1. Crenoterapia in bolile renale: studiu comparativ intre statiunile de ...
1. Crenoterapia in bolile renale: studiu comparativ intre statiunile de ...
1. Crenoterapia in bolile renale: studiu comparativ intre statiunile de ...
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<strong>Crenoterapia</strong> <strong>in</strong> <strong>bolile</strong> <strong>renale</strong>, <strong>renale</strong><br />
<strong>studiu</strong> <strong>comparativ</strong> <strong>in</strong>tre <strong>statiunile</strong> <strong>de</strong><br />
profil d<strong>in</strong> Romania, Franta si Italia<br />
Dr. ADRIAN POPA
Romania are 70 <strong>de</strong> statiuni balneoclimaterice, care reprez<strong>in</strong>ta o treime<br />
d<strong>in</strong> potentialul balneoclimateric al Europei... *<br />
*Site web OPTBR 2011
…si si 15 statiuni balneare pentru tratamentul bolilor <strong>renale</strong><br />
I. Cu ape oligom<strong>in</strong>erale<br />
(care au m<strong>in</strong>eralizare totala sub 1 g/l)<br />
- Termale (acratoterme) folosite<br />
în cura externă: Băile Felix, Bala,<br />
Geoagiu, Călan, Vaţa, Moneasa,<br />
Pucioasa, Călacea, etc.<br />
- Reci (acratopege) utilizate<br />
numai în cura <strong>in</strong>ternă: Slănic<br />
Moldova (izv 300 scari).<br />
II. Cu ape oligom<strong>in</strong>erale sulfuroase<br />
(care cont<strong>in</strong> m<strong>in</strong>im 1 mg <strong>de</strong> sulf titrabil la litru, sub forma<br />
<strong>de</strong> H2S, HS-,tiosulfati sau complexe coloidale sulfuroase)<br />
Băile Olăneşti (izv 10, 11, 12 şi 24),<br />
Călimăneşti (izv 7, 14), Bala (izv 30)<br />
III. Cu ape m<strong>in</strong>erale hipotone<br />
(cu m<strong>in</strong>eralizare totala între 1 si 8 g/l)<br />
- Alcal<strong>in</strong>e (Slănic Moldova, T<strong>in</strong>ca,<br />
Malnaş) şi alcal<strong>in</strong>o-teroase (Slănic<br />
Moldova, S<strong>in</strong>georz, Biborţeni, Lipova,<br />
Vatra Dornei)<br />
- Sulfuroase: Herculane, Govora,<br />
Olăneşti, Călimăneşti, Căciulata 1,<br />
Păuşa 1 si 2, Nicol<strong>in</strong>a-Iaşi, Mangalia<br />
- Carbogazoase simple (Borsec,<br />
Lipova) şi cu componente alcal<strong>in</strong>oteroase<br />
(Bodoc, Ciunget)
Tratamentul balnear al bolilor <strong>renale</strong> <strong>in</strong> Romania<br />
(5-8% d<strong>in</strong> <strong>in</strong>dicatiile <strong>de</strong> cura <strong>in</strong> 2008-2009)<br />
• Indicatia <strong>de</strong> tratament balnear<br />
este facuta <strong>de</strong> medicul <strong>de</strong> familie sau <strong>de</strong><br />
medicul specialist<br />
• Cura este rambursata <strong>de</strong> CNAS<br />
numai pentru serviciile <strong>de</strong> recuperare<br />
locomotorie (<strong>in</strong> <strong>bolile</strong> asociate)<br />
• Durata curei este <strong>de</strong> 12-18 zile (10-14<br />
zile <strong>de</strong> tratament balnear efectiv)<br />
• Se realizeaza sub supravegherea<br />
medicului specialist d<strong>in</strong> statiunea<br />
balneara, numarul reconsultatiilor fi<strong>in</strong>d aleator<br />
• Metodologia curei se aplica pr<strong>in</strong>tr-un<br />
program terapeutic unitar si ar trebui sa fie<br />
standardizata (recomandarile INMFB sau<br />
