Microalbuminuria como marcador de daño renal en pacientes con hipertensión arterial / Microalbuminuria as a marker of kidney damage in patients with arterial hypertension

Introducción: La hipertensión arterial es un poderoso factor de riesgo de daño renal. La prevalencia es muy alta entre los pacientes con Enfermedad Renal Crónica. Objetivo: Determinar la presencia de Microalbuminuria y su valor como marcador de daño renal en pacientes con diagnóstico de Hipertensión arterial. Material y Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo de 123 pacientes. Se determinó edad, sexo, cifras de colesterol, triglicéridos, creatinina y microalbuminuria y factores de riesgo vascular. Se utilizó la estadística descriptiva e inferencial. Resultados: El 40,7 Microalbuminuria as a marker of kidney damage in patients with arterial hypertension de los pacientes pertenecen al grupo de más de 70 años con predominio del sexo masculino (65 por ciento), 62,6 Microalbuminuria as a marker of kidney damage in patients with arterial hypertension presentaron microalbuminuria, 97,3 Microalbuminuria as a marker of kidney damage in patients with arterial hypertension tenían factores de riesgo asociados con prevalencia aumentada del tabaquismo, dislipidemia, obesidad y enfermedades vasculares asociadas con RP>1. Predominó el grupo mayor de 70 años, del sexo masculino, con presencia de microalbuminuria. La presencia de más de tres factores de riesgo se asoció a la microalbuminuria. La presencia de microalbuminuria aumentó con los años de evolución de la enfermedad. Predominó el estadio 3 de la Enfermedad Renal Crónica en los pacientes con hipertensión arterial y microalbuminuria y se relacionó directamente con los años de evolución de la hipertensión arterial. Conclusiones: La determinación de la microalbuminuria en los pacientes con hipertensión arterial es un marcador de riesgo importante y sencillo para determinar el daño renal subclínico y está muy relacionado con el incremento de la edad del paciente, años de hipertensión y asociación con otros factores de riesgo vasculares(AU)

Introduction: Arterial hypertension is a powerful risk factor for kidney damage. The prevalence is very high among patients with chronic kidney disease. Objective: To determine the presence of microalbuminuria as a marker of kidney damage in patients with arterial hypertension admitted between September 2016 and September 2017. Material and Methods: A descriptive, longitudinal, prospective study was conducted in 123 patients. Age; sex; cholesterol, triglycerides, creatinine and microalbuminuria levels and vascular risk factors were determined. Descriptive and inferential statistics were used. Results: The 40.7 percent of patients belong to the group of patients of age more than 70 years, predominating the male sex (65 percent); 62.6 percent of them presented microalbuminuria and 97.3 percent had risk factors associated with an increased prevalence of smoking, dyslipidemia, obesity, and vascular diseases associated with RP> 1. The group of patients older than 70 years, male, and with presence of microalbuminuria predominated in the study. The presence of more than three risk factors was associated with microalbuminuria. The presence of microalbuminuria increased with the years of evolution of the disease. Stage 3 of chronic kidney disease predominated in patients with arterial hypertension and microalbuminuria and it was directly related to the years of evolution of arterial hypertension. Conclusions: The determination of microalbuminuria in patients with arterial hypertension is a simple and important risk marker to determine subclinical kidney damage and it is closely related to the increase in the age of the patient, the years of hypertension, and the association with other risk factors for vascular disease(AU)

Marcadores de Inflamação, Microalbuminúria e Controle de Pressão Arterial em Cuidados de Saúde Primários / Inflammation Markers, Microalbuminuria and Blood Pressure Control in Primary Health Care

Fundamento: A hipertensão arterial sistêmica (HAS) é uma causa importante de morbidade e mortalidade cardiovascular. Apesar da eficácia do tratamento, um alto número de pacientes não obtém controle de pressão arterial (PA), um fato que implica a necessidade de investigar o papel de outros fatores adicionais, como marcadores de inflamação e microalbuminúria, especialmente em ambientes de saúde. Objetivos: Avaliar a associação entre os níveis de fibrinogênio sérico, Proteína C-reativa ultrassensível (PCR) e microalbuminúria, com medidas de pressão arterial (PA) avaliadas através de monitorização ambulatorial da pressão arterial (MAPA) em pacientes hipertensos, em ambiente de cuidados de saúde primários. Métodos: Foi realizado um estudo transversal com pacientes hipertensos que foram atendidos em centros de cuidados de saúde primários. Uma avaliação de PA foi efetuada pelo médico de cuidados primários, e este procedimento foi seguido por um teste de referência de 24 horas (MAPA), realizado por um profissional independente. Adicionalmente, a coleta de sangue periférico foi realizada para análise futura de marcadores bioquímicos. Resultados: 143 pacientes foram incluídos. Havia uma tendência para associação entre a variável independente (PA alterada por MAPA de 24 horas) e variável dependente (PCR), havia uma associação entre os valores > 3 mg/dL e MAPA alterada de 24 horas. A razão de prevalência (RP) foi de 1,36 (CI 95% 0,90 ­ 2,06); p=0,18. A respeito dos achados de microalbuminúria e fibrinogênio, foi observada RP 1,03 (CI 95% 0,41 ­ 2,57); p=1 e RP 1,19 (CI 95% 0,96 ­ 1,46); p=0,019, respectivamente, e ambas não foram significantes para PA alterada por MAPA de 24 horas. Conclusões: Há uma tendência para a associação entre PCR e a PA avaliada através da MAPA de 24 horas no contexto dos cuidados primários

