Please use this identifier to cite or link to this item: http://repositorio.unicamp.br/jspui/handle/REPOSIP/332512
Type: DISSERTAÇÃO DIGITAL
Degree Level: Mestrado
Title: Aplicação dos novos critérios diagnósticos de lesão renal aguda em pacientes com cirrose : prognóstico, evolução para transplante hepático e mortalidade
Title Alternative: Application of new diagnostic criteria for acute kidney injury in patients with cirrhosis : prognosis, evolution for liver transplantation and mortality
Author: Drumond, Nayana Fonseca Vaz, 1998-
Advisor: Mazo, Daniel Ferraz de Campos, 1978-
Abstract: Resumo: Introdução: Lesão renal aguda (LRA) é uma complicação comum da cirrose, associada à elevada morbimortalidade. O diagnóstico se baseia na creatinina sérica (sCr), uma avaliação não ideal da função renal em cirróticos. Reuniões de consenso propuseram nos últimos anos modificações nos critérios diagnósticos de LRA, que classicamente considerava-se sCr ?1,5mg/dL. De acordo com o Consenso do Clube Internacional da Ascite de 2015, a LRA foi definida como elevação ?0,3mg/dL da sCr no período de 48 horas ou aumento de 50% do basal conhecido ou presumido (critérios ICA-AKI), com divisão em três estadios (E). Entretanto, existe uma discordância entre os estudos sobre qual critério eleger em pacientes hospitalizados com cirrose. Objetivos: Avaliar a prevalência da LRA em cirróticos internados; a concordância dos critérios tradicional e ICA-AKI no diagnóstico de LRA; suas características clínicas e laboratoriais, etiologias, fatores de risco, resposta ao tratamento, evolução para transplante hepático e mortalidade. Métodos: Estudo retrospectivo e prospectivo, observacional em pacientes cirróticos admitidos no Hospital de Clínicas da Universidade Estadual de Campinas (UNICAMP), entre outubro de 2016 a agosto de 2017. Critérios de inclusão: ?18 anos com internação não eletiva. O coeficiente Kappa foi utilizado para avaliar a concordância entre os critérios. Foi avaliado o total de internações utilizando o modelo de Prentice, Williams e Peterson para eventos recorrentes, sendo considerado significante p <0,05. Resultados: Foram avaliadas 235 internações em 148 pacientes, sendo incluídas 154 internações (75 pacientes). A idade média foi 56,49 ± 9,65 anos, sendo 60% homens e a principal etiologia da cirrose foi o álcool, em 36% (27 pacientes). Trinta pacientes eram Child-Pugh B (40,5%) e 43 pacientes Child-Pugh C (58,1%), com MELD médio de 18,15. Das internações, 89 (57,79%) cursaram com LRA-ICA-AKI. Houve substancial concordância entre os critérios de LRA (Kappa 0,7293). A principal etiologia de LRA foi pré-renal (69,66%), seguida de renal (26,96%) e síndrome hepatorrenal (10,11%). Na análise univariada, foram fatores de risco para LRA-ICA-AKI MELD (p=0,0233, RR:1,046, IC95%: 1,006-1,087), infecção (p=0,0037, RR: 2,183, IC 95%: 1,288-3,701), sódio sérico (p=0,0053, RR: 0,953, IC 95%: 0,921-0,986), uso de furosemida (p=0,0034, RR: 2,062, IC95%: 1,270-3,348), espironolactona (p=0,0186, RR: 1,803, IC95%: 1,103-2,948) e drogas nefrotóxicas (p=0,0349, RR: 2,044, IC 95%: 1,052-3,971). Já na análise multivariada, MELD (p=0,0188, RR: 1,059, IC 95%: 1,010-1,111) e uso de furosemida (p=0,0014, RR: 2,695, IC95%: 1,465-4,960). Foram associados à mortalidade intra-hospitalar na análise univariada creatinina ?1,5mg/dL (p=0,0373, RR: 4,754, IC95%: 1,096-20,610), MELD (p=0,0296, RR: 1,076, IC95%: 1,007-1,149), bilirrubinas (p=0,0064, RR: 1,053, IC95%: 1,015-1,093), choque (p=0,0003, RR: 5,663, IC95%: 2,201-14,569) e ICA-AKI máximo E3 (p=0,0221, RR: 10,944, IC95%: 1,411-84,886). Na análise multivariada, ICA-AKI máximo E3 (p=0,0252, RR: 10,499, IC95%: 1,339-82,335). Dentre as internações com LRA, foram associados ao óbito ICA-AKI máximo E3 (p=0,0401, RR: 3,803, IC95%: 1,062-12,614), não resolução completa (p=0,0134, RR: 4,685, IC95%: 1,378-15,930) ou parcial da LRA (p=0,0004, RR: 7,336, IC95%: 2,441-22,045) ou necessidade de diálise (p=0,0036, RR: 3,518, IC95%: 1,510-8,196). Conclusões: Observamos uma alta prevalência de LRA pelos critérios de ICA-AKI. Houve substancial concordância entre os critérios de LRA. A principal etiologia foi pré-renal. Os fatores de risco associados à LRA-ICA-AKI foram o MELD, níveis mais baixos de sódio sérico, infecção, uso de diuréticos e drogas nefrotóxicas. Mortalidade intra-hospitalar foi associada com MELD, bilirrubina, creatinina, choque e E3 ICA-AKI. Nos pacientes com LRA a mortalidade intra-hospitalar foi relacionada com gravidade da disfunção renal, não resposta ao tratamento e necessidade de diálise

