Desfechos renais em nefrite lúpica
Arquivos
Data
2017
Autores
Polycarpo, Sabrina Bonvino 
Orientadores
Kirsztajn, Gianna Mastroianni
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
INTRODUÇÃO: A Nefrite Lúpica (NLup) é uma das manifestações mais comuns e graves do lúpus eritematoso sistêmico (LES) e afeta cerca de 60% dos adultos com a doença. É reconhecida como o preditor mais forte de pior prognóstico, influenciando tanto a morbidade quanto a mortalidade dos pacientes com LES. Apesar da evolução do tratamento ao longo dos últimos anos, são escassas as informações sobre a evolução do comprometimento renal de pacientes com LES no longo prazo. OBJETIVOS: Caracterização clínica, laboratorial e histopatológica de pacientes com NLup; definição de fatores que se associam à perda de função renal; determinação do índice de dano SLICC/ACR-DI e principais acometimentos; determinação da pontuação no domínio desse índice referente a cronicidade renal em 1, 5 e 10 anos e fatores associados. CASUÍSTICA E MÉTODOS: Estudo observacional, descritivo, retrospectivo, longitudinal, em que foram avaliados 112 pacientes com seguimento mínimo de um ano e diagnóstico anatomopatológico de NLup. Foram coletados dados demográficos, clínicos e laboratoriais, assim como de biópsia renal, tratamento e infecções; determinou-se a pontuação do SLICC/ACR-DI global e renal. Para as análises inferenciais, adotou-se o nível de significância alfa igual a 5%. RESULTADOS: A maioria dos pacientes era do sexo feminino, com mediana de idade de 29 anos. As manifestações clínicas associadas à NLup predominantes foram: hematológicas (80,4%), sobretudo anemia (74,1%), consumo de complemento (68,8%) e acometimento articular (67%). Hematúria > 100.000/mm3 na apresentação da doença renal ocorreu em 52 pacientes (53,1% daqueles com hematúria) e no final do seguimento em seis pacientes (11,1% daqueles com hematúria nesta etapa). O perfil clínico-laboratorial de apresentação correspondeu a creatinina sérica elevada (média de 1,62mg/dL) e proteinúria > 3,5g/24h em 49% e, em algum momento na evolução, em 72% dos pacientes. Predominou a NLup classe IV (64,3%), de forma isolada ou combinada; essa última ocorreu em 11 pacientes, sendo a maioria (8 de 11) com a classe V. Não se identificou qualquer caso de classe I e foi incomum a classe VI. Hipertensão arterial foi diagnosticada em 76,8% dos pacientes, necessitando na maioria dos casos apenas da prescrição de uma ou duas medicações anti-hipertensivas para controle. A NLup classe IV associou-se a pior função renal no início do acompanhamento (maior creatinina sérica inicial, menor TFGe inicial pelo CKD-EPI), HAS e, no final, a mais DRCT (TFGe < 15 mL/min), assim como detecção mais frequente de critérios de atividade renal (mais hematúria inicial e na evolução > 100.000/mL) e imunológica (maior frequência de positividade para anti-DNA). Infecções ocorreram em 58% dos pacientes em algum momento no curso da doença, predominando as de pele (27%), trato urinário (23%) e pneumonia (23%); quadros infecciosos de vias áreas superiores associaram-se ao uso de ciclofosfamida. Houve aumento estatisticamente significante do escore renal do SLICC/ACR-DI entre 5 e 10 anos de seguimento; tal aumento ocorreu às custas de apenas 11,8% da população avaliada (N=34) nas duas ocasiões. No SLICC/ACR-DI, predominou o acometimento de um só órgão (70,3%), destacando-se os danos ocular, neurológico e vascular. Evoluíram com perda de função renal (definida como dobrar a creatinina sérica inicial) 13,4% dos pacientes e com DRCT 11,6%. CONCLUSÕES: Nesta população com NLup, houve predomínio da classe IV. Perda progressiva de função renal ocorreu em 13,4% dos casos e doença renal crônica estágio 5 em 11,6%. Detectou-se aumento significante de dano renal acumulado dos 5 para os 10 anos de seguimento, o qual ao final do seguimento se associou com TFGe inicial < 75 mL/min e proteinúria 24h > 3,5g na evolução.