Background: Systemic arterial hypertension (SAH) is an important cause of cardiovascular morbidity and mortality. In spite of the effectiveness of the treatment, a high number of patients do not obtain blood pressure (BP) control, a fact that implies the need for investigating the role of other additional factors, such as inflammation markers and microalbuminuria, especially in health care environments. Objectives: To evaluate the association between serum fibrinogen levels, ultra-sensitive C-reactive protein (CRP) and microalbuminuria, with blood pressure (BP) averages evaluated by 24-hour ambulatory blood pressure monitoring (ABPM) in hypertensive patients in primary health care setting.Methods: A cross-sectional study with hypertensive patients who were seen in primary health care centers was performed.A BP evaluation was carried out by the primary care doctor, and this procedure was followed by a reference test 24-hour ABPM, performed by an independent professional. Moreover, the peripheral blood collect was performed for future biochemical markers analysis. Results: 143 patients were included. There was a trend for association between the independent variable (altered BP by 24-hour ABPM) and the dependent variable (CRP), there was an association between the values > 3 mg/dL and altered 24-hour ABPM. The prevalence ratio (PR) was of 1.36 (CI 95% 0.90 ­ 2.06); p=0.18. Regarding microalbuminuria and fibrinogen findings, a 1.03 (CI 95% 0.41 ­ 2.57) PR was seen; p=1 and 1.19 (CI 95% 0.96 ­ 1.46) PR; p=0.019, respectively, and both were not significant for altered BP by 24-hour ABPM. Conclusions: It is a trend for association between CRP with BP evaluated by 24-hour ABPM in the primary care setting

Clinical practice guideline for the prevention, early detection, diagnosis, management and follow up of type 2 diabetes mellitus in adults / Guía de práctica clínica para la prevención, diagnóstico, tratamiento y seguimiento de la diabetes mellitus tipo 2 en la población mayor de 18 años

In Colombia, diabetes mellitus is a public health program for those responsible for creating and implementing strategies for prevention, diagnosis, treatment, and follow-up that are applicable at all care levels, with the objective of establishing early and sustained control of diabetes. A clinical practice guide has been developed following the broad outline of the methodological guide from the Ministry of Health and Social Welfare, with the aim of systematically gathering scientific evidence and formulating recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. The current document presents in summary form the results of this process, including the recommendations and the considerations taken into account in formulating them. In general terms, what is proposed here is a screening process using the Finnish Diabetes Risk Score questionnaire adapted to the Colombian population, which enables early diagnosis of the illness, and an algorithm for determining initial treatment that can be generalized to most patients with diabetes mellitus type 2 and that is simple to apply in a primary care context. In addition, several recommendations have been made to scale up pharmacological treatment in those patients that do not achieve the objectives or fail to maintain them during initial treatment. These recommendations also take into account the evolution of weight and the individualization of glycemic control goals for special populations. Finally, recommendations have been made for opportune detection of micro- and macrovascular complications of diabetes.

En Colombia la Diabetes Mellitus es un problema de salud pública por lo que deben generarse e implementarse estrategias de prevención, diagnóstico, tratamiento y seguimiento, aplicables en todos los niveles de atención con miras a establecer el control de la diabetes en forma temprana y sostenida. Se elaboró una guía de práctica clínica siguiendo los lineamientos de la guía metodológica del Ministerio de Salud y Protección Social para recolectar de forma sistemática la evidencia científica y formular las recomendaciones utilizando la metodología GRADE. El presente documento muestra, de forma resumida, el resultado de ese proceso, incluyendo las recomendaciones y las consideraciones tenidas en cuenta para llegar a ellas. En términos generales, se propone un proceso de tamización mediante el cuestionario FINDRISC adaptado a población Colombiana que permite llegar a un diagnóstico temprano de la enfermedad y un algoritmo para el manejo inicial que es generalizable a la gran mayoría de los pacientes con diabetes mellitus tipo 2 y que es sencillo de aplicar en atención primaria. También se hacen unas recomendaciones para escalar el tratamiento farmacológico de los pacientes que no alcanzan la meta o la pierden con el manejo inicial, teniendo en cuenta principalmente la evolución del peso y la individualización de la meta de control glucémico en poblaciones especiales. Finalmente se proponen algunas recomendaciones para la detección oportuna de las complicaciones micro y macrovasculares de la diabetes.

Diagnóstico de albuminuria en pacientes mayores de 55 años en una red asistencial / Albuminuria diagnosis in patients over 55 years of a care network

Objetivo. Determinar el diagnóstico de albuminuria (microalbuminuria, macroalbuminuria) en pacientes mayores de 55 a±os de la Red Asistencial Rebagliati (RAR), mediante el cociente albúmina/creatinina (A/CR). Materiales y Métodos. Se realizó un estudio transversal descriptivo durante 2012, en adultos mayores de 55 a±os de la RAR, de ambos sexos, a quienes se les realizó los test de albúmina y creatinina en orina. Se utilizó el cociente A/CR para la valoración de albuminuria (microalbuminuria, macroalbuminuria). resultadOs. Participaron en el estudio 3 943 pacientes. La mediana de edad fue 70 ± 8,96 a±os, y 57,10 % (N = 2250) fueron mujeres. El 23 % (N = 918) de pacientes presentaron albuminuria; 17,92 % (N = 706), microalbuminuria; 5,38 % (N = 212), macroalbumi nuria. El Hospital III Sußrez Angamos presentó el mayor porcentaje de pacientes con albuminuria. Cuando se evalúa la fuerza de concordancia kappa entre el método albúmina en orina y el cociente A/CR, se observa una concordancia considerable (k = 0,789) entre estos métodos diagnósticos. Conclusiones. El 23,30 % de los pacientes mayores de 55 a±os de la RAR presentaron albuminuria. Un total de 212 (5,68 %) pacientes presentó macroalbuminuria. Una intervención terapéutica a este tipo de pacientes con micro o macroalbuminuria disminuirß eficazmente el aumento de la ERC en la RAR.