protocoale <strong>de</strong> tratament)<br />
• Climatoterapie<br />
- Climat sedativ <strong>de</strong> cruţare<br />
• Regimul igieno dietetic<br />
- Dieta (<strong>in</strong> functie <strong>de</strong> tipul litiazei)<br />
- Alternanta repaus/activitate fizica (terapia pr<strong>in</strong><br />
mişcare fracţionată dozată, pentru evitarea<br />
pier<strong>de</strong>rilor extra<strong>renale</strong> <strong>de</strong> lichi<strong>de</strong>)<br />
• <strong>Crenoterapia</strong> (cură <strong>de</strong> diureză, pr<strong>in</strong><br />
crenoterapie cu ape oligom<strong>in</strong>erale şi / sau hipotone,<br />
<strong>in</strong> functie <strong>de</strong> tipul litiazei)<br />
- Profilactica<br />
- Curativa<br />
• Proceduri termoterapice locale sau<br />
generale mo<strong>de</strong>rate, utilizate pentru efectul lor<br />
antispastic si antialgic<br />
• Educatia pentru sanatate
Indicatiile si contra<strong>in</strong>dicatiile crenoterapiei cu ape oligom<strong>in</strong>erale (cu sau<br />
fara H2S) <strong>in</strong> afectiunile <strong>renale</strong> sunt relativ b<strong>in</strong>e <strong>de</strong>limitate <strong>de</strong> INMFR<br />
● Indicaţii în scop profilactic:<br />
- Pacienti care au avut, în ATCD, 1-2 colici<br />
<strong>renale</strong>, însoţite <strong>de</strong> elim<strong>in</strong>ări <strong>de</strong> nisip ur<strong>in</strong>ar sau<br />
calculi, fără modificări morfo-funcţionale ale<br />
căilor ur<strong>in</strong>are.<br />
- Pacienti care au în ATCD episoa<strong>de</strong> <strong>de</strong> <strong>in</strong>fecţii<br />
ur<strong>in</strong>are, fără leziuni morfo-funcţionale <strong>de</strong> nefrită<br />
<strong>in</strong>terstiţială.<br />
● Indicaţii în scop terapeutic:<br />
- Litiaza renală si/sau recidivată; litiaza renală<br />
operată si/sau recidivată ; litiaza renală cu calculi<br />
caliceali sau baz<strong>in</strong>etali, cu căi ur<strong>in</strong>are<br />
permeabile, <strong>in</strong>diferent <strong>de</strong> tipul chimic; calculi<br />
ureterali sau baz<strong>in</strong>eto-caliceali compatibili cu<br />
elim<strong>in</strong>area.<br />
- Infecţiile ur<strong>in</strong>are cronice netuberculoase.<br />
- Guta si hiperuricemiile.<br />
● Contra<strong>in</strong>dicaţii locale:<br />
- Litiaze obstructive,<br />
- Calculi mari sau coraliformi,<br />
- Insuficienţă renală > st 2,<br />
- Tumorile <strong>renale</strong><br />
- TBC renala<br />
● Contra<strong>in</strong>dicaţii generale:<br />
- Recomandarile FITEC<br />
- Ord<strong>in</strong>ul MS/1986<br />
- Indicatiile INMFB
«La France compte 120 stations thermales et détient 20% du capital thermal européen<br />
par ses 1 200 sources d'eau m<strong>in</strong>érale»*<br />
*Site web AFRETH 2011<br />
23 <strong>de</strong> statiuni cu orientare terapeutica <strong>in</strong> <strong>bolile</strong> <strong>renale</strong> *
La répartition par <strong>in</strong>dications thérapeutiques<br />
Roques Ch.F., Prési<strong>de</strong>nt du Conseil Scientifique <strong>de</strong> l’AFRETH; Le thermalisme, la mé<strong>de</strong>c<strong>in</strong>e que la terre nous a donnée; Thermalisme No 74; 2010
