'')%!,%!)#!*+4)&&)(#+!&$(#'%#+%8!
"$+*'+#&)(#+!+!&(,*%--%*)-(!,(/+4)-(!$(&&(#(!+&&+*+!'*%''%')!-(#!5)1*+')-)!+5!%/'*)!
0%*4%-)!%#')<)$+*'+#&),)3!&+4$*+!5%!1&%*+!-(#!%''+#2)(#+8!M/-1#)!$%2)+#')3!#(#(&'%#'+!/%!
'+*%$)%!+!/%!*)&(/12)(#+!5+/!:1%5*(3!-(#')#1%#(!%5!+&&+*+!)$+*'+&)8!
`%$/(,1%$*(+,'#()/(/C,"*$6,$%'+(,"#'7")
M#-.+!:1+&'%!?!1#%!0(*4%!$*(/)0+*%'),%3!:1)#5)!%&&(-)%'%!%5!(/"#1,'"G)06(00$)
/'-,$0-$6'-"9)O)!'*%''%!$+*N!5)!1#%!0(*4%!%!$(#'+3!-(#!%&$+'')!$*(/)0+*%'),)!-.+!
-(+&)&'(#(!-(#!1#!)&$+&&)4+#'(!5+//%!4+46*%#%!6%&%/+G!:1+&'(!&$)+7%!$+*-.[!4(/')!5)!
:1+&')!&(77+'')!&)!$*+&+#')#(!%#-.+!-(#!1#%!0'*3,$/()*(+,$0'-")3')1*")-(,#")
Glomerulonefrite membranoproliferativa
'/6$,#"*2"9))
E%!7/(4+*1/(#+0*)'+!4+46*%#($*(/)0+*%'),%!?!4(/'(!)4$(*'%#'+!$()-.[!#+/!;PR!5+)!-%&)!
&)!%&&(-)%!"%%5'*+(2'$*()3")h;jQ!#+)!$%2)+#')!-(#!+$%')'+!\!#('%!?!&+4$*+!6+#+!*)-+*-%*+!
/%!7/(4+*1/(#+0*)'+!4+46*%#($*(/)0+*%'),%3!+!#+)!$%2)+#')!-(#!7/(4+*1/(#+0*)'+!
4+46*%#($*(/)0+*%'),%!6)&(7#%!&+4$*+!*)-+*-%*+!/B)#0+2)(#+!5%!l\h8!
H%'(7+#+&)!
E%!0(*4%!5)!')$(!"!?!/%!$)F!0*+:1+#'+!)#!-/)#)-%!+!$1N!%&&(-)%*&)!%!5),+*&+!-(#5)2)(#)!
-/)#)-.+G!
< ;,'$&%$C1%'*(/'")'*)-$,0$)3')(6"#'#();)
< ;,'$&%$C1%'*(/'")0(*2")(6"#'#();)I_'*+$/'G)%(1-(/'")%'*+"#'-.(G)/"%"##'()
"1#$'//1*'J)
O+!&)!*)&-(#'*%!1#%!7/(4+*1/(#+0*)'+!4+46*%#($*(/)0+*%'),%3!?!)4$(*'%#'+!
*)-.)+5+*+!)/!5(&%77)(!5+//+!-*)(7/(61/)#+!-.+3!&+!$(&)'),(3!5+,+!)#51*-)!%!
*)-+*-%*+!/%!4%/%'')%!5)!6%&+3!&)%!+&&%!/B+$%')'+!\!(!1#B%/'*%!-(#5)2)(#+!-.+!$1N!
-%1&%*+!-*)(7/(61/)#+4)%8!
< _1610)(,'#(/"#$0$)0'0#(/'-$)
< O"%"##'()%'*+$6,$%'+(,"#'7()-,$*'-.()
< R*+(2'$*()3")hKj)
< S%#,()'*+(2'$*')C"##(,'-.()I(0Q)(*3$-",3'#'J)()7',"%')
E%!-%1&%3!#+)!-%&)!%&&(-)%')!%5!l\h3!&+46*%!:1)#5)!+&&+*+!)5+#')0)-%6)/+!#+//%!