Objective. To determine the diagnosis of albuminuria (microalbuminuria, macroalbuminuria) in patients over 55 years of Rebagliati Care Network (RCN) using the albumin/creatinine ratio (A/CR). Materials and Methods. We performed a cross-sectional, descriptive during 2012, in adults over 55 years of RAR, of both sexes, who have conducted tests on urine albumin and creatinine. We used the ratio A/CR for the assessment of albuminuria (microalbuminuria, macroalbuminuria). results. The study involved 3943 patients. The median age was 70 ± 8,96 years and 57,10 % (N = 2250) were women. The 23 % (N = 918) of patients had albuminuria, 17,92 % N = 706) microalbuminuria and 5,38 % (N = 212) macroalbuminuria. The Hospital III Sußrez Angamos had the highest percentage of patients with albuminuria. When evaluating the strength of Kappa between urinary albumin method versus the ratio A/CR observe a substantial concordance (k = 0,789) between these diagnostic methods. ConClusions. The 23,30 % of patients over 55 years of RCN, presented albuminuria. A total of 212 (5,68 %) patients had macroalbuminuria. A therapeutic intervention for these patients with microalbuminuria or macroalbuminuria, effectively decrease the increase of chronic kidney disease in the RCN.

Elevated Brachial-Ankle Pulse Wave Velocity Is Independently Associated with Microalbuminuria in a Rural Population

Microalbuminuria is a marker of generalized endothelial dysfunction resulting from arterial stiffness or insulin resistance, and brachial-ankle pulse wave velocity (baPWV) is a good measure of arterial stiffness. We aimed to investigate whether elevated baPWV is independently associated with microalbuminuria. This study included 1,648 individuals aged over 40 who participated in the baseline Multi-Rural Cohort Study conducted in Korean rural communities between 2005 and 2006. Participants were classified into less than 30 mg/g as normoalbuminuria or 30-300 mg/g as microalbuminuriausing urinary albumin creatinine ratio (UACR). The median and Q1-Q3 baPWV values were significantly higher in the microalbuminuric group both in men (1,538, 1,370-1,777 cm/s vs. 1,776, 1,552-2,027 cm/s, P < 0.001) and women (1,461, 1,271-1,687 cm/s vs. 1,645, 1,473-1,915 cm/s, P < 0.001). BaPWV was independently associated with microalbuminuria in both genders after adjusting for pulse rate; fasting blood glucose; triglyceride; homeostatic model assessment insulin resistance (HOMA(IR)) and, history of hypertension and diabetes. Fasting blood sugar and HOMA(IR) were judged as having nothing to do with multicolinearity (r = 0.532, P < 0.001). Elevated baPWV was independently associated with microalbuminuria regardless of insulin resistance among rural subjects over 40 yr.

Diagnostic accuracy of spot and timed measurements of urinary albumin concentration to determine microalbuminuria in sickle cell disease / Precisión diagnóstica de las mediciones puntuales y cronometradas de la concentración de albúmina en orina para determinar la microalbuminuria en la enfermedad de células falciformes

OBJECTIVE: Whereas measurement of albumin:creatinine ratio (ACR) in spot urine samples is indicated for determining microalbuminuria, its performance or that of urinary albumin excretion rate (UAER) in predicting microalbuminuria in sickle cell disease (SCD) is unclear. We therefore tested the diagnostic performance of these measures in spot and timed urine samples in predicting a UAER in 24-hour samples. METHODS: Thirty participants with SCD had spot, two-hour and four-hour, followed by 24-hour urine collections for ACR, urinary albumin concentration (UAC) and UAER determinations. Receiver operating characteristic (ROC) curve analyses were performed. RESULTS: The areas under the ROC curves for microalbuminuria were 0.99 (CI: 0.97, 1.00) for ACR and 0.97 (CI: 0.92, 1.00) for UAC in spot urine samples. For ACR, at the cut-point of 4.13 mg/mmol, there was 100% sensitivity and 82.6% specificity, allowing an 86.2% correct classification. At the cut-point of UAC = 20.9 mg/L, there was 100% sensitivity and 73.9% specificity, allowing a 79.3% correct classification. Corresponding areas for microalbuminuria in two-hour timed samples were 0.99 (CI: 0.95, 1.00) for ACR and 0.96 (CI: 0.89, 1.00) for UAER. For ACR, the cut-point was 4.64 mg/mmol with 83.3% sensitivity and 91.3% specificity, allowing an 89.7% correct classification. Similarly for UAER, at the cut-point of 21.8 µ/min, there was 83.3% sensitivity and 91.3% specificity, allowing 89.7% correct classification. CONCLUSIONS: The diagnostic performance of ACR and UAC in a spot as well as ACR and UAER in two-hour timed urine samples in patients with SCD is excellent. Healthcare professionals can confidently utilize these measures in this patient population.