INTRODUCTION: Lupus Nephritis (LN) is one of the most common and serious manifestations of systemic lupus erythematosus (SLE) and affects about 60% of adults with the disease. It is recognized as the strongest predictor of poor prognosis, influencing both morbidity and mortality of patients with SLE. Despite the advances in the treatment over the last years, information about the evolution of renal impairment in patients with SLE in the long term is scarce. OBJECTIVES: Clinical, laboratory and histopathological characterization of patients with LN; definition of the factors associated with loss of renal function; determination of cumulative damage using the SLICC/ACR-DI index and main organs involvements; determination of the score in the renal domain of this index in 1, 5 and 10 years and associated factors. CASUISTIC AND METHODS: Retrospective, descriptive, observational, longitudinal study in which 112 patients with a minimum follow-up of one year and anatomopathological diagnosis of LN were evaluated. Demographic, clinical and laboratory data were collected, as well as data from renal biopsy, treatment and infections. The overall and renal SLICC/ACR-DI scores were determined. For inferential analyzes, the alpha level of significance was set at 5%. RESULTS: The majority of the patients were females, with a median age of 29 years. The predominant clinical manifestations associated with LN were hematologic (80.4%), mainly anemia (74.1%), complement consumption (68.8%) and joint involvement (67%). Hematuria > 100,000/mm3 in the presentation of renal disease occurred in 52 patients (53.1% of those with hematuria) and at the end of follow-up in six patients (11.1% of those with hematuria at this stage). At presentation, the clinical-laboratory profile corresponded to elevated serum creatinine (mean of 1.62 mg/dL) and proteinuria > 3.5 g/24h in 49% and, at some point in the course of disease, in 72% of patients. Class IV LN predominated (64.3%), alone or in combination. The latter occurred in 11 patients, the majority (8 of 11) with class V. Class VI was uncommon and there was not class I. Hypertension was diagnosed in 76.8% of the patients, requiring in most cases only one or two antihypertensive medications for control. Class IV LN was associated with worse renal function at baseline (higher initial serum creatinine, lower initial glomerular filtration rate (GFR) estimated by the CKD-EPI formula, hypertension, and, in the end, more end stage renal disease (ESRD) (GFR < 15 mL/min), as well as more frequent detection of renal activity criteria (inicial and follow-up hematúria > 100,000/mL) and immunological activity (higher frequency of anti-DNA positivity). Infections occurred in 58% of the patients at some point during the course of the disease, predominantly those of skin (27%), urinary (23%) and respiratory tracts (with 23% of pneumonia); Infections of upper respiratory tract were associated with the use of cyclophosphamide. There was a statistically significant increase in the renal score of SLICC/ACR-DI between 5 and 10 years of follow-up; this increase occurred at the expense of only 11.8% of the patients evaluated (N=34) on both situations. When scoring the SLICC/ACR-DI, one organ involvement was predominant (70.3%), and the more frequent damages were ocular, neurological and vascular; 13.4% of the patients progressed with renal function impairment (defined as doubling the initial serum creatinine), and 11,6% progressed with ESRD. CONCLUSIONS: In this population with LN, class IV was predominant. Progressive impairment of renal function occurred in 13.4% of cases and ESRD in 11.6%. A significant increase in accumulated renal damage was detected from 5 to 10 years of follow-up, which at the end of follow-up was associated with initial GFR < 75 mL/min and proteinuria 24 h > 3.5 g/24h during follow-up.
INTRODUCTION: Lupus Nephritis (LN) is one of the most common and serious manifestations of systemic lupus erythematosus (SLE) and affects about 60% of adults with the disease. It is recognized as the strongest predictor of poor prognosis, influencing both morbidity and mortality of patients with SLE. Despite the advances in the treatment over the last years, information about the evolution of renal impairment in patients with SLE in the long term is scarce. OBJECTIVES: Clinical, laboratory and histopathological characterization of patients with LN; definition of the factors associated with loss of renal function; determination of cumulative damage using the SLICC/ACR-DI index and main organs involvements; determination of the score in the renal domain of this index in 1, 5 and 10 years and associated factors. CASUISTIC AND METHODS: Retrospective, descriptive, observational, longitudinal study in which 112 patients with a minimum follow-up of one year and anatomopathological diagnosis of LN were evaluated. Demographic, clinical and laboratory data were collected, as well as data from renal biopsy, treatment and infections. The overall and renal SLICC/ACR-DI scores were determined. For inferential analyzes, the alpha level of significance was set at 5%. RESULTS: The majority of the patients were females, with a median age of 29 years. The predominant clinical manifestations associated with LN were hematologic (80.4%), mainly anemia (74.1%), complement consumption (68.8%) and joint involvement (67%). Hematuria > 100,000/mm3 in the presentation of renal disease occurred in 52 patients (53.1% of those with hematuria) and at the end of follow-up in six patients (11.1% of those with hematuria at this stage). At presentation, the clinical-laboratory profile corresponded to elevated serum creatinine (mean of 1.62 mg/dL) and proteinuria > 3.5 g/24h in 49% and, at some point in the course of disease, in 72% of patients. Class IV LN predominated (64.3%), alone or in combination. The latter occurred in 11 patients, the majority (8 of 11) with class V. Class VI was uncommon and there was not class I. Hypertension was diagnosed in 76.8% of the patients, requiring in most cases only one or two antihypertensive medications for control. Class IV LN was associated with worse renal function at baseline (higher initial serum creatinine, lower initial glomerular filtration rate (GFR) estimated by the CKD-EPI formula, hypertension, and, in the end, more end stage renal disease (ESRD) (GFR < 15 mL/min), as well as more frequent detection of renal activity criteria (inicial and follow-up hematúria > 100,000/mL) and immunological activity (higher frequency of anti-DNA positivity). Infections occurred in 58% of the patients at some point during the course of the disease, predominantly those of skin (27%), urinary (23%) and respiratory tracts (with 23% of pneumonia); Infections of upper respiratory tract were associated with the use of cyclophosphamide. There was a statistically significant increase in the renal score of SLICC/ACR-DI between 5 and 10 years of follow-up; this increase occurred at the expense of only 11.8% of the patients evaluated (N=34) on both situations. When scoring the SLICC/ACR-DI, one organ involvement was predominant (70.3%), and the more frequent damages were ocular, neurological and vascular; 13.4% of the patients progressed with renal function impairment (defined as doubling the initial serum creatinine), and 11,6% progressed with ESRD. CONCLUSIONS: In this population with LN, class IV was predominant. Progressive impairment of renal function occurred in 13.4% of cases and ESRD in 11.6%. A significant increase in accumulated renal damage was detected from 5 to 10 years of follow-up, which at the end of follow-up was associated with initial GFR < 75 mL/min and proteinuria 24 h > 3.5 g/24h during follow-up.
Descrição
Citação
POLYCARPO, Sabrina Bonvino. Desfechos renais em nefrite lúpica. São Paulo, 2017. [133] p. Dissertação (Mestrado em Medicina: nefrologia) - Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, 2017.