-,'$&%$C1%'*(/'"9)E+!-*)(7/(61/)#+3!%!,(/'+!5)*+''%4+#'+!-(4$/+&&%'+!%/!,)*1&!\3!&)!
5+$(&)'%#(!%/!/),+//(!7/(4+*1/%*+8!
Si ritiene che la glomerulonefrite membrano-
proliferativa sia provocata dalla deposizione di
immunocomplessi a livello glomerulare, in
particolare sul versante interno sottoendoteliale
della membrana basale, oltre che a livello
mesangiale, con attivazione delle cellule
mesangiali ed espansione della matrice
mesangiale, che stimola la interposizione del
mesangio fino alla periferia del capillare
glomerulare in sede sottoendoteliale, con
conseguente "duplicazione" della stessa (doppio
contorno della MBG). !
"#!7+#+*%/+3!#+//+!0(*4+!5)!')$(!"!&)!*)')+#+!+&&+*+!$*+&+#'+!1#!3(+'-'#)*(%%")-%(","*-()
3(&%')'//1*$-$/6%(00'3!-.+!&)!'*%51-+!)#!1#B%''),%2)(#+!-*(#)-%!5+/!-(4$/+4+#'(3!)!
-1)!/),+//)!&(#(!)#0%'')!0/1''1%#')!)#!:1+&'%!$%'(/(7)%8!!
H+*!:1%#'(!*)71%*5%!/%!+$,/")3')#'6$)RR3!4(/'(!$)F!*%*%3!+&)&'(#(!%#(4%/)+!7+#+')-.+!(!
,+*)!+!$*($*)!%1'(%#')-(*$)!-.+3!6/(--%#5(!7/)!)#)6)'(*)!0)&)(/(7)-)!5+/!-(4$/+4+#'(3!
5+'+*4)#%#(!1#B%''),%2)(#+!5+//%!-%&-%'%!-(4$/+4+#'%*+!%''*%,+*&(!/%!,)%!%/'+*#%'),%8!
_+-(*&(!
L1+&'(!')$(!5)!7/(4+*1/(#+0*)'+!.%!1#%!$*(7#(&)!)#0%1&'%3!)#!:1%#'(!+&'*+4%4+#'+!
5)00)-)/+!5%!-1*%*+G!/%!'+*%$)%!?!)#0%'')!*),(/'%!%//%!+*%5)-%2)(#+!5+/!,)*1&!\3!(6)+''),(!#(#!
&+4$*+!*%77)1#7)6)/+8!"#(/'*+3!/B)#'+*0+*(#!1')/)22%'(!$+*!/%!'+*%$)%!5+//B)#0+2)(#+!5%!l\h!
.%!)/!$*(6/+4%!5+//B)#512)(#+!5+//%!$*('+)#1*)%3!$+*!-1)!)/!'*%''%4+#'(!&'+&&(!$1N!
%77*%,%*+!)/!:1%5*(!*+#%/+8!
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6,(7"%(*#(/(*#())/!*+#+8!!
La vasculite dei piccoli vasi
tipicamente caratterizzata da una
necrosi massiva della parete vascolare
con infiltrati infiammatori intra e
perivascolari. Le lesioni di necrosi del
flocculo e di proliferazione extracapillare
sono assai variabili come intensit e
diffusione da caso a caso o spesso
all'interno di un singolo caso. Alla
necrosi massiva si associa abitualmente
una proliferazione extracapillare diffusa
e circonferenziale, con quadro clinico di
insufficienza renale a rapida
progressione. !
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Prognosi
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Terapia !
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Esami di laboratorio
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!
! World Health Organization Classification of Lupus Nephritis
Classe I: la biopsia renale rivela un rene essenzialmente normale.