OBJETIVO: Si bien la medición del índice urinario albúmina:creatinina (IAC) en muestras de orina puntuales se indica para la determinación de la microalbuminuria, no está clara su eficacia, ni la de la tasa de excreción de albúmina urinaria (TEAU), en la predicción de microalbuminuria en la enfermedad de células falciformes (ECF). Por lo tanto, sometimos a prueba la eficacia diagnóstica de estas mediciones puntuales y cronometradas de las muestras de orina a la hora de predecir una TEAU en muestras de 24 horas. MÉTODOS: A treinta participantes con ECF se les tomaron muestras puntuales de orina, a las dos horas y a las cuatro horas, seguidas por muestras de orina de 24 horas para el IAC, la concentración de albúmina urinaria (CAU), y las determinaciones de TEAU. Se realizaron análisis de la curva de las características operativas del receptor (ROC). RESULTADOS: Las áreas bajo las curvas ROC para la microalbuminuria fueron 0.99 (CI: 0.97, 1.00) para IAC y 0.97 (CI: 0.92, 1.00) para CAU en muestras puntuales de orina. Para IAC, en el punto de corte de 4,13 mg/mmol, hubo 100% sensibilidad y 82.6% de especificidad, lo que permite una clasificación 86.2% correcta. En el punto de corte de CAU = 20,9 mg/L, hubo un 100% de sensibilidad y 73.9% de especificidad, lo que permitió una clasificación 79.3% correcta. Las áreas correspondientes para la microalbuminuria en muestras de tiempo de dos horas fueron 0.99 (CI: 0.95, 1.00) para IAC y 0,96 (CI: 0.89, 1.00) para TEAU. Para IAC, el punto de corte fue 4.64 mg/mmol con 83.3% de sensibilidad y 91.3% de especificidad, lo que permitió una clasificación 89.7% correcta. Del mismo modo para TEAU, en el punto de corte de 21.8 µ/min, hubo una sensibilidad de 83.3% y una especificidad de 91.3%, lo que permitió una clasificación 89.7% correcta. CONCLUSIONES: La eficacia diagnóstica de IAC y UAC en un punto así como el IAC y la TEAU en muestras de orina de tiempo de dos horas en pacientes con ECF es excelente. Los profesionales de la salud pueden utilizar estas mediciones con confianza en esta población de pacientes.

Terapia anti-hipertensiva em hipertensos idosos e microalbuminúria / Antihypertensive therapy in hypertensive elderly and microalbuminuria

Objetivos: Verificar a prevalência de microalbuminúria em idosos hipertensos, relacionando-a ao padrão de terapia medicamentosa, às classes de drogas anti-hipertensivas e ao controle da hipertensão, e analisar a frequência das classes de drogas utilizadas como monoterapia e terapia combinada.Métodos: Estudo observacional, descritivo e transversal, realizado de abril a setembro de 2006 e de novembro de 2008 a agosto de 2009, no Ambulatório de Clínica Médica e de Cardiologia do HU-UFSC, analisando variáveis como sexo, raça, nível pressórico, fatores de risco cardiovascular, microalbuminúria, padrão de terapia medicamentosa, classes de drogas anti-hipertensivas e controle da hipertensão.Resultados: A maioria dos pacientes era do sexo feminino (91/132 (68,9%)) e de cor branca (123/132 (93,2%)). O sedentarismo ((48,5%) 64/132) foi o fator de risco cardiovascular mais frequente e a prevalência de microalbuminúria foi de 9,8% (13/132). A terapia combinada, a mais utilizada (91/132 (68,9%)), proporcionalmente teve maior relação com a microalbuminúria. O diurético e o inibidores da enzima conversora de angiotensina (IECA) foram os mais utilizados como monoterapia [respectivamente, 41,5%(17/41) e 36,6% (15/41)] e em associação [87,9% (80/91) e 67% (61/91)]. A prevalência de microalbuminúria foi proporcionalmente menor nos pacientes em uso de IECA e antagonista do receptor de angiotensina II (ARAII) (8,9% (8/90) e 12,9% (5/42)) e foi semelhante naqueles com hipertensão controlada e não controlada (9,4% (5/53) e 10,1% (8/79)).Conclusões: A prevalência de microalbuminúria é de 9,8%, sendo proporcionalmente maior nos pacientes em terapia combinada, menor naqueles em uso de IECA/ARAII e semelhante quanto ao controle pressórico. O diurético e o IECA são os mais utilizados como monoterapia e em terapia combinada.

Enfermedad renal crónica: Clasificación, identificación, manejo y complicaciones / Clinical guidelines on identitication, management and complications of chronic kidney disease

The key messages of these guidel ines on chronic kidney disease are: • Chronic kidney disease (CKD) is a public health problem due to its wide distribution, high rate of complications and cost. • CKD is a common condition, its prevalence being about 10 percent, and is treatable if it is detected on time. • A patient with CKD has a higher risk of cardiovascular mortality than of progression of its underlying renal disease. • A new definition of CKD, based on estimated Glomerular Filtration Rate (eGFR) and kidney damage, facilitates its detection and management. • CKD is detected with three simple tests: 1) Blood pressure measurement, 2) Detection of proteinuria or albuminuria in an isolated urine sample, and 3) Estimation of renal function (eGFR), based on serum creatinine, age, gender and race. • The CKD risk groups are individuáis with diabetes, hypertension and a family history of renal disease. • The most cost-effective measures are to detect and treat diabetic and hypertensive patients in the community. • Therapy must emphasize the maximal reduction of cardiovascular risk. • The complications of CKD such as anemia and renal osteodystrophy can be identified and treated on time. • Most patients with chronic kidney disease are detected in the community, therefore their initial care must be organized at the level of primary care, along with programs for hypertension and diabetes.