Une cure thermale en France…<br />
GUIDE DES BONNES PRATIQUES THERMALES; Press therm climat 2004;141:101-143<br />
• La cure est prescrite par le mé<strong>de</strong>c<strong>in</strong> traitant (généraliste ou spécialiste), sur un<br />
formulaire spécial.<br />
• Une cure thermale doit obligatoirement se dérouler sur trois sema<strong>in</strong>es, dont 18 jours<br />
<strong>de</strong> traitement, pour être remboursée par la Sécurité Sociale.<br />
• Les so<strong>in</strong>s thermaux sont prescrits par le mé<strong>de</strong>c<strong>in</strong> thermal et mis en oeuvre dans<br />
l’établissement thermal. Il y a environ 600 mé<strong>de</strong>c<strong>in</strong>s thermaux, spécialistes ou<br />
généralistes titulaires <strong>de</strong> la capacité d’hydrologie médicale.<br />
• La cure peut associer la prise en charge d’une <strong>in</strong>dication pr<strong>in</strong>cipale et d’une <strong>in</strong>dication<br />
secondaire ; elle peut, dans <strong>de</strong>s conditions le justifiant, être réalisée dans le cadre d’une<br />
hospitalisation (hôpital thermal, maison d’enfants à caractère sanitaire).<br />
• Le curiste doit subir trois visites médicales pendant son séjour, et trois so<strong>in</strong>s par jour<br />
sont obligatoires. Les techniques thermales regroupent:<br />
-> les so<strong>in</strong>s <strong>in</strong>ternes - sont <strong>de</strong>s cures <strong>de</strong> boisson ou <strong>de</strong>s <strong>in</strong>jections d'eau.<br />
-> les so<strong>in</strong>s externes - <strong>de</strong> douches (froi<strong>de</strong>s, chau<strong>de</strong>s, haute pression, sous-mar<strong>in</strong>es…),<br />
<strong>de</strong> ba<strong>in</strong>s (carbo-gazeux, aéroba<strong>in</strong>s, avec douche en immersion,…), <strong>de</strong> so<strong>in</strong>s en pisc<strong>in</strong>e<br />
(à bulles d'air, <strong>de</strong> marche…), d'étuves (vapeurs d'eaux thermales), d'applications <strong>de</strong><br />
boues thermales, etc…
Afectiunile aparatului ur<strong>in</strong>ar reprez<strong>in</strong>ta una d<strong>in</strong> cele 12 <strong>in</strong>dicatii terapeutice<br />
acceptate <strong>de</strong> «Securitatea sociala» pentru a rambursarea curei termale<br />
• Une cure climatique<br />
• Une cure <strong>de</strong> crénothérapie proprement dite:<br />
-> La cure <strong>de</strong> boisson est un élément majeur <strong>de</strong> la cure hydrom<strong>in</strong>érale <strong>de</strong> diurèse et consiste en<br />
l’<strong>in</strong>gestion d’eau m<strong>in</strong>érale à la buvette <strong>de</strong> l’établissement. Le premier choix sont les oligo-m<strong>in</strong>éraux.<br />
-> Cure <strong>de</strong> boisson à domicile. Le mé<strong>de</strong>c<strong>in</strong> thermal prescrit la livraison à domicile, les 18 jours effectifs<br />
<strong>de</strong> cure, d’eau m<strong>in</strong>érale mise en bouteille dans la nuit, dont une partie plus ou mo<strong>in</strong>s importante sera<br />
consommée au réveil, à jeun, par le curiste en décubitus dans son lit.<br />
I. Eaux oligo-m<strong>in</strong>éraux : Evian, Vittel, Contrexéville, Capvern,Volvic, Valvert, Watwiller<br />