!
Non c evidenza clinica di malattia.
Classe II: Glomerulonefrite mesangiale
Classe IIA: Glomerulonefrite proliferativa mesangiale lieve
MO: Lipercellularit mesangiale lieve o assente.
IF: I depositi immunologici sono confinati al mesangio.
ME: I depositi immunologici sono confinati al mesangio
Classe IIB: Glomerulonefrite proliferativa mesangiale moderata
MO: Ipercellularit mesangiale
confinata alle aree centrolobulari ed
assenza di infiltrati, necrosi o sclerosi.
IF: I depositi immunologici sono
confinati al mesangio
ME: I depositi immunologici sono
confinati al mesangio
!
World Health Organization Classification of Lupus Nephritis
!
Manifestazioni cliniche: Linsufficienza renale invariabilmente presente e
di solito non risponde alla terapia. !
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!
Crioglobulinemia
Le crioglobuline sono immunoglobuline che precipitano alle basse temperature.
La crioglobulinemia pu essere associate con una particolare malattia
(linfoma, malattia autoimmune, malattia infettiva) o pu essere idiopatica ed
allora denominata crioglobulinemia essenziale. In base alla composizione,
si distinguono tre tipi di crioglobulinemia:
! Tipo I, o crioglobulinemia semplice, dovuta ad una Ig monoclonale, di solito
una IgM o una IgG.
! Tipo II e tipo III o crioglobulinemia mista, che contengono un fattore
reumatoide, di solito una IgM, che si complessa con il frammento Fc di Ig
policlonali. A sua volta, il fattore reumatoide pu essere monoclonale (tipo II),
o policlonale (tipo III).
Fisiopatologia: E una malattia da immunocomplessi. I pazienti hanno depositi
intravscolari di Ig e bassi livelli di complemento. La crioprecipitazione in vivo
determina trombosi delle piccole arterie e dei capillari alle estremit
(gangrena) ed a livello glomerulare (IRA), nonch iperviscosit.
Prevalenza: la prevalenza della crioglobulinemia mista esenziale di circa 1
caso su 100.000. Le frequenze relative sono: tipo I 25%, tipo II 25%, e tipo III
50%. Una positivit per la crioglobulinemia (50-60% dei casi) si ritrova nei
soggetti con infezione da HCV. Storia clinica
Le manifestazioni pi tipiche dei tipi II e III sono artralgie ed artriti
delle interfalangee prossimali, metacarpofalangee, ginocchia ed anche;
malattia renale e lesioni vascolari purpuriche. In particolare il tipo II si
associa con elevatissima frequenza ad interessamento renale ed
infezione da HCV. La varie manifestazioni hanno la seguente frequenza:
! Porpora, necrosi distale, orticaria, ulcerazioni, debolezza: 55-100%
! Manifestazioni articolari: 35-72%
! Coinvolgimento renale: 8-57%
! Fenomeno di Raynaud: 28-50%
! Parestesie e neuropatia periferica: 10-30%
! Dolore addominale: 2-22%
! Acrocianosi: 9%
! Emorragie: 7%
! Trombosi arteriolare: 1%
La prognosi dipende in genere dalla malattia di base, ma peggiora
quando c interessamento renale, con una sopravvivenza che varia dal
60% a 5 anni al 30% a 7 anni. La morbilit della crioglobulinemia
legata soprattutto alle trombosi arteriosa ed alla malattia renale.
!
!
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DANNO
CELLULE
TUBULARI
DISFUNZIONE PERFUSIONE
TUBULARE CAPILLARE
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ATROFIA
CRISTALLI, FLOGOSI, FIBROSI TUBULARE
(TCP, BRANCA SPESSA
CILINDRI, ECC INTERSTIZIALE ASCENDENNTE HENLE
AB AB NUMERO E
RIASSORBIMENTO
INTRINSECO ESTRINSECO CALIBRO
CAPILLARI DI ACQUA E SODIO
RELATIVA
VASODILATAZ. ART.
