Manejo das Doenas cardiovasculares na DRD

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Manejo das Doenas cardiovasculares na DRD. Maria Eugnia F Canziani UNIFESP. DCV vs. DRC. OMS DM 217 milhes em 2005 366 milhes em 2030 epidemia mundial de sndrome metablica e DM Maior prevalncia de DM alta morbidade e mortalidade aterosclerose - PowerPoint PPT Presentation

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  • Manejo das Doenas cardiovasculares na DRD Maria Eugnia F Canziani UNIFESP

  • DCV vs. DRC OMS DM 217 milhes em 2005 366 milhes em 2030 epidemia mundial de sndrome metablica e DM Maior prevalncia de DM alta morbidade e mortalidade aterosclerose- Da coronariana- Ac. vascular cerebral- Da arterial perifrica Diabetes Care 2004, 27: 1047NEJM 1998, 339:229

  • DCV vs. DRC Doenas Cardiovasculares 80% causas de bito de pac. DM tipo 2 Estudos epidemiolgicos- DM vs. nDM 2 4 X risco DCV ( 12 X DM I) Framingham Heart Study 2 10 X risco - Da coronariana, AVC, ICC, bito DCV Doena Renal CrnicaDiabetes Care 1979, 2: 120NEJM 1998, 339:229AJKD 2005, 45:S1 USRDS 2005

  • DCV vs. DRC 7582 HA +DM projeto italiano risco de HVE 23% para cada 21mL/min TFG

  • USRDS 1995 a 1999, n= 373.539 pac. incio dilise38,4% HA+DM / 11,4% DM / 37,4% HA / 12,8% nadaOdds ratioDCV vs. DRC

  • DCV vs. DRC 7788 pac ICC 987 pares DRC vs. DRC + DM

  • DiabetesDCV Mortalidade

  • DCV vs. DRCPatognese da hiperglicemia induzindo disfuno endotelialVasc Health and Risk Management 2007; 3(6):853

  • disfuno endotelial placa aterosclerticaNew Engl J Med 1999 340(2):115 Evento IsqumicoDCV vs. DRC

  • Perfil lipdico (n=96) Precoce e qualitativa 87%Tomiyama C, Canziani ME Sobrepeso e obesidade (IMC>25) 53%DCV vs. DRC

    Colesterol (mg/dl)202120 35751% > 200HDL (mg/dl)4929 11423% < 40LDL (mg/dl)11115 25165% > 100TG (mg/dl)14638 110447% > 150

  • Sndrome MetablicaObesidade centralPop. Geral DCV e mortalidadeassociao com dislipidemia tecido adiposo produz TNF,IL6 e IL1Endocrin 2003, 144:2195 J. Clin. Investig, 112: 1785-1788, 2003.DCV vs. DRC

  • ADIPONECTINADRC Inflamao + disfuno endotelialDCV vs. DRC

  • Am J Kidney Dis, 2008123 pacientes em conservador correlao com a gordura visceral medida pela CTFatores de risco DCV (lpides, HOMA, PCR)

    Calcificao coronariana e adipocinas ?

    DCV vs. DRC

  • DRCDiabetesDCVDCV vs. DRC

  • P, 1,25(OH) vitDOsteodistrofiaAlterao do Metabolismo Mineral Doena CardiovascularInflamaoIL-6, TNF, CRP, oxLDL No tradicionais (relac. uremia) Secreo ReninaHipertenso EritropoietinaAnemiaDCV vs. DRC

  • DCV vs. DRC

  • Doena renal crnicaEstresse oxidativoAcmulo de citocinasAcmulo de AGEInfeces crnicasSobrecarga de volume e HASToxicidade urmicaSinais de ativaoTNF-, IL-1OxidantesAGE/RAGELPSMediadores InflamatriosCitocinasFatores de crescimentoMetaloproteinasesPr-coagulantesAteroscleroseOxidao do LDLMigrao de leuccitosInflamaoProliferao de cls. Musc.Calcificao vascular ( fetuina)Uremia Cl. Inflamatria Parede vascularTranscrio Genes inflamatriosInflamaoStenvinkel P, Pecoits-Filho R, et al JASN 2003, 14:1927DCV vs. DRC