The Prevalence of Chronic Kidney Disease (CKD) and the Associated Factors to CKD in Urban Korea: A Population-based Cross-sectional Epidemiologic Study

Chronic kidney disease (CKD) is a worldwide problem. This study was designed to survey the prevalence and risk factors for CKD in Korea. The 2,356 subjects were selected in proportion to age, gender, and city. Subjects 35 yr of age or older were selected from 7 cities. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) Study equation, with albuminuria defined as a urine albumin to creatinine ratio of 30 mg/g or more. The overall prevalence of CKD was 13.7%. The prevalences of CKD according to stage were 2.0% stage 1, 6.7% stage 2, 4.8% stage 3, 0.2% stage 4, and 0.0% stage 5. The prevalences of microalbuminuria and macroalbuminuria were 8.6% and 1.6%, respectively. The prevalence of eGFR less than 60 mL/min/1.73 m2 was 5.0%. Age, body mass index (BMI), hypertension, diabetes mellitus, systolic blood pressure (SBP), diastolic blood pressure (DBP), and fasting blood glucose were independent factors related to the presence of CKD. In conclusions, Korea, in which the prevalence of CKD is increasing, should prepare a policy for early detection and appropriate treatment of CKD. The present data will be helpful in taking those actions.

The Clinical Characteristics of Normoalbuminuric Renal Insufficiency in Korean Type 2 Diabetic Patients: A Possible Early Stage Renal Complication

It has been recently reported that a considerable portion of diabetic patients with renal insufficiency show normoalbuminuria. As little is known about normoalbuminuric renal insufficiency in the Asian population, we examined its prevalence and clinical characteristics in Korean type 2 diabetic patients. We studied 562 patients with type 2 diabetes from Seoul National University Hospital. The estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease formula and the degree of albuminuria was evaluated by spot urine albumin-creatinine ratio. Of 562 patients, 151 (26.9%) patients had renal insufficiency (eGFR <60 mL/min/ 1.73m(2)). Among them, 44 (29.1%) patients had normoalbuminuria. After excluding the patients using renin-angiotensin system (RAS) inhibitors, the prevalence of normoalbuminuric renal insufficiency was 35.3% (18 of 51 patients). Compared with microand macroalbuminuric renal insufficiency, normoalbuminuric renal insufficiency was associated with the female predominance, shorter duration of diabetes, lower prevalence of diabetic retinopathy, and lower prevalence of using antihypertensive drugs except RAS inhibitors. The prevalence decreased progressively with an increase in the duration of diabetes and an increase in the severity of retinopathy. Normoalbuminuric renal insufficiency was prevalent in Korean type 2 diabetic patients. The association with a shorter duration of the diabetes and a lower prevalence of retinopathy suggests that it might be an early stage renal complication.

Assessing albuminuria in spot morning samples from diabetic patients / Avaliação de albuminúria em amostra matinal em pacientes diabéticos

Microalbuminuria assessment is essential for diagnosing incipient nephropathy in diabetic patients. The present study aim to evaluate whether urinary albumin concentration (UAC) and urinary albumin-to-creatinine ratio (UACR) agree with 24 h urine collection in screening for albuminuria > 30 mg/24 h in type 1 and 2 diabetics. In this cross-sectional study were evaluated 293 diabetic patients (117 type 1 and 176 type 2). Albuminuria was determinated by turbidimetric immunoassay. The best discriminator value was 22 mg/l (sensitivity 82.5 percent, specificity 74.0 percent) for UAC and 27.3 mg/g creatinine (sensitivity 83.3 percent, specificity 80.9 percent) for UACR. Areas under ROC curves were 0.868 and 0.878, respectively (p = 0.53). Lower discriminators as 10 mg/l (sensitivity 94.2 percent, specificity 48.6 percent) and 10 mg/g creatinine (sensitivity 96.7 percent, specificity 49.1 percent) attained high sensitivities. UAC and UACR from spot morning urine had similar accuracy in screening microalbuminuria. The simplicity and lower cost of UAC justifies its preferential clinical use.

Pesquisar microalbuminúria é essencial para o diagnóstico de nefropatia incipiente diabética. Este estudo objetiva avaliar concordância entre concentração de albumina urinária (CAU) e relação albuminúria-creatinúria (RAC) com coleta urinária de 24 h para pesquisa de albuminúria > 30 mg/24 h em diabéticos tipos 1 e 2. Estudou-se transversalmente 293 pacientes diabéticos (117 tipo 1 e 176 tipo 2). A albuminúria foi determinada por imunoensaio turbidimétrico. O melhor discriminador para CAU foi 22 mg/l (sensibilidade 82,5 por cento, especificidade 74 por cento) e para RAC 27,3 mg/g de creatinina (sensibilidade 83,3 por cento, especificidade 80,9 por cento). Áreas sob as curvas ROC foram 0,868 e 0,878, respectivamente (p = 0,53). Menores discriminadores como 10 mg/l (sensibilidade 94,2 por cento, especificidade 48,6 por cento) e 10 mg/g de creatinina (sensibilidade 96,7 por cento, especificidade 49,1 por cento) resultaram sensibilidades maiores. CAU e RAC de amostras urinárias isoladas matinais apresentaram acurácia semelhante para pesquisa de microalbuminúria. Simplicidade e baixo custo da CAU justificam seu uso clínico preferencial.

