Información de la revista
Vol. 33. Núm. 5.Septiembre 2013
Páginas 623-868
Vol. 33. Núm. 5.Septiembre 2013
Páginas 623-868
Acceso a texto completo
Factores relacionados con la progresión de la enfermedad renal crónica
Factors related with the progression of chronic kidney disease
Visitas
13018
Claudia Yustea, Daniel Barracaa, Inés Aragoncillo-Saucob, ines Aragoncillo Saucoa, Almudena Vega-Martínezb, Almudena Vega Martíneza, Soraya Abada, Úrsula Verdalles-Guzmánb, Ursula Verdalles Guzmána, Caridad Ruiz-Caroa, Jara Ampueroa, Juan M. López-Gómezb, Juan Manuel López-Gómeza
a Department of Nephrology, Gregorio Marañón University General Hospital, Madrid, Madrid, Spain,
b Department of Nephrology, Gregorio Marañón University General Hospital, Madrid,
Este artículo ha recibido
Información del artículo
Resumen
Bibliografía
Descargar PDF
Estadísticas

Antecedentes: Nuestro propósito era determinar el índice de progresión de la enfermedad renal crónica (ERC) e identificar predictores, con especial énfasis en el metabolismo mineral y óseo. Métodos: Estudio retrospectivo y de observación que incluye a 300 pacientes con ERC avanzada (61,2 % varones, 33,1 % diabéticos; edad 65,6 ± 14 años). El tiempo medio de seguimiento fue de 19,4 ± 10,1 meses. El índice de filtración glomerular estimado (FGe) de referencia (MDRD-4) fue de 22,5 ± 7,18 ml/min. Para calcular la tasa de reducción en el IFGe, utilizamos la pendiente de la línea de regresión entre todas las determinaciones de IFGe y el tiempo de seguimiento. Calculamos los valores medios de proteinuria y fosfato sérico, calcio, ácido úrico y hormona paratiroidea (PTH), así como la excreción urinaria de 24 horas de nitrógeno ureico de cada paciente. El seguimiento fue, como mínimo, de 6 meses e incluyó al menos 4 mediciones de FGe. Resultados: La tasa media de reducción de FGe (–1,64 ml/min/1,73 m2/año) estaba inversamente correlacionada con los niveles de fosfato sérico (4,3 ± 2,1 mg/dl, p < 0,001), PTH (256,3 ± 193,7 mg/l, p < 0,001) y proteinuria (0,84 ± 1,31 g/día, p = 0,004) y directamente correlacionada con el calcio sérico medio (p < 0,001) y la presencia de hipertensión (p < 0,02). Sin embargo, únicamente el fosfato sérico, la PTH sérica y la proteinuria persistieron como predictores en el análisis multivariable. Los pacientes con IFG estable (pendiente positiva) eran mayores (p = 0,041) y presentaban niveles más bajos de fosfato sérico y PTH (p < 0,01 y p < 0,01, respectivamente), y proteinuria más baja (p < 0,01). Conclusiones: La tasa de reducción en el FGe estaba correlacionada con los niveles de fosfato sérico y PTH y la proteinuria. Todos estos factores pueden modificarse con el tratamiento adecuado.

