Recomendaciones para evaluar la tasa de filtrado glomerular menor de 60 ml/min/1, 73 m2 en pacientes con enfermedad renal y diabetes mellitus / Recommendations to evaluate the glomerular filtration rate below 60 ml/min/1. 73 m2 in patients with kidney disease and diabetes

Diagnosticar, clasificar y estadificar la enfermedad renal en pacientes con diabetes mellitus (DM) es un desafío tanto para los médicos de atención primaria como para los especialistas, porque no existe método en la práctica clínica que evalúe la tasa de filtrado glomerular (TFG) en forma precisa. Para evaluar la función renal en enfermedad renal crónica (ERC) con menos de 60 ml/min/1.73m2 , correspondiente a los estadios 3, 4 y 5 de la clasificación actual, los métodos disponibles en los laboratorios clínicos son de limitada exactitud. En este trabajo se desarrollarán las condiciones que debería cumplir un marcador ideal, las dificultades que ofrece la evaluación de la creatinina, la medición de la TFG, así como las ventajas y limitaciones de las recomendaciones del uso de fórmulas para su determinación, y el algoritmo actual para estimar función renal. Conclusiones: actualmente, a pesar de las limitaciones, se recomienda el empleo de fórmulas para la estimación de la TFG, sobre todo en TFG menor a 60 ml/min/1.73 m2. Es un desafío, para un futuro mediato, desarrollar mejores recursos para su evaluación.

To diagnose,classify and stage diabetic kidney disease in patients with diabetes mellitus is a challenge in clinical practice for both primary care physicians and specialists because there is no method in clinical practice that evaluates accurately the glomerular filtration rate (GFR). This challenge is due to difficulties in evaluating kidney function in stages of chronic kidney disease (CKD) below 60 ml/min/1.73m2 corresponding to stages 3, 4 and 5 of the classification, because the available tools in clinical laboratories are of limited accuracy. This work explores the conditions that an ideal marker should meet, the difficulties offered by the evaluation of serum creatinine, the measurement of the glomerular filtration rate (GFR) as well as the advantages and limitations of the recommendations of the use of formulas for its determination and the current algorithm to estimate renal function. Conclusions: currently, despite the limitations, the use of formulas for the diagnosis of renal function is recommended, especially in GFR below 60 ml/min/1.73 m2. It is a challenge for the near future to develop better tools for the evaluation of TGF.

Recomendaciones para evaluar la tasa de filtrado glomerular menor de 60 ml/min/1,73 m2 en pacientes con enfermedad renal y diabetes mellitus / Recommendations to evaluate the glomerular filtration rate below 60 ml/min/1.73 m2 in patients with kidney disease and diabetes

Resumen Diagnosticar, clasificar y estadificar la enfermedad renal en pacientes con diabetes mellitus (DM) es un desafío tanto para los médicos de atención primaria como para los especialistas, porque no existe método en la práctica clínica que evalúe la tasa de filtrado glomerular (TFG) en forma precisa. Para evaluar la función renal en enfermedad renal crónica (ERC) con menos de 60 ml/min/1.73m., correspondiente a los estadios 3, 4 y 5 de la clasificación actual, los métodos disponibles en los laboratorios clínicos son de limitada exactitud. En este trabajo se desarrollarán las condiciones que debería cumplir un marcador ideal, las dificultades que ofrece la evaluación de la creatinina, la medición de la TFG, así como las ventajas y limitaciones de las recomendaciones del uso de fórmulas para su determinación, y el algoritmo actual para estimar función renal. Conclusiones: actualmente, a pesar de las limitaciones, se recomienda el empleo de fórmulas para la estimación de la TFG, sobre todo en TFG menor a 60 ml/min/1.73 m.. Es un desafío, para un futuro mediato, desarrollar mejores recursos para su evaluación.

Abstract To diagnose,classify and stage diabetic kidney disease in patients with diabetes mellitus is a challenge in clinical practice for both primary care physicians and specialists because there is no method in clinical practice that evaluates accurately the glomerular filtration rate (GFR). This challenge is due to difficulties in evaluating kidney function in stages of chronic kidney disease (CKD) below 60 ml/min/1.73m. corresponding to stages 3, 4 and 5 of the classification, because the available tools in clinical laboratories are of limited accuracy. This work explores the conditions that an ideal marker should meet, the difficulties offered by the evaluation of serum creatinine, the measurement of the glomerular filtration rate (GFR) as well as the advantages and limitations of the recommendations of the use of formulas for its determination and the current algorithm to estimate renal function. Conclusions: currently, despite the limitations, the use of formulas for the diagnosis of renal function is recommended, especially in GFR below 60 ml/min/1.73 m2. It is a challenge for the near future to develop better tools for the evaluation of TGF. Key words: renal function; glomerular filtration rate; creatinine; creatinine clearance.