Detecção precoce da nefropatia diabética / Early detection of diabetic nephropathy

Em virtude do prognóstico desfavorável das fases avançadas da nefropatia diabética (ND), o ideal é identificar o envolvimento renal de maneira precoce. A recomendação é a medida anual da excreção urinária de albumina (EUA), em amostras de urina casual, para detectar os estágios da ND [microalbuminúria (EUA 17-174 mg/l ou 30 a 300 mg albumina/g de creatinina) e macroalbuminúria (> 174 mg/l ou > 300 mg/g)]. No entanto, tem sido sugerido que níveis de EUA abaixo dos de consenso já seriam indicativos de risco de progressão renal e de mortalidade aumentada, devendo ser revisados esses pontos de corte. Uma quantidade expressiva da EUA, a fração não imunorreativa, não é detectada pelos métodos convencionais, e HPLC poderá ser mais sensível para identificar dano renal, medindo EUA total (imuno + não-imunorreativa). Outra observação recente é a presença de diminuição da taxa de filtração glomerular (TFG) mesmo em normoalbuminúricos. Portanto, além da EUA, recomenda-se estimar a TFG com equação empregando creatinina, como a do estudo Modification of Diet in Renal Disease (MDRD), disponível em www.mdrd.com. Em razão das conhecidas limitações da creatinina, marcadores endógenos alternativos estão em investigação, sendo a cistatina C um marcador promissor. Finalmente, novas estratégias que poderão ser ainda mais precoces para detecção da ND incluem biomarcadores, como proteoma, definindo um perfil de proteínas urinárias que identifiquem risco subseqüente de doença renal.

Due to the unfavorable prognosis of advanced stages of diabetic nephropathy (DN), the ideal approach is to identify renal involvement as early as possible. It is recommended to measure urinary albumin excretion (UAE) annually, in random urine samples, in order to detect the stages of DN [microalbuminuria (UAE 17-174 mg/l or 30-300 mg albumin/g of creatinine) and macroalbuminuria (> 174 mg/l or > 300 mg/g)]. However, it has been suggested that UAE levels below the threshold of consensus could already signal the risk for DN progression and increased mortality, indicating the need to revise cutoff values. As a substantial amount of UAE (the immunounreactive fraction), is not detected by conventional methods, HPLC would be more sensitive to identify the presence of damage by measuring total UAE (immunoreactive + immunounreactive). Another recent observation is that diminished glomerular filtration rates (GFR) occurs in the presence of normoalbuminuria. Therefore, besides evaluating UAE, it is recommended to estimate GFR with equations employing creatinine; such as the Modification of Diet in Renal Disease (MDRD) study, available at www.mdrd.com. Owing to the known limitations of creatinine, alternative endogenous markers are being studied, and cystatin-C is a promising marker under investigation. Finally, new strategies that could detect DN even earlier, include biomarkers such as proteomics, defining a profile of urinary protein excretion able to identify the subsequent risk of renal disease.

Avaliação da função e da lesão renal: um desafio laboratorial: [revisão] / Evaluation of renal function and damage: a laboratorial challenge: [review]

Atualmente a doença renal é um grande problema de saúde pública, que acomete milhares de pessoas no Brasil e no mundo. O estudo da função e dos diversos processos patológicos renais tem despertado o interesse de muitos pesquisadores, principalmente no campo do desenvolvimento de testes que auxiliem os médicos a estabelecer um diagnóstico precoce, classificar a doença de base, obter prognóstico seguro e monitorar terapêutica medicamentosa. Neste artigo sete marcadores de função e de lesão renal são avaliados: uréia, creatinina, cistatina C, proteinúria, dismorfismo eritrocitário, microalbuminúria e fração hepática das proteínas ligadas a ácidos graxos. É apresentado um breve histórico da utilização clínica e da fisiopatologia de cada um deles, seguidas de sua aplicabilidade e dos avanços técnicos e metodológicos disponíveis. Apesar de melhorias terem sido conseguidas e incorporadas à prática laboratorial, nenhum marcador atualmente disponível é completamente eficaz em analisar a função e/ou a lesão renal de forma precisa, sendo imprescindível o conhecimento de todos eles para uma correta avaliação desses testes comuns na rotina laboratorial.

Nowadays, renal disease is an important public health problem, affecting millions of people in Brazil and in the world. The study of renal function and renal pathologic processes has aroused the interest of researchers, mainly in the field of development of new assays that could aid physicians in establishing early diagnosis, better classifying the disease, obtaining better outcome and monitoring drug therapeutics. In this article, seven laboratory markers of renal function or damage are evaluated: urea, creatinine, cystatin C, proteinuria, dysmorphic erythrocytes, microalbuminuria and liver-type fatty acid binding protein (L-FABP). For each one of them, a short historical report of its clinical utility and physiopathology is presented. Then technical and methodological approaches are described as well as its utility in clinical management of kidney patients. Although improvements have been reached and incorporated in laboratorial practice, none of these markers is effective enough to define precisely kidney function and/or damage and an extensive understanding of all of these markers is crucial to correct evaluate renal function.

O laboratório clínico no rastreamento de doenças renais / The clinical pathology laboratory and the screening of renal diseases

Testes diagnósticos podem ser usados para rastreamento de anormalidades diversas, desde que sejam de aplicação fácil, não sejam dispendiosos, tenhamalta sensibilidade e boa especificidade. Vale ressaltar que, nesse contexto, é importante que a detecção de alguma anormalidade leve a uma conduta quealtere o prognóstico do indivíduo. Recentemente várias organizações ligadas à Nefrologia têm defendido a aplicação de procedimentos de rastreamento, com vistas à detecção precoce de pacientes com lesões renais e à adoção subseqüente de medidas que prolonguem a sobrevida do indivíduo sem necessidade de terapia substitutiva da função renal. Destacam-se entre os testes de maior aplicabilidade no rastreamento da doença renal crônica:dosagem sérica de creatinina, pesquisa de proteinúria e de microalbuminúria, e mesmo o exame completo de urina. São aqui discutidas peculiaridadesdesses testes e as situações em que seu uso está indicado para fins de triagem.

