Avaliação da perfusão renal de cadelas em sepse por piometra por meio da ultrassonografia com contraste por microbolhas e doppler
Data
2019-03-01
Autores
Gasser, Beatriz [UNESP]
Título da Revista
ISSN da Revista
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Editor
Universidade Estadual Paulista (Unesp)
Resumo
A sepse é uma síndrome clínica que ocasiona alta morbimortalidade em humanos e animais, devido à disfunção orgânica a qual conduz, sendo a principal complicação a lesão renal aguda (LRA), originada por alteração da perfusão dentre outros fatores. No entanto, até o presente momento as técnicas utilizadas para o diagnóstico precoce de alterações na perfusão renal são pouco acuradas, invasivas ou de alto risco para o paciente. Por tal motivo, este estudo clínico avaliou parâmetros clínicos, hematológicos, urinários, de ultrassonografia Modo-B, Doppler espectral e contrastada por microbolhas (CEUS), utilizando o exame histopatológico da biopsia renal como padrão diagnóstico de LRA, em 20 cadelas com piometra de origem natural como modelo experimental de sepse. Objetivou-se identificar alterações patofisiológicas que expliquem o desenvolvimento da LRA e sepse neste tipo de pacientes e verificar a acurácia dos métodos estudados para o diagnóstico desta lesão, utilizando um grupo de 12 pacientes saudáveis como controle. Todas as pacientes apresentaram algum grau de lesão renal de diversas origens celulares e 40% apresentaram-se em sepse. A LRA pôde ser explicada em 57% dos casos por alteração da hemodinâmica renal, principalmente redução da magnitude e velocidade do fluxo sanguíneo renal avaliados pelo Doppler e da perfusão cortical pela CEUS; e em 22% dos casos por alterações inflamatórias sistémicas, associadas à redução da concentração plasmática de albumina e aumento das globulinas. Os parâmetros que apresentaram melhor valor diagnóstico para LRA (acurácia > 80%) foram: razão proteína-creatinina urinária (UPC), albumina sérica, tempo médio de velocidade na artéria renal (TaMin), indice de pulsatilidade (IP), relação comprimento renal-aorta (RelCompAor) e pico de realce do contraste no córtex renal. A sepse e as alterações na albumina, PaO2, TaMin, hematócrito, UPC, RelCompAor, fosfatase alcalina e IP, associaram-se a degeneração tubular, infiltração inflamatória, necrose tubular aguda, fibrose intersticial, glomerulonefrite membranoproliferativa e glomerulonefrite membranosa, mais severas, sendo estas as lesões renais encontradas na análise histopatológica. Além disso, sugere-se a utilização da UPC ao invés da creatinina como método de avaliação renal no escore SOFA para determinação de sepse em cães.
Sepsis is a clinical syndrome that causes high morbidity and mortality in humans and animals, due to the organic dysfunction it leads to. The main complication is acute kidney injury (AKI), caused by changes in perfusion, among other factors. Unfortunately, to date the techniques used for the early diagnosis of changes in renal perfusion are not accurate, invasive or at high risk for the patient. Therefore, this clinical study evaluated clinical, hematological, urinary and utrasonographic B-mode, spectral Doppler and microbubble contrast (CEUS) techniques, using histopathological exam of renal biopsy as the diagnostic standard of AKI in 20 bitches with pyometra of natural causes as an experimental model of sepsis. The aim was to identify pathophysiological changes that explain the development of AKI and sepsis in this kind of patients and to verify the accuracy of the methods studied for the diagnosis of this lesion, using a group of 12 healthy control patients. All animals with pyometra presented some degree of renal damage from multiple cellular origins and 40% presented with sepsis. The LRA could be explained in 57% of cases due to renal hemodynamics changes, mainly reduction of renal blood flow magnitude and velocity evaluated by Doppler ultrasonography and cortical perfusion evaluated by CEUS; and in 22% of cases due to systemic inflammatory alterations, associated to reduction of plasmatic concentration of albumin and increase of globulins. The parameters that presented the best diagnostic value for AKI (accuracy> 80%) were: urinary protein-creatinine ratio (UPC), serum albumin, mean renal artery velocity (TaMin), pulsatility index (PI), kidney length/aorta ratio (KLAorR) and peak contrast enhancement in the renal cortex. Sepsis and alterations in albumin, PaO2, TaMin, hematocrit, UPC, KLAorR, alkaline phosphatase and PI were associated with aggravation of tubular degeneration, inflammatory infiltration, acute tubular necrosis, interstitial fibrosis, membranoproliferative glomerulonephritis and membranous glomerulonephritis, these being the renal lesions found in the histopathological analysis. In addition, we suggest the use of UPC instead of creatinine as a renal evaluation in the SOFA score for determination of sepsis in dogs.
Sepsis is a clinical syndrome that causes high morbidity and mortality in humans and animals, due to the organic dysfunction it leads to. The main complication is acute kidney injury (AKI), caused by changes in perfusion, among other factors. Unfortunately, to date the techniques used for the early diagnosis of changes in renal perfusion are not accurate, invasive or at high risk for the patient. Therefore, this clinical study evaluated clinical, hematological, urinary and utrasonographic B-mode, spectral Doppler and microbubble contrast (CEUS) techniques, using histopathological exam of renal biopsy as the diagnostic standard of AKI in 20 bitches with pyometra of natural causes as an experimental model of sepsis. The aim was to identify pathophysiological changes that explain the development of AKI and sepsis in this kind of patients and to verify the accuracy of the methods studied for the diagnosis of this lesion, using a group of 12 healthy control patients. All animals with pyometra presented some degree of renal damage from multiple cellular origins and 40% presented with sepsis. The LRA could be explained in 57% of cases due to renal hemodynamics changes, mainly reduction of renal blood flow magnitude and velocity evaluated by Doppler ultrasonography and cortical perfusion evaluated by CEUS; and in 22% of cases due to systemic inflammatory alterations, associated to reduction of plasmatic concentration of albumin and increase of globulins. The parameters that presented the best diagnostic value for AKI (accuracy> 80%) were: urinary protein-creatinine ratio (UPC), serum albumin, mean renal artery velocity (TaMin), pulsatility index (PI), kidney length/aorta ratio (KLAorR) and peak contrast enhancement in the renal cortex. Sepsis and alterations in albumin, PaO2, TaMin, hematocrit, UPC, KLAorR, alkaline phosphatase and PI were associated with aggravation of tubular degeneration, inflammatory infiltration, acute tubular necrosis, interstitial fibrosis, membranoproliferative glomerulonephritis and membranous glomerulonephritis, these being the renal lesions found in the histopathological analysis. In addition, we suggest the use of UPC instead of creatinine as a renal evaluation in the SOFA score for determination of sepsis in dogs.
Descrição
Palavras-chave
Canino, Hemodinâmica renal, Lesão renal, Disfunção orgânica, Infecção, Útero