GLOM. EFF.
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:1)#5)3!1#(!&'%'(!5)!'*01++'-'(*2"),(*"%()-,$*'-"9))
=(+,'#')R*#(,0#'2'"%')
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?9 V"),'&(##$)-,$*'-$)3'),(*()#,"6'"*#"#$)
E+!0(*4+!&+-(#5%*)+!%!4%/%'')+!&)&'+4)-.+!)#-/15(#(!-+*'%4+#'+!/+!4%/%'')+!
%1'()441#)3!-(4+!)/!EaO3!/%!7*%#1/(4%'(&)!5)!t+7+#+*3!/%!4)-*($(/)%#7)()'+3!/%!
&)#5*(4+!5)!Opy7*+#3!4%!%#-.+!4%/%'')+!(#-(+4%'(/(7)-.+3!-(4+!)/!4)+/(4%!41/')$/(!+!
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$1N!+&&+*+!/%!&+71+#'+G!
CAUSE
IDIOPATICA
IDIOPATICA ENDEMICA (nefropatia dei Balcani)
EREDITARIE: nefronoftisi, malattia cistica midollare, nefropatia iperuricemica
familiare giovanile, ADPKD, ARPKD
INFEZIONI: pielonefrite cronica, pielonefrite xantogranulomatosa,
malacoplachia, TBC.
FARMACI E TOSSICI: analgesici, acido aristolochico, litio, ciclosporina,
tacrolimus, indinavir, cisplatino.
METALLI PESANTI: piombo, cadmio, arsenico, mercurio, oro, uranio.
RADIAZIONI, ONDE DURTO
ALTERAZIONI METABOLICHE: iperuricemia, ipopotassiemia, ipercalcemia,
iperossaluria, cistinosi.
MALATTIE AUTOIMMUNI: LES, sindrome di Syogren, sarcoidosi, sindrome di
Wegener ed altre vasculiti.
OSTRUZIONE CRONICA, REFLUSSO VESCICO-URETERALE
MALATTIE EMATOLOGICHE: mieloma, leucemie, linfomi, anemia falciforme,
emoglobinuria parossistica notturna
MALATTIE VASCOLARI: malattia renale aterosclerotica
RIGETTO CRONICO DI TRAPIANTO RENALE
SECONDARIA A MALATTIE GLOMERULARI PROGRESSIVE:
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CORTICALE - normale
MIDOLLARE ESTERNA normale
CORTICALE - normale
MIDOLLARE ESTERNA comparsa alterazioni focali
Stage II
Atrofia in corrispondenza della papilla necrotica
CORTICALE
Ipertrofia (raggi midollari risparmiati)
Stage III
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NEFROPATIA CRONICA DA LITIO
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DANNO GLOMERULARE
Usuale relativo RISPARMIO dei glomeruli
Casi di GLOMERULONEFRITE A LESIONI MINIME
In pazienti con insufficienza renale (= tardivamente) frequente riscontro di
GLOMERULOSCLEROSI GLOBALE o GLOMERULOSCLEROSI FOCALE
SEGMENTARIA con glomerulomegalia
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T2 RARE !
T2 (rapid acquisition relaxation enhancemen)
!
Numerose microcisti rotondeggianti del diametro di 1-2
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NEFROPATIA
=(+,$6"#'")3")"-'3$)1,'-$) DA ACIDO URICOBobadilla NA, AJP Renal Physiol 2007; 29
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PURINE (acidi nucleici)
ACIDO URICO
Ominidi e
Primati Primati
superiori inferiori
URICASI
< Studi epidemiologici non sono riusciti ad identificare lacido urico come fattore di
rischio indipendente di insufficienza renale.
VASOCOSTRIZIONE
(SISTEMICA E RENALE)
ARTERIOLOPATIA AFFERENTE
FIBROSI INTERSTIZIALE
IPERTENSIONE
(sensibile al sale)
INSUFFICIENZA RENALE !