Palabras clave:
Progresión de insuficiencia renal
Palabras clave:
Metabolismo óseo
Palabras clave:
Enfermedad renal crónica
Palabras clave:
Proteinuria
Palabras clave:
Hormona paratiroidea (PTH)
Palabras clave:
Fosfato sérico

Background: Our aims were to determine the rate of progression of chronic kidney disease (CKD) and to identify predictors, with particular emphasis on bone and mineral metabolism. Methods: Retrospective and observational study including 300 patients with advanced CKD (61.2% males, 33.1% diabetics; age 65.6±14 years). Mean follow-up time was19.4±10.1 months. Baseline estimated glomerular filtration rate (eGFR) (MDRD-4) was 22.5±7.18mL/min. To calculate the rate of decline in eGFR, we used the slope of the regression line between all determinations of eGFR and follow-up time. We calculated the mean values for proteinuria and serum phosphate, calcium, uric acid, and PTH, as well as 24-hour urinary excretion of urea nitrogen over time for each patient. Follow-up was at least 6 months and included at least 4 measurements of eGFR. Results: The mean rate of decline eGFR (–1.64 mL/min/1.73m2/year) was inversely correlated with serum phosphate levels (4.3±2.1 mg/dL, p<.001), PTH (256.3±193.7ng/L, p<.001) and proteinuria (0.84±1.31g/day, p=.004) and directly correlated with mean serum calcium (p<.001) and the presence of hypertension (p<.02). However, only serum phosphate, serum PTH, and proteinuria persisted as predictors in the multivariate analysis. Stable-GFR patients (positive slope) were older (p=.041) and had lower serum phosphate and PTH levels (p<.01 and p<.01 respectively) and lower proteinuria (p<.01). Conclusions: The rate of decrease in eGFR was correlated with serum phosphate and PTH levels and proteinuria. All of these factors can be modified with an adequate treatment.

Keywords:
Progression of renal insufficiency
Keywords:
Bone metabolism
Keywords:
Chronic kidne disease
Keywords:
Proteinuria
Keywords:
Parathyroid hormone (PTH)
Keywords:
Serum phosphate
El Texto completo está disponible en PDF
Bibliografía
[1]
Otero A, Gayoso P, Garcia F, de Francisco AL; EPIRCE study group. Epidemiology of chronic renal disease in the Galician population: results of the pilot Spanish EPIRCE study. Kidney Int Suppl 2005;(99):S16-9. [Pubmed]
[2]
Sarnak MJ, Levey AS, Schoolwerth AC, Coresh J, Culleton B, Hamm LL, et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation 2003;108:2154-69.
[3]
3.  Lucove J, Vupputuri S, Heiss G, North K, Russell M. Metabolic syndrome and the development of CKD in American Indians: the Strong Heart Study. Am J Kidney Dis 2008;51(1):21-8. [Pubmed]
[4]
Taal MW, Brenner BM. Predicting initiation and progression of chronic kidney disease: developing renal risk scores. Kidney Int 2006;70:1694-705. [Pubmed]
[5]
Kronenberg F. Emerging risk factors and markers of chronic kidney disease progression. Nat Rev Nephrol 2009;5:677-89. [Pubmed]
[6]
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373-83. [Pubmed]
[7]
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. Modification of Diet in Renal Disease Study Group. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med 1999;130:461-70. [Pubmed]
[8]
Maroni BJ, Steinman TI, Mitch WE. A method for estimating nitrogen intake of patients with chronic renal failure. Kidney Int 1985;27:58-65. [Pubmed]
[9]
Zitt E, Lamina C, Sturm G, Knoll F, Lins F, Freistätter O, et al. Interaction of time-varying albumin and phosphorus on mortality in incident dialysis patients. Clin J Am Soc Nephrol 2011;6(11):2650-6. [Pubmed]
[10]
Kuro OM. Phosphate and Klotho. Kidney Int Suppl 2011;121:S20-S23.
[11]
Schwarz S, Trivedi BK, Kalantar-Zadeh K, Kovesdy CP. Association of disorders in mineral metabolism with progression of chronic kidney disease. Clin J Am Soc Nephrol 2006;1:825-31. [Pubmed]
[12]
Voormolen N, Noordzij M, Grootendorst DC, Beetz I, Sijpkens YW, van Manen JG, et al.; PREPARE study group. High plasma phosphate as a risk factor for decline in renal function and mortality in pre-dialysis patients. Nephrol Dial Transplant 2007;22:2909-16. [Pubmed]
[13]
Lorenzo V. Similar renal decline in diabetic and non-diabetic patients with comparable levels of albuminuria. Nephrol Dial Transplant 2010;25:835-41. [Pubmed]
[14]
Zoccali C, Ruggenenti P, Perna A, Leonardis D, Tripepi R, Tripepi G,  et al. Phosphate may promote CKD progression and attenuate renoprotective effect of ACE inhibition. J Am Soc Nephrol 2011;22:1923-30. [Pubmed]
[15]
Fliser D, Kollerits B, Neyer U, Ankerst DP, Lhotta K, Lingenhel A, et al.; MMKD Study Group. Fibroblast growth factor 23 (FGF23) predicts progression of chronic kidney disease: the Mild to Moderate Kidney Disease (MMKD) Study. J Am Soc Nephrol 2007;18(9):
[16]
2600-8.
