IMMUNOSUPRESIVE THERAPY OF PRIMARY FOCAL SCLEROSING GLOMERULONEPHRITIS IN THE ADULT: A SYSTEMATIC REVIEW
TRATAMIENTO INMUNOSUPRESOR DE LA HIALINOSIS SEGMENTARIA Y FOCAL PRIMARIA del ADULTO: UNA REVISION SISTEMATICA
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Grupo de Nefrología Basada en la Evidencia de la Sociedad Española de Nefrología, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "TRATAMIENTO INMUNOSUPRESOR DE LA HIALINOSIS SEGMENTARIA Y FOCAL PRIMARIA del ADULTO: UNA REVISION SISTEMATICA" ] ] "tienePdf" => false "PalabrasClave" => array:2 [ "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec436295" "palabras" => array:2 [ 0 => "Glomerulonefritis Esclerosante Focal" 1 => "Hialinosis Glomerular Segmentaria y Focal ; Sindrome Nefrótico ; Revision Sistemática ; Tratmiento inmunosupreso" ] ] ] "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec436296" "palabras" => array:1 [ 0 => "Focal Sclerosing Glomerulonephritis ; Focal segmental glomerular hialynosis ; Nephrotic Syndrome ; Systematic Review ; Inmmunosupresive Tharapy" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "SUMMARY and CONCLUSIONS Objective: To analyse and critically give a hierarchical structure, through a systemic review, to results obtained from clinical research focused on the effect of immunosuppressive therapy on nephrotic syndrome (NS) and focal segmental glomerulosclerosis (FSG) in adults. Study selection: Systematic reviews, randomised controlled trials, and cohort studies with at least 10 patients which studied immunosuppressive therapy in NS and FSG in adults (aged over 19 years). Outcome variables: Complete or partial remission of nephrotic syndrome, two-fold increase in serum creatinine, end-stage renal disease or haemodialysis, relapses, and infections. Data sources: The following literature databases: 1.- MEDLINE. 2.- Ovid system, EBM Reviews-ACP Journal Club reviews, EBM Reviews-Cochrane Central Register of Controlled Trials, EBM Reviews-Cochrane Database of Systematic Reviews, EMBASE. And a manual review of retrieved references, UpToDate and reviews published since 2000. Analysis: Two reviewers abstracted every article and resolved discrepancies by agreement or consulting to a third reviewer. No meta-analysis was done because of the small number and heterogeneity of randomised controlled trials. Trial quality was assessed using the quality criteria proposed by the Cochrane Renal Group. Observational studies were included if they clearly stated their outcome variables. Results: - In a patient diagnosed with FSG initial treatment with prednisone should be recommended (level of evidence 1c, grading of recommendation A). - Corticoid therapy is recommended for a long period, from 6 to 8 months (level of evidence 4, grading of recommendation C). - Due to the little evidence available it is not recommended to add any immunosuppressor to prednisone at therapy start, except for cases with high risk of steroid toxicity (level of evidence 4, grading of recommendation C). - Response to therapy and renal survival are related to glomerular renal filtration, but no threshold can be determined under which the response is less likely to be successful. If renal insufficiency, therapy should be tailored based on its benefit/risk ratio (level of evidence 4, grading of recommendation C). - Cyclosporine A is the only drug in which there is evidence based on controlled trials on its efficacy in corticosteroid resistance or dependence in NS in FSG in adults (level of evidence 2 b, grading of recommendation B). However, its results are unsatisfactory since it leads to a high incidence of relapses and nephrotoxicity. - There is little evidence to support therapy with tacrolimus, sirolimus or mycophenolate mofetil in corticoid-resistant NS due to FSG in adults (level of evidence 4, grading of recommendation C). - A pilot study supports therapy with tacrolimus in corticoid-resistant and cyclosporine A-resistant NS (level of evidence 4, grading