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IPERCALCEMIA CRONICA
filtrazione glomerulare
DEPOSIZIONE INTERSTIZIALE
DI CALCIO
INFILTRAZIONE CELLULARE
MONONUCLEATA
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$('"+GG+"()+2+"5%'#"+)3&)+44+''()#11%"%''3"#)'(,,+"(:+&%5(=)$+"'#&'()#$$#"+)5"35%#,+),#)
"%5+"5#)&+,)5#7$()1+,)1#&&()1#)%25<+7%#_"%$+"432%(&+8))
H#)$"+2+&'#6%(&+)%&@%",''#;)%&0+5+;).)$%F)4#5%,7+&'+)5(7$"+&2%G%,+8)H+)7(,+5(,+)WMS)1+,)
1(&#'("+)2(&()$3")2+7$"+)$"('+%&+;)+)5(7+)'#,%)$%#&()$%#&()23G%"#&&()3&)'3"&K(0+"8)
J3"#&'+)%,),("()'3"&K(0+";)D3+2'+)$"('+%&+)2#"#&&()$"%7#)()$(%)5#$'#'+)1#,,+)5+,,3,+)NZS)
1+,)"%5+0+&'+;)5<+),+)$"(5+22+"#&&()5(7+)4#"+GG+"()5(&)D3#,2%#2%)#,'"()#&'%:+&+)+),+)
$"+2+&'+"#&&()#22(5%#'+)#)&("7#,%)7(,+5(,+)WMSK2+,48)-&D)D3+2'()5#2(;)D3%&1%;),+)
7(,+5(,+)WMS)#,,(:+&%5<+)0+&:(&()'"#''#'+)5(7+)3&)D3#,2%#2%)#&'%:+&+)&(&)2+,4;)+)
2'#'%2'%5#7+&'+)+2%2'+"I)3&),%&4(5%'#)!)1+,)"%5+0+&'+)5#$#5+)1%)"%5(&(25+"+)%,)5(7$,+22()
7(,+5(,#)WMS)2+,4)])$+$'%1+)&(&)2+,4)1+"%0#'()1#,,#)7(,+5(,#)WMS)1+,)1(&#'("+8))
APC HLA Canali del Ca
TCR Ca++
Calmodulina
CNA Calcineurina
Fosfatasi Nucleo
Linfocita T NFAT
Trascrizione citochine
pro-infiamm.,CD40L
Citoplasma
)
E3+2'+)2(&(),+)G#2%)1+,)"%:+''(;)#)53%)1(GG%#7()#::%3&:+"+)3&)#,'"()#2$+''()
+2'"+7#7+&'+)%7$("'#&'+=),#)-(0$#'%L%.%'O)35PC)a,%)#&'%:+&%)N[b)2(&()+2$"+22%;)
(,'"+5<P)23:,%)+"%'"(5%'%;)23,,+)5+,,3,+)+&1('+,%#,%8)c+)&(&)0%+&+)"%2$+''#'#),#)5(7$#'%G%,%'I)
N[b;)%,)"%5+0+&'+)%&%6%+"I)%77+1%#'#7+&'+)#)4("7#"+)#&'%5("$%)1%"+''%)5(&'"():,%)#&'%:+&%)
N[b)1+,)1(&#'("+;)5(2%55<P),/+&1('+,%()2#"I)($2(&%66#'()+)2%)#0"I)#''%0#6%(&+)1+,)
5(7$,+7+&'()5(&)5(&2+:3+&6+)1%2#2'"(2+8)N)D3+2'#)"+:(,#;)5(73&D3+;)0%)2(&()#,53&+)
+55+6%(&%8))
)
H/MHN)&+,,#)5,%&%5#)
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)
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7(7+&'%=)
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)
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7(7+&'()1+,)$"+,%+0()1+,,/(":#&(;)+)23)'3''%)%)5#&1%1#'%)1(&#'("%)A+2=)$#"+&'%)+)&(&B8)c%)
#"'%5(,#)%&)13+)'%$%)1%)%&1#:%&+=)
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#&'%:+&%)1%)5,#22+)-)AN;)[;)SdB)+)--)AJZ;)JE;)J*B8)
K !%$%HH#H%(&,)0(.,-(.#",?)5%(.),/%&1#:%&+)5<+)$+"7+''+)1%)2+D3+&6%#"+)%),(5%)
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"+#''%0%'I8)-&)5#2()$(2%'%0(;)&(&)2%)$3@)$"(5+1+"+)#,)'"#$%#&'(8)-&)5#2()&+:#'%0(;).)