[17]
Kendrick J, Cheung AK, Kaufman J, Greene T, Roberts W, Smits G, et al., and the HOST investigators. FGF-23 associates with death, cardiovascular events, and initiation of chronic dialysis. J Am Soc Nephrol 2011;22:1913-22. [Pubmed]
[18]
Haruna Y, Kashihara N, Satoh M, Tomita N, Namikoshi T, Sasaki T, et al. Amelioration of progressive renal injury by genetic manipulation of Klotho gene. Proc Natl Acad Sci U S A 2007;104:2331-6. [Pubmed]
[19]
Remuzzi G, Ruggenenti P, Perico N. Chronic renal diseases: renal protective benefits of renin-angiotensin system inhibition. Ann Intern Med 2002;136: 604-15. [Pubmed]
[20]
Lorenzo V. Fósforo y supervivencia. Nefrologia 2009;29(Suppl 5):6-9. [Pubmed]
[21]
Zeeuw D, Remuzzi G, Parking H-H, Keane WF, Zhang Z, Shahinfar S, et al. Proteinuria, a target for renoprotection in patients with type 2 diabetic nephropathy: Lessons from RENAAL. Kidney Int 2004;65:2309-20. [Pubmed]
[22]
Klahr S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW, et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med 1994;330:877-84.
[23]
Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003;139:137-47. [Pubmed]
[24]
23.  El-Ghoul B, Elie C, Sqalli T, Jungers P, Daudon M, Grünfeld JP, et al. Nonprogressive kidney dysfunction and outcomes in older adults with chronic kidney disease. J Am Geriatr Soc 2009;57:2217-23. [Pubmed]
[25]
Van Biesen W, Lameire N, Veys N, Vanderhaegen B. From curing to caring: one character change makes a world of difference. Issues related to withholding/withdrawing renal replacement therapy (RRT) from patients with important co-morbidities. Nephrol Dial Transplant 2004;19:536-40. [Pubmed]
[26]
Murtagh FE, Marsh JE, Donohoe P, Ekbal NJ, Sheerin NS, Harris FE. Dialysis or not? A comparative survival study of patients over 75 years with chronic kidney disease stage 5. Nephrol Dial Transplant 2007;22:1955-62. [Pubmed]
[27]
Taal MW, Brenner BM. Renal risk scores: Progress and prospects. Kidney Int 2008;73:1216-9. [Pubmed]
[28]
Levey AS, Adler S, Caggiula AW, England BK, Greene T, Hunsicker LG, et al. Effects of dietary protein restriction on the progression of advanced renal disease in the Modification of Diet in Renal Disease Study. Am J Kidney Dis 1996;27:652-63. [Pubmed]
[29]
USRDS 2007 Annual Data Report. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. 2007, 84.
[30]
Neugarten J, Acharya A, Silbiger SR. Effect of gender on the progression of nondiabetic renal disease: a meta-analysis. J Am Soc Nephrol 2000;11:319-29. [Pubmed]
[31]
Xu R, Zhang LX, Zhang PH, Wang F, Zuo L, Wang HY. Gender differences in age-related decline in glomerular filtration rates in healthy people and chronic kidney disease patients. BMC Nephrology 2010;11:20. [Pubmed]
[32]
31.                  Keane WF, Zhang Z, Lyle PA, Cooper ME, de Zeeuw D, Grunfeld JP; RENAAL Study Investigators. Risk scores for predicting outcomes in patients with type 2 diabetes and nephropathy: The RENAAL Study. Clin J Am Soc Nephrol 2006;1:761-7.  [Pubmed]
Idiomas
Nefrología
Opciones de artículo
Herramientas
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?