of recommendation C). Conclusions: The therapy of NS and FSG in adults is based on little evidence so that an important effort in research on this field is necessary. " ] "es" => array:1 [ "resumen" => "<p class="elsevierStylePara">RESUMEN y CONCLUSIONES Objetivo : Analizar y jerarquizar críticamente, mediante una revisión sistemática, los resultados públicados sobre el tratamiento inmunosupresor del Síndrome Nefrósico (SN) por Hialinosis Segmentaria y Focal primaria (HSF) en adultos. Selección de trabajos: Se incluyeron artículos de tratamiento inmunosupresor del SN de la HSF en enfermos adultos (edad > 19 años) : revisiones sistemáticas; ensayos clínicos controlados y estudios observacionales que incluyan al menos 10 enfermos. Variables de resultado : remisión (completa o parcial) del síndrome nefrótico, alcance al doble de la creatinina plasmática, insuficiencia renal terminal-hemodiálisis, recidivas, infecciones. Fuentes de la búsqueda: Se realizó en las bases bibliográficas :1.- Medline. 2.- Sistema Ovid,: EBM Reviews-ACP Journal Club ; EBM Reviews-Cochrane Central Register of Controlled Trials; EBM Reviews-Cochrane Database of Systematic Reviews; EMBASE 3.- Se realizó revisión manual: de la bibliografia de la RS, ECC, UpToDate y revisiones desde el año 2000 Análisis: Los trabajos fueron revisados por 2 observadores, que resolvieron las diferencias por consenso y consulta con un tercer observador. Dados el escaso numero y la heterogeneidad de los ensayos clínicos controlados, encontrados no pudo realizarse agregación o metanalísis de los mismos. Su calidad fue evaluada usando el listado de calidad del Cochrane Renal Group. Los estudios observacionales fueron incluidos si describían de forma clara las variables de resultado. Resultados - En un enfermo diagnosticado de HSF debe recomendarse el tratamiento inicial con Prednisona. (nivel de evidencia 1c . Grado de recomendación A). - Se recomienda mantener tratamiento corticoideo por un periodo largo entre 6 y 8 meses (Nivel de evidencia 4; Grado de recomendación C). - La poca evidencia existente no recomienda iniciar el tratamiento asociando Prednisona a otro inmunosupresor, salvo casos con alto riego de toxicidad esteroidea (nivel de evidencia 4; Grado de recomendación C) - La respuesta al tratamiento y la supervivencia renal se relacionan con el filtrado glomerular, pero no puede determinarse un nivel por debajo del cual la respuesta terapéutica sea poco probable. Si existe insuficiencia renal, los casos deben ser individualizados en base al cociente riesgo / beneficio del tratamiento (nivel de evidencia 4; grado de recomendación C). - La Ciclosporina A es la única droga de la que tenemos pruebas de eficacia mediante estudios controlados en situacion de corticorresistencia o corticodependencia en el SN por HSF en el adulto (Nivel de evidencia 2 b ; Grado de recomendación B). Sin embargo, los resultados son insatisfactorios por la alta incidencia de recidivas y por la nefrotoxicidad. - Existe un nivel de evidencia muy bajo que sustente las intervenciones con Tacrolimus, Sirolimus o Mofetil-Micofenolato en el SN por HSF corticorresistente en el adulto (nivel de evidencia 4; grado de recomendación C). - Un estudio piloto, respalda el tratamiento con Tacrolimus en al SN corticorresistente y resistente a la Ciclosporina A (nivel de evidencia 4; grado de recomendación C). Conclusión : El tratamiento del síndrome nefrótico del Adulto por hialinosis focal y segmentaria promaria se basa en niveles de evidencia muy bajos, siendo necesario un importante esfuerzo investigador en este campo.</p>" ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000002700000003/v0_201502091552/X2013251407021206/v0_201502091552/en/main.assets" "Apartado" => null "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251407021206?idApp=UINPBA000064" ]
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ISSN: 20132514Original language: English
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