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"+:(,+)$%F)4"+D3+&'+7+&'+)2+:3%'+;)%&)("1%&+)1%)%7$("'#&6#=)
RC 6(0$#'%L%.%'O)'"#)@(&#'(",),)"%-,A,&',)
Z(5()1#)1%"+)23)D3+2'(=).),#)5(&1%'%()2%&+)D3#)&(&8)
)
SC Q(0%+.%#&H#)@%),'O)'"#)@(&#'(",),)"%-,A,&',)
L00+"(;)'+&'%#7()&+%),%7%'%)1+,)$(22%G%,+)1%)&(&)#22+:&#"+)#1)3&)"#:#66(),/(":#&()
$"+,+0#'()1#)3&#)$+"2(&#)#&6%#&#;)+)0%5+0+"2#8)S+"5<%#7()D3%&1%)1%)4("&%"+)#%)
$#6%+&'%)1#)'"#$%#&'#"+)3&)"+&+)5(&)3&#)$"+237%G%,+)43&6%(&+)"+&#,+)%&),%&+#)5(&)
D3+,,#)#''+2#)$+"),/+'I)1+,)$#6%+&'+8)
)
VC !,0$()@%)#'',*#)
L00+"(;)2%)'+&'#)1%)1#"+),#)$"+5+1+&6#)#%)$#6%+&'%)5<+)2%)'"(0#&()1#)$%F)'+7$()%&)
,%2'#)1/#''+2#8)E3+2'()&(&)2+7$"+).)$(22%G%,+;)2($"#''3''()%&)"+,#6%(&+)#,,+)$"%7#)
13+)"+:(,+)5<+)#GG%#7()5%'#'(8)
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N&6%'3''(;).)&+5+22#"%#),#)5(7$#'%G%,%'I)1+:,%)#&'%:+&%)+"%'"(5%'#"%;)2+5(&1()D3+2'+)"+:(,+=)
-&)"+#,'I;)0%)2(&()3&)5+"'()&37+"()1%)
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+2$+"%+&6#)#&5<+)&+,)'"#$%#&'()N[b)
%&5(7$#'%G%,+C)%)$"('(5(,,%)2%)G#2#&()
+22+&6%#,7+&'+)23,)"%5("2()#1)3&#)
'+"#$%#)%773&(2($$"+22%0#)$%F)
#::"+22%0#)+)#,,#)$,#27#4+"+2%)#,,()
25($()1%)#,,(&'#&#"+)1#,)$,#27#),+)
%773&(:,(G3,%&+)#&'%K#&'%:+&%)
+"%'"(5%'#"%)$"(1(''+)1#,)$#6%+&'+8)-&)
,%&+#)1%)$"%&5%$%(;)5(73&D3+;),#)
5(7$#'%G%,%'I)N[b).)&+5+22#"%#8))
)
)
)
SCORE USED
) FOR THE SELECTION OF PATIENTS IN LIST
) FOR CADAVER KIDNEY TRANSPLANT
E3+2'#)
'#G+,,#)%&0+5+)
5%)7(2'"#)%,)
$3&'+::%()5<+)
0%+&+)
#''"%G3%'()#,,+)
0#"%+)
2%'3#6%(&%)1%)
7%27#'5<)
MHN8)Z*N)2'#)
$+")Q$#&+,)
"+#5'%0+)
#&'%G(1%+2R=).)