  • DRC - DiabetesDCV vs. DRCDoena de Baixo Remodelamento

  • ClcioFsforoPTHPTHCalcificaoDepsito TecidualClcioFsforoXXDCV vs. DRC

  • Tomografia Coronariana normalTC com calcificaoaortaCDCXDADCV vs. DRC

  • Coronary calcification is associated with lower bone formation rate in CKD patients not yet in dialysis treatment.CristianneTomiyama1, Aluizio B. Carvalho1, Andrea Higa1, Vanda Jorgetti2, Srgio A. Draibe1, Maria Eugnia F. Canziani1. 1Department of Internal Medicine/ Division of Nephrology, Federal University of So Paulo, So Paulo, Brazil; 2Department of Internal Medicine/ Division of Nephrology, University of So Paulo, So Paulo, Brazil CT + biopsia ssea n= 50 51 11anos, 68% masc, 30% DM, Clcr 39 19 mL/minJBMR 2009- in pressDeficincia de Vitamina D 10%Insuficincia de Vitamina D - 32%

    BMI > 25 kg/m2 (%)27 (54%)Ionized calcium (mmol/L)1.30 0.06Phosphorus (mg/dL)3.8 0.7Alkaline phosphatase (U/L)116 (37 634)Intact parathyroid hormone (pg/mL)83 (26 548)25(OH) vitamin D (ng/mL) 30.8 10.11.25 (OH)2 vitamin D (pg/mL)39.9 18.1

  • DiabetesDoena de baixoremodelamento

    Reference rangesMALEFEMALE StructureBV/TV %17.2 5.724.0 6.121.8 7.2Tb.Th m 124.3 26.8127.9 29.7126.0 28.8Tb.Sp m 658.3 237.1420.6 124.1498.3 195.9Tb.N n/mm 1.38 0.381.89 0.421.76 0.52 FormationOV/BV % 2.29 2.52.9 2.71.55 1.9Ob.S/BS %1.8 2.21.2 1.41.2 3.2O.Th m 7.8 3.111.7 3.510.8 3.2OS/BS % 15.5 13.616.1 12.69.2 8.4BFR/BS m3/ m2/day 0.017 0.020.13 0.070.07 0.03*MLT days 204.8 240.521.3 2.323.7 2.7 ResorptionES/BS % 7.8 6.41.75 1.212.3 2.4Oc.S/BS %0.73 0.790.03 0.110.03 0.06 FibrosisFb.V/BV %0.05 0.1000

  • Regresso Logstica ajustada para idade, sexo e DM

    BFR/BS (p = 0.009; OR= 0.15; 95% CI 0.036 - 0.619).

    Without calcification (n = 17)With calcification (n = 33)PAge (years)46 1254 90.01Male gender (%)47790.02Diabetes (%)18510.03Creatinine clearance (ml/min/1,73m2)38 1739 190.81Ionized calcium (mmol/L)1.32 0.041.29 0.060.01Phosphorus (mg/dL)3.9 0.63.7 0.80.49Intact parathyroid hormone (pg/mL)92 (33 416)108 (26 548)0.12Alkaline phosphatase (U/L)95 (37 257)122 (51 634)0.521.25 (OH)2 vitamin D (pg/mL)38.7 14.341.2 20.50.6625(OH) vitamin D (ng/mL)33.4 9.929.4 10.10.17Bicarbonate (mEq/L)24 424 30.62BVTV (%) 18.8 5.216.3 5.80.16OVBV (%)2.4 1.82.2 2.80.20Ob.S/BS (%)2.00 1.691.72 2.430.21ES/BS % 8.98 6.826.81 5.860.30Oc.S/BS (%)0.88 0.700.65 0.830.10BFR (3/ 2/day)0.028 0.0210.012 0.021< 0.001

