Patofisiología de la hiperfiltración glomerular en la diabetes. Parte II
Resumen
La hiperfiltración glomerular (HF) en la enfermedad renal diabética es un complejo fenómeno hemodinámico que ocurre en etapas tempranas de la evolución de la enfermedad, y muy probablemente tenga influencias negativas, en cuanto a la progresión hacia la aparición de la microalbuminuria y la evolución de la nefropatía diabética (NFDBT) evidente. Los factores involucrados en su fisiopatología son múltiples, e incluyen al medio diabético y numerosos factores humorales como óxido nítrico, prostaglandinas, sistema renina angiotensina aldosterona, péptido auricular natriurético, especies reactivas de oxígeno y otros factores humorales y de crecimiento, que actúan básicamente provocando o potenciando la vasodilatación de la arteriola aferente (AA), o factores con propiedad de vasoconstricción de la arteriola eferente, todos considerados como factores vasculares primarios. No obstante, estos factores no pueden explicar otras alteraciones observadas y que componen anormalidades tubulares primarias, como la mayor reabsorción en el túbulo contorneado proximal, probablemente condicionada por el crecimiento renal en la DBT y por la sobreexpresión del cotransportador SGLT2. Esta mayor reabsorción proximal generaría una menor llegada de solutos a la mácula densa (MD), lo cual sería incompatible con una acción mediada por el feedback túbuloglomerular (FBTG), que sensaría esta disminución de la concentración de ClNa en la MD, desactivando el FBTG y produciendo vasodilatación de la AA, con el consiguiente aumento del filtrado glomerular (FG) y del flujo plasmático renal (FPR), característicos del proceso de HF y una dieta alta en sal disminuiría el FG y el FPR, lo cual podría tener implicancias clínicas inesperadas. A las medidas terapéuticas habituales del control metabólico estricto, la dieta hipoproteica y el uso de IECA o bloqueantes AT1, no testeados clínicamente para este fin, pero de extendido uso clínico, parecen agregarse los nuevos inhibidores específicos del cotransportador SGLT2, que han demostrado efectos beneficiosos en varios aspectos del manejo de los diabéticos, y ya existen algunos trabajos con efecto específico sobre la HF que parecen ser alentadores. Menos experiencia existe con el uso potencial del péptido C, como herramienta terapéutica en estas situaciones clínicas. Es evidente que determinar situaciones clínicas. Es evidente que determinar con más claridad los mecanismos involucrados en este complejo fenómeno, permitirá un mejor conocimiento del mismo y un mejor abordaje terapéutico.Citas
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