3&)$#"#7+'"()
5<+)2%)
"%4+"%25+)#)
'+2')
2%+"(,(:%5%)
4#''%)23,)2%+"()
1+,)$#6%+&'+)+)
0(,'%)#,,#)
1%7(2'"#6%(&
+)1%)#&'%5("$%)
#&'%K#&'%:+&%)
37#&%C)2%)+2$"%7+)%&)$+"5+&'3#,+;)%&'+2#)5(7+)Q$+"5+&'3#,+)1%)%&1%0%13%)&+,,#)
FASCE DI ETA
$($(,#6%(&+):+&+"#,+)0+"2()%)D3#,%)%,)2%+"()1+,)$#6%+&'+)2#"+GG+)"+#''%0(R8))
Z+")D3#&'()"%:3#"1#)%,)5"%'+"%()1+,,/,'O?)2%)2+:3+)%&):+&+"#,+)D3+2'#)"+:(,#=)
DONATORE RICEVENTE
A 16 30 A1 16 45
B 31 50 B1 42 59
C 51 60 C1 60 66
D 61 70 D1 > 66
E > 70
)
)
)
!+"#$%#)%773&(2($$"+22%0#)
H#)'+"#$%#)%773&(2($$"+22%0#)<#)"%0(,36%(&#'(),#)'"#$%#&'(,(:%#)A+),#)7+1%5%&#)%&)
:+&+"#,+B8)H#)0+"#)"%0(,36%(&+).)2'#'#)"#$$"+2+&'#'#)2%53"#7+&'+)1#,,/%&'"(136%(&+)1+:,%)
%&%G%'("%)1+,,#)5#,5%&+3"%&#;)5(7+),#)-%-.(*$("%&#C)H#)5%5,(2$("%&#).):"#0#'#)1#)3&)
%7$("'#&'%22%7()$"(G,+7#)1%)&+4"('(22%5%'I;)D3%&1%)$"%7#)1%)2(77%&2%'"#",#)%&):+&+"+)2%)
)
Reversibili Irreversibili )
Sito dazione Funzionali Strutturali Strutturali )
Arteriola afferente GFR Vasocostrizione Danno endoteliale
)
Danno delle cellule )
Urea
muscolari lisce
Pressione )
sanguigna Obliterazione dei vasi
)
Tubulo prossimale Alterazioni bioumorali Vacuoli Atrofia
K+ )
Mitocondri giganti Fibrosi interstiziale
Mg )
Microcalcificazioni
)
HCO3
)
Acido urico
-&)'+7$%)$%F)"+5+&'%;):,%)%&%G%'("%)1%)7!L*;)5(7+)"#$#0%-%&#?)*%"(.%0>*?),A,"(.%0>*?)