  • DCV vs. DRC

  • DCV vs. DRC

  • DCV vs. DRCImpact of vascular calcification in CKD patients not yet on dialysisWatanabe R; Lemos MM; Draibe AS;Canziani ME n = 117 pac, 2 anos de segmento p= 0.051p= 0.002

  • AJKD, 2008 DCV vs. DRC

  • Sevelamer or Phoslo100 pacientes64 pacientesBO / Lab. dose quelante [Ca] dialisato CalcitriolDCV vs. DRC

  • Baixo remodelamento no incio No-progressores vs ProgressoresBone formation rate m3/m2/dayp = 0.003Mudanas dos parmentros histomorfomtricos em 1 anoDCV vs. DRC

    Basal12-mesesNo-progressores0.007 0.0080.11 0.10Progressores0.01 0.010.02 0.02

    Plan1

    Non-progressors

    Bone diag1BVTV0BVTV12bvtvnpOVBV0OVBV12ovbvnpMlt0Mlt12mltnpBFRBS0BFRBS12bfrnp

    111.216.35.12.141.916.6311294.40.060.003-0.057

    121.526.550.743.34.6120.61160.10.02-0.08

    121.327.56.24.61.7-2.914.26651.80.240.02-0.22

    111.211.30.10.76.86.1233112880.250.003-0.247

    112.315.53.218.76.5-12.2251309.358.30.030.01-0.02

    115.519.423.925.364.6-0.7661.88223.58161.70.1360.0112-0.1248

    05.40509019357.18414921892.39102488497.62548359122.09642552937.1776040571105.9276734381120.4873105352120.85015515090.10261578830.00852642950.1019593056

    Bone diag1BVTV0BVTV12bvtvnpOVBV0OVBV12ovbvnpMlt0Mlt12mltnpBFRBS0BFRBS12bfrnp

    211.111.70.61.31.50.231131100.0030.0030

    21512.9-2.14.25.71.531110-3010.0030.270.267

    229.310.6-18.71.32.71.431127.6-283.40.0030.050.047

    217.823.35.51.60.8-0.849.115.7-33.40.020.250.23

    217.612.6-52.811.8931147.4-263.60.0030.110.107

    218.510.1-8.42.95.52.659.17111.90.020.030.01

    27.915.37.417.36.331140.2-270.80.0030.110.107

    216.742857142913.7857142857-2.95714285712.15714285715.04285714292.8857142857237.674.7-162.90.00785714290.11757142860.1097142857

    06.77860780764.52932245548.88647983231.17311145093.81744117743.5130369442125.3875990678106.2013967265146.76310844350.00829515060.10507752240.1041916732

    Plan2

    Progressors

    Bone diag1BVTV0BVTV12bvtvpOVBV0OVBV12ovbvpMlt0Mlt12mltpBFRBS0BFRBS12bfrp

    116.217.91.782.1-5.9145.3311165.70.030.003-0.027

    115.17.7-7.42.81.4-1.466.3311244.70.030.003-0.027

    113.214.81.64.57.93.450.4311260.60.040.003-0.037

    118.612.8-5.84.83.9-0.931127.5-283.50.0030.10.097

    11122.711.76.75.5-1.252.610.3-42.30.080.40.32

    117.418.51.19.27.6-1.631121.9-289.10.0030.20.197

    117.313.6-3.746.72.738.722.7-160.050.220.17

    114.921.16.24.87.93.123.125.32.20.10.20.1

    124.220.5-3.711.48.7-2.750.4311260.60.120.003-0.117

    116.433333333316.62222222220.18888888896.24444444445.7444444444-0.5116.5333333333150.188888888933.65555555560.05066666670.12577777780.0751111111

    03.72256631914.79394873196.09763159852.80004960272.69263398513.0634947364115.4382952057152.6315043204217.6482891680.04125227270.13966726330.1393103051