Diagnostic tests can be used for screening of several abnormalities, since they are of easy application, non expensive, and they have high specificity and sensitivity. In such context it is important that the detection of some abnormality conduct to measures with potential to change the prognosis of the indivi -dual. Recently many organizations related to Nephrology have supported the application of screening procedures in order to detect early patients with renal lesions and to use subsequently measures that increase survival of the individual without renal substitutive therapy. The tests more applicable for scree -ning of chronic renal disease are: determination of serum creatinine, proteinuria and microalbuminuria, and even a complete urinalysis. Here we discuss peculiar aspects of these tests and situations in which their use is indicated for screening.

Nefropatia diabética e doença cardíaca / Diabetic nephropathy and cardiac disease

Pacientes em diferentes estágios de nefropatia diabética (ND) apresentam freqüentemente comprometimento cardíaco expresso por isquemia miocárdica e/ou cardiomiopatia diabética. Estas alterações já estão presentes em estágios iniciais da ND e provavelmente mesmo antes de a excreção urinária de albumina (EUA) atingir níveis tradicionalmente diagnósticos de microalbuminúria. As alterações cardíacas são responsáveis por uma proporção significativa de mortes nos pacientes com ND e podem ser reduzidas através de intervenção nos múltiplos fatores de risco cardiovascular encontrados nesses pacientes. A avaliação de doença cardíaca deve idealmente ser realizada em todos os pacientes com qualquer grau de ND através de métodos específicos para detectar isquemia e disfunção miocárdica, além do emprego rotineiro da monitorização ambulatorial da pressão arterial em 24 h. Em pacientes com aterosclerose avançada também devem ser avaliadas outras artérias (carótidas, aorta, renais). O tratamento rigoroso da hipertensão arterial, o uso de fármacos cardioprotetores, o tratamento da dislipidemia e da anemia, assim como o emprego de medicamentos anti-plaquetários, poderão reduzir a elevada mortalidade cardiovascular na ND.

Patients in different stages of diabetic nephropathy (DN) frequently present cardiac disease expressed by myocardial ischemia and/or diabetic cardiomyopathy. These changes are already present at early stages of DN, probably even before urinary albumin excretion (UAE) reaches the traditionally diagnostic levels of microalbuminuria. The cardiac changes are responsible for a significant proportion of the increased death rates in patients with DN and can be reduced through multiple intervention on the several risk factors present in these patients. Cardiac disease assessment should ideally be performed in every patient, irrespective of renal status, through specific methods to detect ischemia and myocardial dysfunction, besides routinely performing 24-h ambulatory blood pressure monitoring. In patients with advanced atherosclerosis, other arteries (aorta, carotid, renal) should be evaluated as well. Intensive treatment of arterial hypertension, and use of cardioprotective drugs, correction of the associated dyslipidemia and anemia, and use of antiplatelet agents can reduce the elevated cardiovascular mortality in patients with DN.

Fatores preditivos de hipertensão gestacional em adolescentes primíparas: análise do pré-natal, da MAPA e da microalbuminúria / Predictive factors for pregnancy hypertension in primiparous adolescents: analysis of prenatal care, ABPM and microalbuminuria / Predictive factors for pregnancy hypertension in primiparous adolescents: analysis of prenatal care, ABPM and microalbuminuria

OBJETIVO: Quantificar a prevalência de HG em adolescentes primíparas; definir fatores de preditividade para a ocorrência de HG e sua repercussão nos recém-nascidos. MÉTODOS: Foram acompanhadas 29 adolescentes primíparas durante o pré-natal até a 12ª semana de puerpério, com idade média de dezesseis anos, do ambulatório do Serviço de Adolescentes da Maternidade Escola Assis Chateaubriand (MEAC) da Universidade Federal do Ceará (Fortaleza). As gestantes foram dividas em dois grupos; ou seja, nas que permaneceram normotensas (Grupo I) e naquelas que desenvolveram hipertensão gestacional -HG - (Grupo II). As variáveis investigadas na avaliação de valor de preditividade no desenvolvimento de HG foram valores antropométricos, aspectos socioeconômicos, o hábito de fumar, a hereditariedade para HAS (pai/mãe), os exames do pré-natal solicitados na primeira consulta do pré-natal e a microalbuminúria e a monitorização ambulatorial da pressão arterial (MAPA) na 28ª semana de gestação. As gestantes foram acompanhadas no parto e no puerpério tardio (12ª semana de puerpério). Os recém-nascidos das mães do nosso estudo foram avaliados ao nascer pelos índices de APGAR e de Capurro, peso, estatura e pela presença de hipóxia perinatal. RESULTADOS: A prevalência de HG foi de 51,7 por cento . A hereditariedade para HAS apresentou-se com o maior valor de preditividade para HG com odds ratio de 10,99. A pressão arterial diastólica maior ou igual a 70 mmHg, na idade média gestacional de 35 semanas, apresentou significância estatística como valor de preditividade para HG. Na MAPA encontramos valor de preditividade para HG: carga pressórica diastólica em vigília, carga pressórica sistólica e diastólica no sono noturno, variabilidade pressórica e pressão máxima diastólica no sono. Especificamente a pressão arterial diastólica (PAD) máxima na MAPA no período do sono noturno ³64 mmHg apresentou odds ratio de 6 para HG com sensibilidade de 80 por cento e especificidade de 60 por cento para o desenvolvimento de HG...

