Terapia dialítica no paciente cardiopata / Dialysis therapy in patients with heart disease

A otimização das medidas para controle volêmico tem papel preponderante naabordagem de pacientes com disfunção cardíaca e renal combinada, uma vez quealterações crônicas ou agudas em um desses órgãos, em geral, induzem ou perpetuam anormalidades (funcionais e/ou estruturais) no outro. Esta revisão de literatura propõe uma análise sobre as principais medidas terapêuticas no cardiopata com disfunção renal...

Optimizing the methods used in the control of volemia is very important in the treatment of patients with combined heart and renal dysfunction, as chronic or acute changes in either of these organs generally induces or perpetuates abnormalities (functional and/orstructural) in the other. This literature review analyzes the main therapeutic methods used in heart disease with renal dysfunction...

Comparação de critérios diagnósticos de insuficiência renal aguda em cirurgia cardíaca / Comparison of diagnostic criteria for acute kidney injury in cardiac surgery

FUNDAMENTO: Há grande controvérsia quanto ao diagnóstico de Insuficiência Renal Aguda (IRA), existindo mais de 30 diferentes definições. OBJETIVO: Avaliar a incidência e os fatores de risco para desenvolvimento de IRA no pós-operatório de cirurgia cardíaca de acordo com os critérios RIFLE, AKIN e KDIGO, e comparar o poder prognóstico desses critérios. MÉTODOS: Estudo de corte transversal que incluiu 321 pacientes (62 [53 - 71] anos, 140 homens) consecutivamente submetidos a cirurgia cardíaca entre junho de 2011 e janeiro de 2012. Os pacientes foram acompanhados por 30 dias, com vistas ao desenvolvimento de um desfecho composto (mortalidade, necessidade de diálise e internação prolongada). RESULTADOS: A incidência de IRA variou de 15% - 51%, conforme o critério diagnóstico adotado. Enquanto a idade se associou ao risco de IRA nos três critérios, houve variação nos demais determinantes. Durante o acompanhamento, 89 pacientes apresentaram o desfecho e todos os critérios se associaram ao risco aumentado na análise Cox univariada e após o ajuste para idade, sexo, diabetes e tipo de cirurgia. Contudo, após novo ajuste para tempo de circulação extracorpórea e presença de baixo débito cardíaco, apenas o diagnóstico de IRA pelo critério KDIGO manteve esta associação significativa (HR= 1,89 [95% IC: 1,18 - 3,06]). CONCLUSÕES: A incidência e os fatores de risco para IRA pós-cirurgia cardíaca têm grande variação de acordo com os critérios diagnósticos utilizados. Em nossa análise, o critério KDIGO se mostrou superior ao AKIN e ao RIFLE quanto ao seu poder prognóstico.

BACKGROUND: There is considerable controversy regarding the diagnosis of Acute Kidney Injury (AKI), and there are over 30 different definitions. OBJECTIVE: To evaluate the incidence and risk factors for the development of AKI following cardiac surgery according to the RIFLE, AKIN and KDIGO criteria, and compare the prognostic power of these criteria. METHODS: Cross-sectional study that included 321 consecutively patients (median age 62 [53-71] years; 140 men) undergoing cardiac surgery between June 2011 and January 2012. The patients were followed for up to 30 days, for a composite outcome (mortality, need for dialysis and extended hospitalization). RESULTS: The incidence of AKI ranged from 15% - 51%, accordingly to the diagnostic criterion adopted. While age was associated with risk of AKI in the three criteria, there were variations in the remaining risk factors. During follow-up, 89 patients developed the outcome and all criteria were associated with increased risk in the univariate Cox analysis and after adjustment for age, gender, diabetes, and type of surgery. However, after further adjustment for extracorporeal circulation and the presence of low cardiac output, only AKI diagnosed by the KDIGO criterion maintained this significant association (HR= 1.89 [95% CI: 1.18 - 3.06]). CONCLUSION: The incidence and risk factors for AKI after cardiac surgery vary significantly according to the diagnostic criteria used. In our analysis, AKI the KDIGO criterion was superior to AKIN and RIFLE with regard its prognostic power.