II. Eaux oligo-m<strong>in</strong>éraux soufrés : Thonon, Sa<strong>in</strong>t-Nectaire, Plombieres, Sa<strong>in</strong>t-Perrier<br />
III. Eaux m<strong>in</strong>éraux hypotones: Vichy Célest<strong>in</strong>s , Eugénie-les-Ba<strong>in</strong>s, Aulus, La Preste, Chatel-Guyon<br />
• Une cure d'hydrothérapie<br />
- 72 so<strong>in</strong>s prévus dans le cadre du handicap uro-néphrologique: ba<strong>in</strong>s, douches, boues thermales…<br />
- posturothérapie par hydrothérapie pulsée <strong>in</strong>versée (post ESWL)<br />
« Les so<strong>in</strong>s et la cure d’eau m<strong>in</strong>érale facilitent la migration et l’élim<strong>in</strong>ation <strong>de</strong>s calculs ur<strong>in</strong>aires »<br />
• Une cure <strong>de</strong> pédagogie médicale<br />
GUIDE DES BONNES PRATIQUES THERMALES ; Press therm climat 2004;141:101-143
Indicatiile crenoterapiei cu ape oligom<strong>in</strong>erale<br />
Press therm climat 2004;141:101-143<br />
Curele <strong>in</strong>terne cu apele oligom<strong>in</strong>erale acratopege sunt <strong>in</strong>dicate în:<br />
- litiază ur<strong>in</strong>ară (mai ales formele evolutive sau/si cu recă<strong>de</strong>ri), sau post ESWL,<br />
- <strong>in</strong>fecţii reno-vezicale cronice sau recidivante,<br />
- gută si/sau hiperuricemie,<br />
- prostatite cronice,<br />
- “cistalgia cu ur<strong>in</strong>i clare”,<br />
- IRC st I si II <strong>de</strong> cauze glomerulare sau <strong>in</strong>terstitiale.<br />
Curele <strong>in</strong>terne cu ape oligom<strong>in</strong>erale acratopege sunt contra<strong>in</strong>dicate în:<br />
- litiază ur<strong>in</strong>ară cu calculi obstructivi,<br />
- hidronefroze uretero-pielice peste gr. II,<br />
- reziduu vezical postmictional peste 100 ml,<br />
- IRC care <strong>de</strong>paseste stadiul II.<br />
Curele externe cu ape acratoterme sunt <strong>in</strong>dicate în:<br />
- litiază ur<strong>in</strong>ară <strong>in</strong>diferent <strong>de</strong> forma si sediu,<br />
- fragmentele gravelare post ESWL,<br />
- prostatite cronice.<br />
Curele externe cu ape acratoterme sunt contra<strong>in</strong>dicate în:<br />
- <strong>in</strong>fectiile ur<strong>in</strong>are acute,<br />
- IRC > st. II
Non-dications et contre-<strong>in</strong>dications <strong>de</strong> la mé<strong>de</strong>c<strong>in</strong>e thermale<br />
en uro-néphrologie<br />
• Non-<strong>in</strong>dications<br />
Presse thermale et climatique 2000; 137: 89-96<br />
Hydronéphrose<br />
Reflux urétéro-vésicaux non traités urologiquement<br />
• Contre-<strong>in</strong>dications spécifiques<br />
Hypertrophie prostatique bénigne avec dysurie<br />
Gran<strong>de</strong> <strong>in</strong>suffisance rénale<br />
Tuberculose ur<strong>in</strong>aire<br />
• Contre-<strong>in</strong>dications d’ordre général<br />
Les affections évolutives susceptibles d’être aggravées par la cure:<br />
cancers en phases évolutives, maladies <strong>in</strong>flammatoires en poussée,<br />
<strong>in</strong>fections actives.<br />
Les maladies ne permettant pas <strong>de</strong> supporter la cure sur le plan général,<br />
notamment <strong>in</strong>suffisances cardiaque, hepatique et respiratoire.