',0*%"(.%0>*;)<#&&()5(&2+&'%'()1%)#::%3&:+"+)#,)&(2'"()"+$+"'("%()4#"7#5%)7+&()
&+4"('(22%5%)+)$%F)7#&+::+0(,%8)L::%;)%)1+"%0#'%)1+,,#)"#$#7%5%&#)2(&()3'%,%66#'%22%7%)%&)
5,%&%5#8))
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%,)'"#$%#&'(;)+),#)E#*,)@%)0#&',&%0,&'(;)5<+)2#"I)$"(2+:3%'#)%&1+4%&%'#7+&'+)#,)4%&+)1%)
7#&'+&+"+),()2'#'()1%)'(,,+"#&6#)%773&%'#"%#)+)1%)$"+0+&%"+)%,)"%:+''(8)H#)4#2+)1%)
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#53'(8)N,'"#)5(2#).)%&0+5+)%,)'"#''#0,&'()@,.)"%+,''(=)2%)'"#''#)2(2'#&6%#,7+&'+)1%)3&)
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1+,)"%:+''(8))
=,+%0,)@%)%&@>H%(&,W)
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1+4%&%25+),#)7("'+)5(7+=)!"##$%&'(")&**"+"*#&,&-").&)/0//")-")$//&+&/1)."--2"(!"3$-'4)E3%&1%;)
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*$%&#.,C))
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)
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-)'"+)7+1%5%)1+0(&()"%$+'+"+)+)-(&E,"0#",)%,)"%,%+0()2%73,'#&+()1%)'3''+),+)5(&1%6%(&%)
5<+)#GG%#7()+,+&5#'()2($"#)#,,/%&%6%()1+,,/(22+"0#6%(&+;)#)7+'I)1+,,/(22+"0#6%(&+)+)
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"%,%+0()1+,,#)$"+2+&6#)2%73,'#&+#)1+,,+)5(&1%6%(&%)2311+''+8))
IDONEITA DEL DONATORE IDONEITA
ORGANO
Anamnesi
Esame Obiettivo Ispezione
Esami di Laboratorio Palpazione Oncologica Idoneit / Non Idoneit
Esami Strumentali Accertamento Autoptico
V+&:(&()5#'+:("%5#7+&'+)+25,32%)1#)D3#,2%#2%)'%$()1%)$"+,%+0()$#6%+&'%)5(&=)
! Q%,"($(*%'%A%'O)@#)1DUR)()S?)
! Q%,"($(*%'%A%'O)-(&',0$("#&,#)$,")15*3+),@)1:U?)
! [,($.#*%#)0#.%+&#)%&)#''()B'"#&&,)#.->&,)$",-%*,),--,H%(&%I?)
! D&E,H%(&%)*%*',0%-J,)*(*',&>',)@#)0%-"(("+#&%*0%)$,")%)F>#.%)&(&),*%*'(&()
($H%(&%)',"#$,>'%-J,)$"#'%-#L%.%?)0#.#''%,)@#)$"%(&%)#--,"'#',C)
)
[,($.#*%,)
H+)&+($,#2%+)5<+)&(&)+25,31(&()%,)'"#$%#&'()2(&(=)
K S#"5%&(7%)%&)2%'3)
K S#"5%&(7#)2$%&(5+,,3,#"+)53'#&+()&(&)7+'#2'#'%5()
K S#"5%&(7#)$#$%,,#"+)3"('+,%#,+)
K [#2#,%(7#) CASI PARTICOLARI:
IDONEITA DONATORE (II)
-)'37("%)%&'"#5"#&%5%)2(&()3&)5#$%'(,()$#"'%5(,#"+=)#,53&%)&(&)+25,31(&(),#)1(%(&+;)
#,'"%)"%5<%+1(&()3&#)0#,3'#6%(&+C)%&4%&+;)0+)&+)2(&()1%)$#"'%5(,#"%)5<+)+25,31(&(),#)
Altri Tumori:
1(%(&+)A7+13,,(G,#2'(7#)+1)#2'"(5%'(7#)#&#$,#2'%5(B8))
-,)5#"5%&(7#)$"(2'#'%5().)3&)#,'"()'37("+)5<+)%&)$#"'%5(,#"%)5(&1%6%(&%)$3@)5(&2+&'%"+)
Carcinoma prostatico
5(73&D3+),#)1(%(&+=)
)
DONATORE PSA pos (>50aa)
-PSA totale < 4 ng/ml
-PSA totale / PSA libero < 10 ng/ml / > 25% SI
Esame
Se valoriistopatologico:
superiori:
Adenocarcinoma confinato allinterno della capsula con
-visita urologica
Gleason -eco
<4 intransrettale
tutti i campioni: Rischio Standard
(se possibile)
-esame istopatologico: 1) estemporaneo
Se uno o pi campioni Gleason 4 e/o 2) diffusione
definitivo
extracapsulare: Rischio aumentato ma accettabile
3) immunoistochimica
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