Study of the incidence of dialysis in São Paulo, the largest Brazilian city

OBJECTIVES: Chronic kidney disease is a major public health problem worldwide. In Brazil, approximately 100,000 patients (January 2012) receive renal replacement therapy. Nevertheless, data on dialysis incidence in the Brazilian population are scarce. This study aims to analyze the incidence of patients starting dialysis therapy in São Paulo City, the largest Brazilian metropolis. METHOD: This cohort study analyzed data from 9,994 patients starting hemodialysis or peritoneal dialysis funded by the Brazilian Public Health System during a 5-year period (2007-2011). Patient data for this study (recorded as electronic files) were obtained from the São Paulo City's Dialysis Regulatory Bureau, which regulates the allocation of patients requiring dialytic therapy. RESULTS: The dialysis incidence rates were 178, 174, 170, 185 and 188 per million population for the years 2007, 2008, 2009, 2010 and 2011, respectively. The incidence rates increased with age. Hypertension and diabetes were the main etiologies diagnosed. Hemodialysis was the chosen dialysis modality in the majority of patients (92.6%), whereas the percentage of patients referred for peritoneal dialysis decreased from 10.1% to 5.5%. CONCLUSION: The incidence of patients starting renal replacement therapy from 2007-2011 in São Paulo was stable but higher than the projected incidence for the entire country. The authors emphasize the need for further studies of the incidence of dialysis in the Brazilian population and for the creation of a Brazilian registry of dialysis patients, which would be a valuable tool for developing healthcare policies and renal replacement therapy strategies. .

Impacto na reclassificação da hipertensão pela Monitorização Ambulatorial da Pressão Arterial (MAPA) segundo a V Diretriz Brasileira de MAPA / Impact on hypertension reclassification by Ambulatory Blood Pressure Monitoring (ABPM) according to the V Brazilian Guidelines on ABPM

FUNDAMENTOS: Novas recomendações sobre valores de referência para normalidade em exames de monitorização ambulatorial da pressão arterial (MAPA) foram propostas pela V Diretriz Brasileira de Monitorização Ambulatorial da Hipertensão Arterial, com base principalmente no estudo IDACO. OBJETIVOS: O presente estudo epidemiológico tem o objetivo de avaliar o impacto da adoção desses novos critérios em um ambulatório de referência em hipertensão arterial. MÉTODOS: Foram analisados resultados de 1.567 exames de MAPA realizados entre 2005 e 2010, excluídos 481 pacientes da amostra por não preencherem critérios mínimos de qualidade do exame. Para a classificação desses exames quanto à anormalidade, foram utilizados os valores de referência da IV Diretriz Brasileira de MAPA (2005) e comparados com as mudanças propostas na V Diretriz Brasileira de MAPA (2011). Foi realizada análise estatística pelo método do Q² de Pearson, considerando-se p significativo < 0,05. RESULTADOS: Para os 1.086 exames avaliados, houve importante diferença na proporção de pacientes com MAPA alterado, em especial para a variável pressão arterial sistólica do sono: 49% adotando os valores de corte de 2005 e 71% adotando os de 2011, com significância estatística, p < 0,0001. CONCLUSÕES: A recomendação da nova diretriz causou grande impacto na classificação da hipertensão pelos exames de MAPA dentro da população estudada. A questão sobre os limiares desses exames para metas terapêuticas de pacientes sabidamente hipertensos ainda está em aberto e carece de mais estudos, preferencialmente nacionais, para melhor definição do assunto.

BACKGROUND: New recommendations on reference values for normal test results in ambulatory blood pressure monitoring (ABPM) were proposed by the V Brazilian Guidelines on Ambulatory Blood Pressure Monitoring, based mainly on the IDACO study. Objectives: This epidemiological study is aimed at evaluating the impact of adopting these new standards in an arterial hypertension referral center. METHODS: The results of 1,567 ABPM tests carried out between 2005 and 2010 were analyzed; 481 patients were excluded from the sample for not meeting minimum quality criteria of the test. Reference values from the IV Brazilian Guidelines on ABPM (2005) were used for the classification of these tests regarding the abnormality and compared with the changes proposed by the V Brazilian Guidelines on ABPM (2011). Statistical analysis was performed by Pearson's chi-square method and p values < 0.05 were considered statistically significant. RESULTS: For the 1,086 tests evaluated, there was a significant difference in the proportion of patients with altered ABPM results, especially for the variable systolic pressure in the sleeping period: 49% when adopting the cutoff values of 2005 and 71% when adopting the values of 2011, with statistical significance, p < 0.0001. CONCLUSIONS: The recommendations of the new guidelines had a great impact on the hypertension classification by ABPM test results in the study population. The question of thresholds of these tests for therapeutic targets of patients known to be hypertensive is still open and requires further studies, preferably national ones, for better definition of the subject.