“L'Italia è la nazione al mondo con il maggior numero di<br />
fonti di acqua termale”<br />
W Giglioli; S Vaccaro; L’Impiego <strong>de</strong>lle Acque M<strong>in</strong>erali nella Dietoterapia <strong>de</strong>gli Stati Fisiologici e Patologici; Giornate Reggiane di Dietetica e Nutrizione Cl<strong>in</strong>ica Settembre 2007<br />
www.sorgentitermali.it/acque-sorgenti/fonti-termali-italia.htm<br />
147 statiuni termale<br />
31 cu <strong>in</strong>dicatie <strong>in</strong> tratamentul bolilor <strong>renale</strong> :<br />
Acquasanta Terme<br />
Acquasparta<br />
Assisi<br />
Bognanco<br />
Carignano<br />
Casamicciola Terme<br />
Castellammare di Stabia<br />
Contursi Terme<br />
Fiuggi<br />
Fonti di Cottorella<br />
Forio D' Ischia<br />
Gaver<strong>in</strong>a Terme<br />
Lurisia<br />
Massa Martano<br />
Merano<br />
Pejo<br />
Porretta Terme<br />
Rabbi<br />
Recoaro Terme<br />
Riolo Terme<br />
San Gem<strong>in</strong>i<br />
Sarnano<br />
San Pellegr<strong>in</strong>o Terme<br />
Sardara<br />
Terme di Suio<br />
Tolent<strong>in</strong>o....
Le acque m<strong>in</strong>erali utilizzate <strong>in</strong> terapia idrop<strong>in</strong>ica<br />
*B. Mess<strong>in</strong>a, G. Tirri, A. Fraioli, M. Grassi; Medic<strong>in</strong>a termale e termalismo nella medic<strong>in</strong>a contemporanea;; C a l e i d o s c o p i o: 1999<br />
**Association of Italian Urologists; Gui<strong>de</strong>l<strong>in</strong>e on Ur<strong>in</strong>ary Stones; 2007; 250-302<br />
***W Giglioli; S Vaccaro; L’Impiego <strong>de</strong>lle Acque M<strong>in</strong>erali nella Dietoterapia <strong>de</strong>gli Stati Fisiologici e Patologici; Giornate Reggiane di Dietetica e Nutrizione Cl<strong>in</strong>ica Settembre,2007<br />
****Valli PP ; Hyperhydration with low m<strong>in</strong>eral Rocchetta water after extracorporeal lithotripsy; Arch Ital Urol Androl. 2000 Apr;72(1):29-31<br />
I. Le acque oligom<strong>in</strong>erale* / **<br />
(il residuo fisso a 180°C, il residuo fisso è compreso tra 50 e 500 mg/l;)<br />
- oligom<strong>in</strong>erale: Comano, Fonte Bracca,<br />
Lurisia, Merano, Recoaro Terme, Bognanco,<br />
Pejo, Rocca, Roveta, Stravignano.<br />
- oligom<strong>in</strong>erale sulfuree : Fiuggi, Bormio,<br />
Tabiano, Apuania, Acquasparta,<br />
Bagni Contursi, Caramanico, Viterbo,<br />
Montepulciano, Stigliano,Terme Pompeo.<br />
- oligom<strong>in</strong>erale bicarbonato-alcal<strong>in</strong>e***<br />
II. Le acque m<strong>in</strong>imamente m<strong>in</strong>eralizate****<br />
(il residuo fisso a 180°C, uguale o <strong>in</strong>feriore a 50 mg/litri)<br />
Rochetta, Santa Anna, Levissima<br />
III. Le acque mediom<strong>in</strong>erale**<br />
(il residuo fisso è tra 500 e 1500 mg/l)<br />
- hipotoniche sulfuree: Saturnia, Acqui<br />
Terme, Porretta Terme, Riolo Terme,<br />
Telese Terme, Stabia, Montepulciano,<br />
Riccione, Tivoli,.V<strong>in</strong>adio.<br />
- cloruro-sodiche<br />
<strong>1.</strong> Sono <strong>in</strong>dicate acque m<strong>in</strong>erali diverse a secondo <strong>de</strong>l tipo di calcolo e <strong>de</strong>l quadro metabolico <strong>de</strong>l paziente***<br />
2. Fra le oligom<strong>in</strong>erali trovano specifica <strong>in</strong>dicazione le acque a basso contenuto di sodio e prevalenza di ioni<br />
calcio e bicarbonato***.