Exercício físico de moderada intensidade contribui para o controle de parâmetros glicêmicos e clearance de creatinina em pessoas com Diabetes Mellitus tipo 2 / Aerobic physical training at moderate intensity contributes to the control of glycemic parameters and clearance of creatinine in individuals with Diabetes Mellitus type 2

As doenças crônicas não transmissíveis há muitos anos vêm causando grande impacto à saúde pública, particularmente as patologias relacionadas ao mau funcionamento do metabolismo, dentre as quais podemos incluir o diabetes mellitus tipo 2 (DM2). A principal estratégia para o seu controle sustenta-se na tríade exercício físico, alimentação saudável e medicamento. Diante de tais fatos, Diante de tais fatos, nosso objetivo foi avaliar o efeito de um programa de exercício físico aeróbio, mais especificamente caminhada com intensidade moderada, sobre os parâmetros glicêmicos (glicemia de jejum, glicemia pós-prandial e hemoglobina glicada), e clearance de creatinina de pessoas diagnosticados com DM2, e realizando acompanhamento clínico e farmacológico há, ao menos, três anos. O modelo de estudo caracterizou-se como quase experimental longitudinal "antes e depois". Os pacientes (n=25) foram avaliados em quatro momento: M0=início do experimento; M1=quatro semanas; M2=oito semanas; M3=final do experimento (12 semanas). Foram realizadas coletas sanguíneas e de urina conforme determina os protocolos para análise de glicemia de jejum, glicemia pós-prandial e hemoglobina glicada e clearance de creatinina. O programa de exercícios físicos promoveu redução significativas na glicemia pós-prandial, na hemoglobina glicada e clearance de creatinina. Analisando o conjunto dos resultados obtidos, conclui-se que o programa de exercício físico de moderada intensidade foi capaz de promover melhor controle glicêmico e contribuir para a redução discreta do clearance de creatinina, sendo este associado a patologias renais que, comumente, acomete essa população.(AU)

The non-communicable chronic diseases generate great impact to public health, particularly the pathologies related to malfunction of metabolism, among which is include the diabetes mellitus type 2 (DM2). The main strategy for DM2 control is the triad physical exercise, healthy nutrition and medicine. Thus, our goal was to evaluate the effect of aerobic exercise program (walking at moderate intensity) on metabolic parameters (fasting blood glucose, postprandial glycaemia and glycated hemoglobin), and creatinine clearance of individuals with DM2. The study model was characterized as almost longitudinal trial "before and after. The patients (n=25) has been evaluated in four moments: M0 = beginning of the experiment; M1 = four weeks; M2 = eight weeks; M3 = end of the experiment (12 weeks). Blood and urine samples has been collected for determination of fasting glucose, postprandial glycaemia, glycated hemoglobin and clearance of creatinine. The physical exercise program promoted reduction in fasting blood glucose, postprandial blood glucose, glycated hemoglobin and creatinine clearance in men males and postprandial blood glucose and creatinine clearance in women's group evaluated. Thus, it is possible to infer that the applied exercise sessions three times a week, for three months, were enough to induce substantial changes, especially in men, with regard to biochemical as well as clinical parameters evaluated. The physical exercise program promoted significative reduction in the postprandial glycaemia, glycated hemoglobin, and creatinine clearance. Taken together, our results allow us to conclude that the aerobic physical training at moderate intensity was able to induce to a better glycemic control as well as to contribute to the discreet reduction of creatinine clearance, being this associated to renal pathologies that, commonly, affect this population.(AU)

Comparación entre las ecuaciones CKD-EPI y MDRD para la estimación del filtrado glomerular en pacientes con enfermedad renal crónica / Comparison between CKD-EPI and MDRD-equations to estimate glomerular filtration rate in chronic kidney disease patients