Índice Internacional de Função Erétil Simplificado e doença coronariana em pacientes hipertensos / Simplified International Index of Erectile Function (IIEF-5) and coronary artery disease in hypertensive patients

FUNDAMENTO: A Disfunção Erétil (DE) se associa ao risco aumentado de Doença Arterial Coronariana (DAC). OBJETIVO: Avaliar a associação entre DE, determinada pelo Índice Internacional de Função Erétil Simplificado (IIFE-5), e DAC. MÉTODOS: Estudo de corte transversal que avaliou 263 hipertensos (55 [50 - 61] anos). A DE foi avaliada pelo IIEF-5 e a DAC, por meio da história de revascularização miocárdica prévia e/ou por cineangiocoronariografia. RESULTADOS: O IIFE-5 se correlacionou com o clearance de creatinina [ClCr] (Rho = 0,23; p < 0,001) e com a idade (Rho = -0,22; p < 0,001). Quarenta e dois pacientes apresentavam DAC; e o IIFE-5 foi capaz de discriminá-los (área sob a curva ROC = 0,63; p = 0,006). Os pacientes foram divididos em dois grupos: IIFE-5 < 20 (n = 140) e IIFE- 5 > 20 (n = 123); aqueles com menor IIFE-5 tinham idade mais elevada (57 [52 - 61] vs. 54 [45 - 60] anos; p = 0,002), maior prevalência de DAC (22% vs. 9%; p = 0,004), tabagismo (64% vs. 47%; p = 0,009) e do uso de inibidores dos canais de cálcio (65 % vs. 43%; p = 0,001), além de menor ClCr (67,3 [30,8 - 88,6] vs. 82,6 [65,9 - 98,2] ml/min; p < 0,001). O IIFE-5 < 20 se associou ao maior risco de DAC em regressão logística; tanto univariada (RR = 2,89 [IC 95% 1,39 - 6,05]), quanto após ajustes para idade, diabetes, ClCr, tabagismo, pressão arterial média e uso de anti- hipertensivos (RR = 2,59 [IC 95%: 1,01 - 6,61]). CONCLUSÃO: O IIFE-5 se associa ao diagnóstico de DAC e sua utilização pode agregar informação ao estadiamento do risco cardiovascular em pacientes hipertensos.

BACKGROUND: Erectile Dysfunction (ED) is associated with increased risk of coronary artery disease (CAD). OBJECTIVE: To evaluate the association between ED, determined by the Simplified International Index of Erectile Function (IIEF-5) and CAD. METHODS: This was a cross-sectional cohort study that evaluated 263 hypertensive patients (55 [50-61] years). ED was assessed through the IIEF-5 and CAD by the history of previous myocardial revascularization and/or coronary angiography. RESULTS: The IIEF-5 correlated with creatinine clearance [CrCl] (Rho = 0.23, p <0.001) and age (Rho = -0.22, p <0.001). Forty-two patients had CAD, and IIEF-5 was able to discriminate them (area under the ROC curve = 0.63, p = 0.006). Patients were divided into two groups: IIEF-5 < 20 (n = 140) and IIEF-5 > 20 (n = 123); those with lower IIEF-5 scores were older (57 [52-61] vs. 54 [45-60] years, p = 0.002), had higher prevalence of CAD (22% vs. 9%, p = 0.004), smoking (64% vs. 47%, p = 0.009) and use of calcium channel inhibitors (65% vs. 43.%, p = 0.001), as well as lower CrCl (67.3 [30.8 to 88.6] vs. 82.6 [65.9 - 98.2] ml/min, p <0.001). The IIEF-5 < 21 was associated with increased risk of CAD in the logistic regression, both univariate (RR = 2.89 [95%CI: 1.39 - 6.05]), and after adjusting for age, diabetes, CrCl, smoking, mean arterial pressure and use of antihypertensive drugs (RR = 2.59 [95% CI: 1.01 - 6.61]). CONCLUSION: The IIEF-5 is associated with the diagnosis of CAD and its use can add information to cardiovascular risk staging in hypertensive patients.