• Indicazioni<br />
Indicazioni e contro<strong>in</strong>dicazioni<br />
- Calcolosi <strong>de</strong>lle vie ur<strong>in</strong>arie e sue recidive*<br />
- Profilassia dopo SWL**<br />
-Gotta***<br />
- Infezioni <strong>de</strong>lle vie ur<strong>in</strong>arie***<br />
• Contro<strong>in</strong>dicazioni locali****<br />
- Calcolosi ostruente,<br />
- Insufficienza <strong>renale</strong> severa,<br />
- Presenza di disturbi m<strong>in</strong>zionali<br />
• Contro<strong>in</strong>dicazioni di carattere generale*****<br />
- Cardiopatia scompensata,<br />
- Ipertensione arteriosa severa non trattata<br />
farmacologicamente,<br />
- Gastropatia ulcerosa <strong>in</strong> fase attiva,<br />
- Insufficienza respiratoria grave,<br />
- Insufficienza <strong>renale</strong> ed epatica (cirrosi),<br />
- Stati di immuno<strong>de</strong>ficienza gravi congeniti/<br />
acquisiti,<br />
- Neoplasie <strong>in</strong> atto o recenti <strong>in</strong>terventi per malattie<br />
neoplastiche,<br />
- Ipertermia, malattie <strong>in</strong>fettive,<br />
- Gravidanza.<br />
*Cochrane Database Syst.Rew.2004<br />
**Valli PP, Cesaroni M, Mear<strong>in</strong>i L; Hyperhydration with low m<strong>in</strong>eral Rocchetta water<br />
after extracorporeal lithotripsy; Arch Ital Urol Androl. 2000 Apr;72(1):29-3<strong>1.</strong> ****Association of Italian Urologists; Gui<strong>de</strong>l<strong>in</strong>e on Ur<strong>in</strong>ary Stones; 2007; 250-302<br />
**B. Mess<strong>in</strong>a, G. Tirri, A. Fraioli, Medic<strong>in</strong>a Termalee Termalismo,1999; pg 38 *****Giovanni Agost<strong>in</strong>i : Manuale di medic<strong>in</strong>a termale ; Archimedica, Tor<strong>in</strong>o 1997
3-5% d”<strong>in</strong>dicazioni di cura<br />
W Giglioli; S Vaccaro; L’Impiego <strong>de</strong>lle Acque M<strong>in</strong>erali nella Dietoterapia <strong>de</strong>gli Stati Fisiologici e Patologici; Giornate Reggiane di Dietetica e Nutrizione Cl<strong>in</strong>ica Settembre,2007<br />
Trascorrere una vacanza benessere con <strong>de</strong>lle cure agevolate <strong>in</strong> è possibile a le terme<br />
qui sono convenzionate con il Servizio Sanitario Nazionale*.<br />
<strong>1.</strong> Le agevolazioni <strong>de</strong>l Servizio Sanitario Nazionale valgono anche per la cura idrop<strong>in</strong>ica.<br />
2. Per acce<strong>de</strong>re gratuitamente alle seguenti cure termali:<br />
• bagni termali<br />
• idromassaggi<br />
• <strong>in</strong>alazioni ed aerosol<br />
• ventilazioni polmonari<br />
• irrigazioni vag<strong>in</strong>ali<br />
basta presentarsi con la sola ricetta <strong>de</strong>l proprio medico di famiglia, unitamente alla tessera<br />
sanitaria ed al codice fiscale. Le ricetta <strong>de</strong>ve riportare la diagnosi corrispon<strong>de</strong>nte ad una<br />
<strong>de</strong>lle patologie previste dal D.M. 15.12.1994 (malattie <strong>de</strong>ll'apparato ur<strong>in</strong>ario: calcolosi <strong>de</strong>lle vie<br />
ur<strong>in</strong>arie e sue recidive) ed il correlato ciclo di cure da praticare.<br />
I medici consigliano mediamente 14 giorni effective di cura.<br />
3.Tutti possono usufruire una volta all'anno di un ciclo di cure termali a carico <strong>de</strong>l S.S.N.<br />
