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Refractariedad a diuréticos en la sobrecarga de volumen: a propósito de un caso tratado con metolazona
Refractorily to diuretics in volume overload: report of a case treated with metolazone
Manuel Heras Benito
Autor para correspondencia
mherasb@saludcastillayleon.es

Autor para correspondencia.
Servicio de Nefrología, Hospital Universitario de Salamanca, Salamanca, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">La metolazona&#44; un agente diur&#233;tico conocido y utilizado desde la d&#233;cada de los 70<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a>&#44; ha vuelto a cobrar vigencia en los &#250;ltimos a&#241;os como tratamiento complementario a diur&#233;ticos convencionales en casos de refractariedad a estos y situaciones de sobrecarga de volumen<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#46; La metolazona es un diur&#233;tico de quinazolina relacionado con la clase de las tiazidas&#44; que inhibe la reabsorci&#243;n tubular de cloruro s&#243;dico&#44; principalmente en el t&#250;bulo distal pero con acciones tambi&#233;n en el t&#250;bulo proximal&#44; produce un aumento de la excreci&#243;n renal de agua y cloruro s&#243;dico<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>&#46; Su principal efecto diur&#233;tico se consigue con el sinergismo con otros diur&#233;ticos&#44; fundamentalmente de asa&#44; siendo poco efectivo en monoterapia<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Var&#243;n de 73 a&#241;os&#44; con antecedentes personales de alergia a pirazolonas y grupo PARA&#44; fibrilaci&#243;n auricular y cardiopat&#237;a isqu&#233;mica&#44; s&#237;ndrome cardiorrenal con varios ingresos por descompensaci&#243;n cardiaca&#46; En el ingreso actual&#44; la anemizaci&#243;n sin causa clara fue el motivo de ingreso&#59; el tratamiento diur&#233;tico que recib&#237;a previamente se hab&#237;a retirado&#44; por lo que el paciente comenz&#243; con descenso de diuresis y ganancia progresiva de peso&#46; Se consult&#243; con Nefrolog&#237;a para el ajuste de tratamiento en paciente con enfermedad renal cr&#243;nica&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se describe la respuesta cl&#237;nica de la asociaci&#243;n de metolazona oral&#44; de forma puntual a los diur&#233;ticos convencionales a altas dosis &#40;furosemida y&#47;o canreonato de potasio&#41;&#46; Con esta asociaci&#243;n&#44; tras la primera dosis de metolazona se consigui&#243; una diuresis amplia&#44; que permiti&#243; reducir en d&#237;as posteriores la dosis de diur&#233;ticos convencionales y evit&#243; que el paciente fuera sometido a sesiones de hemodi&#225;lisis-ultrafiltraci&#243;n para tratar la refractariedad al tratamiento diur&#233;tico&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Los pacientes con enfermedad renal cr&#243;nica&#44; particularmente en situaciones avanzadas&#44; que presentan anuria o sobrecarga de volumen sin respuesta efectiva a diur&#233;ticos&#44; suelen precisar de terapia de reemplazo renal con ultrafiltraci&#243;n para solucionar la situaci&#243;n cl&#237;nica&#44; para lo cual la implantaci&#243;n de un cat&#233;ter venoso central temporal suele ser mandatorio&#44; con los riesgos que conlleva realizar una t&#233;cnica invasiva &#40;infecciones&#44; punciones arteriales&#44; entre otros&#41;&#46; En este caso que se presenta&#44; se da la circunstancia que&#44; con hiperhidrataci&#243;n&#44; la funci&#243;n renal hab&#237;a mejorado inicialmente&#44; pero con refractariedad a diur&#233;ticos convencionales&#44; y la adici&#243;n de una dosis &#250;nica de metolazona junto con 1<span class="elsevierStyleHsp" style=""></span>g de furosemida intravenosa y canreonato de potasio permiti&#243; recuperar la diuresis a ritmo poli&#250;rico&#44; permitiendo liberar al paciente de terapia con ultrafiltraci&#243;n&#46; Este efecto beneficioso de conseguir diuresis a ritmo poli&#250;rico puede tener consecuencias negativas&#44; si no se realizan modificaciones en la reducci&#243;n de los diur&#233;ticos convencionales &#8211;al perpetuarse la poliuria y posibilidad de aparici&#243;n de alteraciones electrol&#237;ticas como hipopotasemia&#8211; lo cual implica una supervisi&#243;n estrecha de estos pacientes bajo esta terapia<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a>&#46; En el caso que se presenta&#44; solo fue preciso utilizar 2 dosis de metolazona para conseguir recuperar la din&#225;mica renal y mejorar la volemia&#44; adem&#225;s de una reducci&#243;n considerable de los diur&#233;ticos convencionales utilizados&#46; Entre las posibles indicaciones de uso de metolazona se ha comunicado su uso en pacientes con nefropat&#237;a terminal no candidatos a di&#225;lisis o en cuidados paliativos para conseguir un balance negativo de l&#237;quidos y permitir aliviar los s&#237;ntomas como disnea y mejorar la calidad de vida de estos pacientes<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; la metolazona podr&#237;a ser un f&#225;rmaco &#250;til en adici&#243;n a diur&#233;ticos convencionales en situaciones de sobrecarga de volumen&#44; antes de plantear terapias con di&#225;lisis&#44; y requiere una estrecha supervisi&#243;n&#44; realizando modificaciones en el tratamiento diur&#233;tico conforme a la respuesta cl&#237;nica obtenida&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Consideraciones &#233;ticas</span><p id="par0025" class="elsevierStylePara elsevierViewall">Se siguen las normas &#233;ticas correspondientes a publicaci&#243;n cient&#237;fica&#46; En este manuscrito no aparecen datos de pacientes&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financiaci&#243;n</span><p id="par0030" class="elsevierStylePara elsevierViewall">Ninguna&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicto de intereses</span><p id="par0035" class="elsevierStylePara elsevierViewall">Ninguno&#46;</p></span></span>"
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Información del artículo
ISSN: 00257753
Idioma original: Español
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos