Inflamación subclínica en enfermedad renal crónica: marcadores, causas y mortalidad cardiovascular
Resumen
Los pacientes con enfermedad renal crónica sometidos a hemodiálisis de mantenimiento (HD) tienen un riesgo de mortalidad cardiovascular y general muy elevado. La uremia se ha asociado a inflamación sistémica. Esta inflamación ha sido relacionada con la mortalidad general y cardiovascular de estos pacientes. La elevación de la proteína c reactiva, uno de los marcadores de inflamación más comunes es predictiva de mortalidad cardiovascular en la población en diálisis. Otros marcadores de inflamación predictivos de eventos adversos en diálisis son la interleukina -6 y el factor de necrosis tumoral alfa. Recientemente otro marcador de inflamación, la pentraxina 3 (PTX3) ha demostrado ser un predictor de mortalidad, y en pacientes en HD se ha relacionado con enfermedad cardiovascular y malnutrición calórico-proteica.
Varios estudios han demostrado que contaminaciones con muy pequeñas cantidades de endotoxinas bacterianas producen una respuesta inflamatoria subclínica. En los pacientes en HD hay varias fuentes de endotoxemia, como fluidos, tejidos y cuerpos extraños. Los líquidos de diálisis están contaminados con bacterias Gram-negativas y sustancias inductoras de citoquinas derivadas de estos microorganismos. La presencia de biofilms incrementa el riesgo de una contaminación continua de estos líquidos. La periodontitis severa está asociada a incrementos en las concentraciones séricas de hs-CRP y es frecuente en pacientes en HD y trasplantados. Las uremia per se puede ser una causa de translocación de endotoxina desde el intestino. Finalmente otras fuentes de infección oculta que pueden llevar a una respuesta inflamatoria subclínica son la presencia de catéteres para diálisis, las fístulas arteriovenosas no funcionantes y los injertos no funcionantes.
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