*SSN Ital<strong>in</strong>o: Cure termali / Guida Terme; 2011
Consens - efectele curei<br />
• Efect mecanic pr<strong>in</strong> hiperdiureză: ↑ fluxului ur<strong>in</strong>ar = 150-180 ml/h; diluţia ur<strong>in</strong>ei si<br />
↓ <strong>de</strong>nsităţii ur<strong>in</strong>are = 1012, ⇒ cu spălarea mecanică şi înlăturarea fenomenelor disk<strong>in</strong>etice<br />
• Efect chimic pr<strong>in</strong> modificarea compoziţiei fizico-chimice a ur<strong>in</strong>ei: aport <strong>de</strong> substanţe<br />
cu modificarea compoziţiei ionice a ur<strong>in</strong>ei ⇒ înlăturarea condiţiilor litoformatoare,<br />
modificarea pH-ului şi a raportului Ca/Mg<br />
• Efect <strong>de</strong> sterilizare a ur<strong>in</strong>ei: <strong>de</strong>bit ur<strong>in</strong>ar↑ ⇒fluxul ur<strong>in</strong>ar crescut şi cont<strong>in</strong>uu împiedică<br />
ascensionarea germenilor d<strong>in</strong> vezica ur<strong>in</strong>ară spre r<strong>in</strong>ichi (important <strong>de</strong> adm<strong>in</strong>istrat doza <strong>de</strong><br />
seara pentru că în condiţiile <strong>de</strong> cl<strong>in</strong>ostatism ↓ diureza si hiperconcentrarea nocturna a<br />
ur<strong>in</strong>ei)<br />
• ↑ <strong>de</strong>bitului sangu<strong>in</strong> în medulara renală (are 1/10 d<strong>in</strong> <strong>de</strong>bitul sangu<strong>in</strong> renal şi un<strong>de</strong> se<br />
localizeaza leziunile <strong>in</strong>flamatorii-<strong>in</strong>fecţioase d<strong>in</strong> nefropatii <strong>in</strong>terstiţiale şi pielonefrită) ⇒<br />
↑ mecanismele imunologice <strong>de</strong> apărare locale<br />
• ↓ hipertoniei osmotice medulare <strong>renale</strong> (concentraţia osmotică medulară este <strong>de</strong> 4 ori<br />
mai mare <strong>de</strong>cât în plasmă cu medulara mai hipertonă si vulnerabilă la <strong>in</strong>fecţii)<br />
⇒ activareamecanismelor imunologice <strong>de</strong> apărare locală<br />
⇒ blocarea mecanismului <strong>in</strong>trarenal <strong>de</strong> concentrare a ur<strong>in</strong>ei «<strong>in</strong> contracurent»
Consens - terapeutic<br />
• Cura balneara reprez<strong>in</strong>ta o metoda terapeutica adjuvanta <strong>in</strong> <strong>bolile</strong> <strong>renale</strong>.<br />
• Adresabilitatea pentru aceasta grupa <strong>de</strong> afectiuni este mult sub cea a bolilor reumatismale, ale cailor respiratorii si cardiovasculare<br />
(care reprez<strong>in</strong>ta global, 75-85% d<strong>in</strong> solicitarile <strong>de</strong> cura).<br />
• In toate statisticile, litiaza renala si formele ei reprez<strong>in</strong>ta prima si cea mai frecventa <strong>in</strong>dicatie.<br />
• Alegerea statiunii:<br />
I. se prefera <strong>in</strong> toate cazurile apele oligom<strong>in</strong>erale <strong>in</strong> “cura <strong>de</strong> diureza”: 30-50 ml?Kgc/zi.<br />
II.se poate t<strong>in</strong>e cont <strong>de</strong> corespon<strong>de</strong>nta d<strong>in</strong>tre tipul apelor m<strong>in</strong>erale si compozitia liliazei. Cont<strong>in</strong>utul <strong>de</strong> NaHCO 3 , Ca, CO 2 ,<br />
