Duplo bloqueio do sistema renina-angiotensina-aldosterona como medida antiproteinúrica em glomerulopatias primárias
Data
2024-03-27
Tipo
Dissertação de mestrado
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Introdução: A proteinúria é uma das principais características da doença glomerular, e mudanças precoces na proteinúria reduzem a progressão da doença renal no longo prazo. Algumas estratégias anti-proteinúricas estão disponíveis, incluindo a inibição do sistema renina-angiotensina-aldosterona (SRAA) com inibidores da enzima conversora da angiotensina (IECA) ou bloqueadores do receptor de angiotensina II (BRA). Existem algumas razões fisiopatológicas para o uso combinado de IECA e BRA para controle de proteinúria, porém existem divergências em relação à efetividade e segurança desta medida terapêutica. Objetivo: avaliar o grau de redução da proteinúria e os desfechos renais, assim como os efeitos colaterais da combinação de IECA e BRA em diferentes glomerulopatias proteinúricas com diagnóstico histológico definido por biópsia renal. Métodos e casuística: Trata-se de estudo observacional, retrospectivo e unicêntrico, através de coleta de dados de prontuários do Ambulatório de Glomerulonefrites da UNIFESP - EPM. Foram avaliados 400 prontuários, e incluídos 23 pacientes de idade < 65 anos, com os seguintes diagnósticos: Nefropatia por IgA (43,5%), doença de lesões mínimas ou glomeruloesclerose segmentar e focal (34,8%) e nefropatia membranosa (21,7%). Estes pacientes se encontravam já sem imunossupressão ou com dose estável, com proteinúria mantida após 6 a 12 meses a despeito do uso de IECA ou BRA, e que foram submetidos ao duplo bloqueio com associação IECA + BRA, com seguimento médio de 12 meses após a associação. Foram avaliados os seguintes desfechos: redução da proteinúria, aumento da creatinina sérica, hipercalemia, eventos cardiovasculares e óbito. Resultados: Em relação à função renal, 58% dos pacientes tiveram aumento percentual da creatinina - resultado semelhante à taxa de filtração glomerular (TFG), porém nenhum paciente evoluiu com evolução para DRCET. Quanto à proteinúria, 47% reduziram mais que 25% seus níveis de proteinúria e 17% reduziram - porém menos que 25%. Ocorreu aumento de proteinúria em 21%. Os níveis de potássio não apresentaram alteração significativa ao longo do tempo (p=0,900). Não houve relato em prontuário de hipotensão documentada em consulta, e houve 1 evento cardiovascular (IAM) relatado. Nenhum óbito foi documentado durante o seguimento. Conclusão: em nossa amostra, verificamos redução satisfatória de proteinúria com a associação IECA + BRA. Excluímos da análise pacientes de alto risco para eventos adversos (idosos, portadores de DRC avançada, diabéticos) e, por isso, não observamos aumento de risco com a associação.
Introduction: Proteinuria is one of the main features of glomerular disease, and early changes in proteinuria reduces the long-term progression of kidney disease. Some anti-proteinuric strategies are available, including inhibition of the renin-angiotensinaldosterone system (RAAS) with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs).There are some pathophysiological reasons for the combined use of ACE inhibitors and ARBs to control roteinuria, but there are disagreements regarding the effectiveness and safety of this therapeutic measure. Objective: to evaluate the degree of duction in proteinuria and renal outcomes, as well as the side effects of the combination of ACE inhibitors and ARBs in different proteinuric glomerulopathies with histological diagnosis defined by renal biopsy.Methods and sample: This is an observational, retrospective and single-center study, collecting data from medical records at the Glomerulonephritis Outpatient Clinic at UNIFESP - EPM. 400 medical records were evaluated, and 23 patients aged < 65 years were included, with the following diagnoses: IgA nephropathy (43.5%), minimal change disease or focal segmental glomerulosclerosis (34.8%) and membranous nephropathy (21.7%). These patients were already without immunosuppression or on a stable dose, with proteinuria maintained after 6 to 12 months despite the use of ACE inhibitors or ARBs, and who underwent double blockade with a combination of ACE inhibitors + ARBs, with an average follow-up of 12 months after Association. The following outcomes were evaluated: reduction in proteinuria, increase in serum creatinine, hyperkalemia, cardiovascular events and death. Results: In relation to renal function, 58% of patients had a percentage increase in creatinine - a result similar to the glomerular filtration rate (GFR), but no patient developed ESRD. As for proteinuria, 47% reduced their proteinuria levels by more than 25% and 17% reduced it - but less than 25%. There was an increase in proteinuria by 21%. Potassium levels did not show significant changes over time (p=0.900). There was no report in the medical records of hypotension documented in consultation, and there was 1 cardiovascular event (AMI) reported. No deaths were documented during follow-up. Conclusion: in our sample, we found a satisfactory reduction in proteinuria with the combination of ACEI + ARB. We excluded from the analysis patients at high risk for adverse events (elderly, people with advanced CKD, diabetics) and, therefore, we did not observe an increase in risk with the association.
Introduction: Proteinuria is one of the main features of glomerular disease, and early changes in proteinuria reduces the long-term progression of kidney disease. Some anti-proteinuric strategies are available, including inhibition of the renin-angiotensinaldosterone system (RAAS) with angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs).There are some pathophysiological reasons for the combined use of ACE inhibitors and ARBs to control roteinuria, but there are disagreements regarding the effectiveness and safety of this therapeutic measure. Objective: to evaluate the degree of duction in proteinuria and renal outcomes, as well as the side effects of the combination of ACE inhibitors and ARBs in different proteinuric glomerulopathies with histological diagnosis defined by renal biopsy.Methods and sample: This is an observational, retrospective and single-center study, collecting data from medical records at the Glomerulonephritis Outpatient Clinic at UNIFESP - EPM. 400 medical records were evaluated, and 23 patients aged < 65 years were included, with the following diagnoses: IgA nephropathy (43.5%), minimal change disease or focal segmental glomerulosclerosis (34.8%) and membranous nephropathy (21.7%). These patients were already without immunosuppression or on a stable dose, with proteinuria maintained after 6 to 12 months despite the use of ACE inhibitors or ARBs, and who underwent double blockade with a combination of ACE inhibitors + ARBs, with an average follow-up of 12 months after Association. The following outcomes were evaluated: reduction in proteinuria, increase in serum creatinine, hyperkalemia, cardiovascular events and death. Results: In relation to renal function, 58% of patients had a percentage increase in creatinine - a result similar to the glomerular filtration rate (GFR), but no patient developed ESRD. As for proteinuria, 47% reduced their proteinuria levels by more than 25% and 17% reduced it - but less than 25%. There was an increase in proteinuria by 21%. Potassium levels did not show significant changes over time (p=0.900). There was no report in the medical records of hypotension documented in consultation, and there was 1 cardiovascular event (AMI) reported. No deaths were documented during follow-up. Conclusion: in our sample, we found a satisfactory reduction in proteinuria with the combination of ACEI + ARB. We excluded from the analysis patients at high risk for adverse events (elderly, people with advanced CKD, diabetics) and, therefore, we did not observe an increase in risk with the association.
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Citação
MENEZES, Shirley Gonçalves. Duplo bloqueio do sistema reninaangiotensinaaldosterona Como medida antiproteinúrica em glomerulopatias primárias. 2024. 76 f. Dissertação (Mestrado em Nefrologia) – Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2024.