Abstract: Introduction: Acute kidney injury (AKI) is a common complication of cirrhosis, associated with high morbidity and mortality. The diagnosis of AKI is based on serum creatinine (sCr), a non-ideal marker of renal function in cirrhotic patients. In recent years, consensus meetings have proposed changes in AKI diagnostic criteria, which traditionally comprised a sCr ?1.5 mg/dL. According to the 2015 International Club of Ascites Meeting, AKI was defined as a sCr ?0.3 mg/dL increase within 48 hours or a 50% increase in the known or presumed baseline sCr (ICA-AKI criteria), with three severity stages. However, there is disagreement between the studies on which criteria to choose in hospitalized patients with cirrhosis. Objectives: To evaluate the prevalence of AKI in cirrhotic patients; to evaluate the agreement between traditional and ICA-AKI criteria in the diagnosis of AKI; to assess its clinical and laboratory characteristics, etiologies, risk factors, responses to treatment, progression for liver transplantation and mortality. Methods: Retrospective and prospective observational cohort study conducted in cirrhotic patients admitted to the University of Campinas (UNICAMP) Clinics Hospital, from October 2016 to August 2017. Inclusion criteria: ? 18 years old cirrhotic patients undergoing non-elective hospitalization. Kappa coefficient was used to evaluate the agreement between the two AKI criteria. The total number of hospitalizations was evaluated using the Prentice, Williams and Peterson¿s statistical model for recurring events; p value <0.05 was considered significant. Results: A total of 235 hospitalizations were evaluated in 148 patients and 154 admissions of 75 patients were included in the study. The mean age was 56.49 ± 9.65 years old, 60% were men and the main etiology of cirrhosis was alcohol (36%; 27 patients). Thirty patients were Child-Pugh B (40.5%) and 43 were Child-Pugh C (58.1%), with a mean MELD score of 18.15. Among the hospitalizations, 89 (57.79%) met ICA-AKI criteria. There was substantial agreement between both AKI classifications (Kappa 0.7293). The main etiology of AKI was pre-renal (69.66%), followed by renal (26.96%) and hepatorenal syndrome (10.11%). Risk factors for ICA-AKI identified in the univariate analysis were a higher MELD score (p=0.0233, RR:1.046, 95%CI: 1.006-1.087), infection occurrence (p=0.0037, RR: 2.183, 95CI%: 1.288-3.701), lower serum sodium (p=0.0053, RR: 0.953, 95%CI: 0.921-0.986), the use of furosemide (p=0.0034, RR: 2.062, 95%CI: 1.270-3.348), spironolactone (p=0.0186, RR: 1.803, 95%CI: 1.103-2.948) and nephrotoxic drugs (p=0.0349, RR: 2.044, 95%CI: 1.052-3.971). In the multivariate analysis, the MELD score (p=0.0188, RR: 1.059, 95%CI: 1.010-1.11) and use of furosemide (p=0.0014, RR: 2.695, 95%CI: 1.465-4.960) were associated to ICA-AKI. In-hospital mortality in the univariate analysis was associated with sCr?1.5 mg/dL (p=0.0373, RR: 4.754, 95%CI: 1.096-20.610), MELD score (p=0.0296, RR: 1.076, 95%CI: 1.007-1.149), bilirubin (p=0.0064, RR: 1.053, 95%CI: 1.015-1.093), shock (p=0.0003, RR: 5.663, 95%CI: 2.201-14.569) and peak stage 3 ICA-AKI (p=0.0221, RR: 10.944, 95%CI: 1.411-84.886). In the multivariate analysis, peak stage 3 ICA-AKI (p=0.0252, RR: 10.499, 95% CI: 1.339-82.335) was associated with mortality. Among the hospitalizations with AKI, death was significantly associated with peak stage 3 ICA-AKI (p=0.0401, RR: 3.803, 95% CI: 1.062-12.614), absence of AKI complete resolution (p=0.0134, RR: 4.685, 95%CI: 1.378-15.930), absence of AKI partial resolution (p=0.0004, RR: 7.336, 95%CI: 2.441-22.045) and dialysis (p=0.0036, RR: 3.518, 95%CI: 1.510-8.196). Conclusions: A high prevalence of AKI according to ICA-AKI criteria was observed. There was substantial agreement between both AKI criteria sets. Risk factors associated with ICA-AKI were MELD score, lower levels of serum sodium, infection, use of diuretics and nephrotoxic drugs. In-hospital mortality was associated with MELD score, bilirubin, creatinine, shock and stage 3 ICA-AKI. In patients with AKI, in-hospital mortality was related to the severity of renal dysfunction, non-response to treatment and dialysis
Subject: Cirrose hepática
Lesão renal aguda
Language: Português
Editor: [s.n.]
Date Issue: 2018
Appears in Collections:FCM - Tese e Dissertação

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