La ecuación MDRD para la estimación del índice de filtrado glomerular (IFG), es la estrategia más utilizada para evaluar pacientes con enfermedad renal crónica (ERC). Sin embargo, puede subestimar el IFG con el riesgo de asignar al paciente a estadios más avanzados de ERC. La nueva ecuación CKD-EPI, mejoraría la exactitud y precisión de las estimaciones. Sus autores sugieren que reemplace a la anterior. No habiendo comparaciones de estas ecuaciones aplicadas en un gran número de pacientes en nuestro país, nuestro objetivo fue realizarla en una amplia cohorte de pacientes. Se evaluó la concordancia de asignación en estadios de ERC entre ambas ecuaciones, tomando como referencia los datos surgidos de MDRD. Se calculó la media de las diferencias de los IFG obtenidos empleando ambas ecuaciones y se aplicó el análisis estadístico de Bland-Altman. Se estudió una cohorte de 9 319 pacientes con una media de creatinina sérica de 1.60 ± 1.03 mg/dl, 67% de sexo femenino y edad media 58 ± 20 años. En el grupo total, CKD-EPI presentó una media de IFG 0.61 ml/min/1.73 m² mayor que MDRD (p: NS). En los estadios 2 y 3A las medias del IFG fueron respectivamente 6.95 ± 4.76 y 3.21 ± 3.31, y la concordancia de 81 y 74%. El porcentaje de pacientes con un IFG menor de 60 ml/min/1.73 m², se redujo de 76.3% (MDRD) a 70.1% (CKD-EPI). Por lo tanto, la nueva ecuación CKD-EPI disminuye el número de pacientes con IFG debajo de 60 ml/min/1.73 m² y asigna estadios de IFG más elevado a un número mayor de pacientes.

The MDRD equation to estimate glomerular filtration rate (GFR) is the most widely used strategy to assess chronic kidney disease. Nonetheless, for the individual patient the true GFR can be underestimated with the risk of diagnosing a more elevated CKD stage. This novel CKD-EPI equation would improve accuracy and precision of estimations, and several authors recommend this new equation replace the former. In our country there is only a limited registration of these comparisons performed on a large number of patients. Therefore, our aim was to develop a comparison in a wide cohort of patients. The concordance between both equations to assign the GFR stages was determined by using the MDRD formula as a reference. The mean difference of GFR obtained with both equations as well as the Bland-Altman analysis were calculated. A cohort of 9 319 individuals, of whom 67% were females, aged 58 ± 20 years, with serum creatinine values of 1.6 ± 1.03 mg/dl, was studied. In the whole group, CKD-EPI displayed an average GFR 0.61 ml/min/1.73 m² larger than MDRD (p: NS). For CKD stages 2 and 3A the mean estimated GFR difference was 6.95 ± 4.76 and 3.21 ± 3.31, while the concordance was 81 and 74% respectively. The percentage of patients with GFR < 60 ml/min/1.73 m², decreased from 76.3% with the former equation to 70.1% with the latter. The novel equation CKD-EPI reduces the number of patients with GFR values lower than 60 ml/min/1.73 m² and consequently assigns a higher GFR stage to a considerable quantity of individuals.

Insuficiência renal aguda / Acute renal failure

A Insuficiência Renal Aguda (IRA) pode estar associada a várias etiologias no organismo humano,sendo este um dos motivos da importância dispensada àa esta doença. A prevenção é a principal ferramenta do médico e quando esta não foi possível, o tratamento visa afastar as principais causas,com investigação das demais e medidas de suporte para manter a viabilidade renal, muitas das vezes com êxito. A taxa de mortalidade em pacientes com IRA não se alterou muito nos últimos 30 anos. Os óbitos podem ocorrer em consequência da doença de base e não da própria IRA, pois o rim é um dos poucos órgãos cuja função pode ser substituída em parte por longos períodos (ex. diálise).

The Acute Renal Failure (ARF) can be related to several etiologies in the human organism, being one ofthe reasons of the importance given to this disease. The prevention is the doctor's main tool and, whenit is not possible, the treatment looks forward repelling the main causes, also investigating the othersand keeping supportive care to maintain the renal viability, most of the times, successfully. The mortalityrate in patients with ARF did not change much in the last 30 years. The deaths can occur as a result of theunderlying disease and not of ARF, because the kidney is one of the few organs which function can besubstituted, in part, for long periods (ex. dialysis).

Cistatina C: um novo marcador para a filtração glomerular comparada ao clearance de creatinina e a creatinina sérica / Cystatin C: a new marker for glomerular filtration rate compared to creatinine clearance and serum creatinine

A Cistatina C é uma proteína de baixo peso molecular (- 13 kDa) produzida constantemente em todas as células nucleadas. Esta molécula é livremente filtrada no glomérulo renal, reabsorvida e catabolizada no túbulo proximal, sendo os níveis séricos dependentes e indicadores da função de filtração glomerular. Esta revisão aborda o desempenho da Cistatina C em relação aos testes usualmente empregados na rotina laboratorial para avaliação da função renal. Verifica-se que a Cistatina C é um marcador confiável da filtração glomerular mais sensível e específico que as determinações de creatinina sérica e clearance de creatinina, e pode ser uma alternativa atrativa, especialmente quando a população pediátrica é considerada.