OBJECTIVE: To quantify PH prevalence in primiparous adolescents; define predictive factors for the occurrence of PH and its impact on newborns. METHODS: We followed 29 primiparous adolescents from the prenatal period through the 12th week of the puerperium, with a mean of sixteen years of age, served at the Outpatient Facility for Adolescents of Maternidade Escola Assis Chateaubriand (MEAC) of Universidade Federal do Ceará (Fortaleza, Brazil). The pregnant adolescents were divided into two groups, that is, those who remained normotensive (Group I) and those who developed PH (Group II). The variables investigated in the assessment of the value of predictability for the development of PH were anthropometric measures, socioeconomic aspects, smoking habit, inheritance for SAH (father/mother), prenatal tests requested in the first prenatal care visit in addition to microalbuminuria and ambulatory blood pressure monitoring (ABPM) in the 28th week of gestation. The pregnant adolescents were followed up at delivery and late puerperium (12th week after the puerperium). The newborns to the mothers included in our study were assessed at birth according to the Apgar score and the Capurro method, for weight, height and perinatal hypoxia. RESULTS: The prevalence of PH was 51.7 percent. Inheritance for SAH presented the highest predictive value for PH with an odds ratio of 10.99. Diastolic arterial pressure equal to or above 70 mmHg at the gestational age of 35 weeks was statistically significant as a predictive value for PH. At ABPM we found a predictive value for PH: diastolic pressure load during alertness, diastolic and systolic pressure load during night sleep, pressure variability and maximum diastolic pressure during sleep. Specifically a maximum diastolic arterial pressure (DAP) at ABPM during the period of night sleep ³64 mmHg presented an odds ratio of 6 for PH with a sensitivity of 80 percent and a specificity of 60 percent for the development of PH...

Proliferative diabetic retinopathy is associated with microalbuminuria in patients with type 2 diabetes

Diabetic retinopathy is one of the leading causes of blindness in working-age individuals. Diabetic patients with proteinuria or those on dialysis usually present severe forms of diabetic retinopathy, but the association of diabetic retinopathy with early stages of diabetic nephropathy has not been entirely established. A cross-sectional study was conducted on 1214 type 2 diabetic patients to determine whether microalbuminuria is associated with proliferative diabetic retinopathy in these patients. Patients were evaluated by direct and indirect ophthalmoscopy and grouped according to the presence or absence of proliferative diabetic retinopathy. The agreement of diabetic retinopathy classification performed by ophthalmoscopy and by stereoscopic color fundus photographs was 95.1 percent (kappa = 0.735; P < 0.001). Demographic information, smoking history, anthropometric and blood pressure measurements, glycemic and lipid profile, and urinary albumin were evaluated. On multiple regression analysis, diabetic nephropathy (OR = 5.18, 95 percent CI = 2.91-9.22, P < 0.001), insulin use (OR = 2.52, 95 percent CI = 1.47-4.31, P = 0.001) and diabetes duration (OR = 1.04, 95 percent CI = 1.01-1.07, P = 0.011) were positively associated with proliferative diabetic retinopathy, and body mass index (OR = 0.90, 95 percent CI = 0.86-0.96, P < 0.001) was negatively associated with it. When patients with macroalbuminuria and on dialysis were excluded, microalbuminuria (OR = 3.3, 95 percent CI = 1.56-6.98, P = 0.002) remained associated with proliferative diabetic retinopathy. Therefore, type 2 diabetic patients with proliferative diabetic retinopathy more often presented renal involvement, including urinary albumin excretion within the microalbuminuria range. Therefore, all patients with proliferative diabetic retinopathy should undergo an evaluation of renal function including urinary albumin measurements.

Avaliação da microalbuminúria em indivíduos não diabéticos / Evaluation of microalbuminuria in non-diabetic individuals

OBJETIVO: Avaliar a presença de microalbuminúria em indivíduos não diabéticos, associando-a à presença de fatores de risco cardiovasculares como hipertensão arterial, tabagismo, dislipidemia e obesidade. A taxa de excreção urinária de albumina (EUA) foi avaliada em relação aos índices de secreção e resistência insulínica (RI). PACIENTES E MÉTODOS: 105 indivíduos com idade de 33,4 ± 1,4 anos (57,1 por cento mulheres) foram submetidos ao TOTG com 75 g de dextrose, sendo avaliadas as curvas de glicose e insulina: valores basais e em 2h, valores de pico e áreas sob a curva (ASC). Para a avaliação da secreção e RI, utilizamos os índices: insulinogênico, delta, HOMA, QUICKI, relação glicose/insulina e relação entre os índices insulinogênico e HOMA. As amostras para avaliação da albuminúria foram colhidas overnight. Os indivíduos foram divididos em dois grupos: 1) tolerância normal à glicose e 2) alteração do metabolismo glicídico. RESULTADOS: Houve diferença entre os 2 grupos para idade, IMC, PA, cintura, RCQ, colesterol, triglicerídeos (TG), glicemias (GJ e G2h), ASCg, índices HOMA e QUICKI, e relação entre os índices insulinogênico e HOMA. A EUA foi de 4,28 ± 2,73 æg/mL, apresentando correlação com PAD, GJ, G2h, ASCg, VPG, HOMA, I2h, VPI e ASCi. Após regressão em stepwise, apenas ASCg foi preditora de EUA. Na comparação da amostra estratificada em quartis de EUA, o 1° e o 4° quartis foram estatisticamente diferentes para IMC, PAS, PAD, cintura, quadril, G2h, TG, LDL, ASCg, ASCi, VPG e índices HOMA e QUICKI. CONCLUSÃO: Embora não houvesse nenhum indivíduo com microalbuminúria, encontramos diferença entre a EUA em indivíduos com diferentes graus de tolerância à glicose e diferenças entre as variáveis clínicas e laboratoriais entre o 1° e o 4° quartis de EUA. Nossos achados sugerem que em indivíduos não diabéticos o aumento da EUA está relacionado a algumas características da síndrome metabólica, o que pode conferir uma maior suscetibilidade aterogênica.