si H 2 S (?) creste efectul diuretic si <strong>de</strong> aceea a doua optiune apart<strong>in</strong>e acestor grupe <strong>de</strong> ape (oligom<strong>in</strong>erale sau hipotone).<br />
Cont<strong>in</strong>utul m<strong>in</strong>eral si pH-ul apelor poate <strong>in</strong>terveni <strong>in</strong> sens corector al unor conditii litogene speciale (guta, cist<strong>in</strong>oza)<br />
• Este recunoscut efectul profilactic al curei (sca<strong>de</strong> <strong>in</strong>ci<strong>de</strong>nta > 50% recidivelor si/sau dimensiunea calculilor restanti).<br />
• Efectul curativ – elim<strong>in</strong>ator, nu este <strong>in</strong>tot<strong>de</strong>auna <strong>de</strong>monstrat, elim<strong>in</strong>area calculilor <strong>de</strong>p<strong>in</strong>zand si <strong>de</strong> conditii anatomice<br />
<strong>in</strong>dividuale.<br />
• Procedurile asociate (termoterapia si hidroterapia) faciliteaza efectul elim<strong>in</strong>ator al crenoterapiei si actioneaza <strong>in</strong> sens<br />
antialgic-antispastic. Avantajul statiunilor termale cu ape oligom<strong>in</strong>erale acratoterme sulfuroase este <strong>de</strong> a asocia cura<br />
<strong>in</strong>terna cu balneatia <strong>in</strong> acelasi pachet terapeutic.<br />
• Indicatiile curei balneare sunt aceleasi <strong>in</strong> toate tarile, dar rambursarea pr<strong>in</strong> asigurarile <strong>de</strong> sanatate este diferita.<br />
• Contra<strong>in</strong>dicatiile curei balneare sunt b<strong>in</strong>e <strong>in</strong>cadrate <strong>in</strong> toate tarile (<strong>de</strong>si nu exista studii <strong>de</strong> referita pentru efectele adverse<br />
a curelor balneare).<br />
• Metodologia curei balneare este perfect standardizata <strong>in</strong> Franta, pr<strong>in</strong> colaborarea d<strong>in</strong>tre S<strong>in</strong>dicatul medicilor d<strong>in</strong> <strong>statiunile</strong><br />
termale si Asigurarile <strong>de</strong> sanatate.
… <strong>in</strong> Romania<br />
• Ju<strong>de</strong>tul Valcea cu <strong>statiunile</strong> Olanesti si Calimanesti, <strong>de</strong>t<strong>in</strong>e monopolul apelor oligom<strong>in</strong>erale d<strong>in</strong> Romania.<br />
Prezenta H 2 S <strong>in</strong> aceste ape nu reprez<strong>in</strong>ta un element limitativ al curei.<br />
• Adresabilitatea pacientilor cu sufer<strong>in</strong>te <strong>renale</strong> catre aceste statiuni este <strong>de</strong> 70 - 75% d<strong>in</strong> numarul <strong>de</strong><br />
recomandari terapeutice (ca afectiune pr<strong>in</strong>cipala sau asociata).<br />
• Recunoasterea <strong>de</strong> catre CNAS a <strong>in</strong>dicatiei <strong>de</strong> cura pentru afectiuni <strong>renale</strong> <strong>in</strong> aceste statiuni balneare<br />
reprez<strong>in</strong>ta o problema <strong>de</strong> fond<br />
• Cura externa, practicata <strong>in</strong> cele doua statiuni nu este recunoscuta si rambursata <strong>de</strong> CNAS<br />
• Procedurile <strong>de</strong> fizio-k<strong>in</strong>etoterapie d<strong>in</strong> cadrul programelor <strong>de</strong> recuperare locomotorie<br />
(ca patologie asociata) efectuate <strong>in</strong> aceste statiuni sunt recunoscute si rambursate <strong>de</strong> CNAS
Va multumesc !