    Bone diag1BVTV0BVTV12bvtvpOVBV0OVBV12ovbvpMlt0Mlt12mltpBFRBS0BFRBS12bfrp

    223.527.94.41.10.8-0.331120-2910.0030.040.037

    29.29.60.42.51.2-1.324.521-3.50.030.030

    210.5110.56.21.7-4.531131100.0030.0030

    29.213.64.45.54-1.531131100.0030.0030

    212.722.910.231.6-1.441.246.65.40.050.02-0.03

    21619.23.23.10.8-2.331131100.0030.0030

    213.614.30.71.31-0.380.662.9-17.70.010.010

    221.922.10.23.91.8-2.16627.9-38.10.020.050.03

    212.310.9-1.43.44.51.162.557.6-4.90.030.040.01

    21211.4-0.63.81.3-2.531131100.0030.0030

    220.719.2-1.50.71.7119.3223.32040.010.004-0.006

    21116.95.90.30.70.431131100.0030.0030

    212.413.81.411014.813-1.80.020.040.02

    216.711.9-4.80.80.2-0.617.64.7-12.90.010.020.01

    22120.4-0.62.20.3-1.92313.7-9.30.060.070.01

    26.813.97.10.11.1131153.2-257.80.0030.010.007

    211.527.616.17.34.4-2.981.789.47.70.030.030

    214.176470588216.85882352942.68235294122.71764705881.6529411765-1.0647058824153.4235294118128.7235294118-24.70.01711764710.02229411760.0051764706

    04.96255093325.79299780165.03726553972.12815509721.34588151741.5564146204137.3975142125130.8741548655107.3929874340.01764540430.02032782790.0147869676

    BVTVhigh

    3.920.18888888892.39102488492.39102488496.09763159856.0976315985

    Non-progressors

    Progressors

    OVBVhigh

    -0.76-0.57.17760405717.17760405713.06349473643.0634947364

    Non-progressors

    Progressors

    Mlt high

    161.733.6555555556217.648289168217.648289168120.8501551509120.8501551509

    Non-progressors

    Progressors

    BFRhigh

    -0.12480.07511111110.10195930560.10195930560.13931030510.1393103051

    Non-progressors

    Progressors

    BVTVlow

    -2.95714285712.68235294128.88647983238.88647983235.03726553975.0372655397

    Non-progressors

    Progressors

    OVBVlow

    2.8857142857-1.06470588243.51303694423.51303694421.55641462041.5564146204

    Non-progressors

    Progressors

    MLTlow

    -162.9-24.7146.7631084435146.7631084435107.392987434107.392987434

    Non-progressors

    Progressors

    BFRlow

    0.10971428570.00517647060.10419167320.10419167320.01478696760.0147869676

    Non-progressors

    Progressors

    Plan3

    Bone diag1BVTV0BVTV12bvtvnpOVBV0OVBV12ovbvnpMlt0Mlt12mltnpBFRBS0BFRBS12bfrnp

    115.519.423.925.364.6-0.7661.88223.58161.70.1360.0112-0.1248

    05.40509019357.18414921892.39102488497.62548359122.09642552937.1776040571105.9276734381120.4873105352120.85015515090.10261578830.00852642950.1019593056

    216.742857142913.7857142857-2.95714285712.15714285715.04285714292.8857142857237.674.7-162.90.00785714290.11757142860.1097142857

    06.77860780764.52932245548.88647983231.17311145093.81744117743.5130369442125.3875990678106.2013967265146.76310844350.00829515060.10507752240.1041916732

    Bone diag1BVTV0BVTV12bvtvpOVBV0OVBV12ovbvpMlt0Mlt12mltpBFRBS0BFRBS12bfrp

    116.433333333316.62222222220.18888888896.24444444445.7444444444-0.5116.5333333333150.188888888933.65555555560.05066666670.12577777780.0751111111

    03.72256631914.79394873196.09763159852.80004960272.69263398513.0634947364115.4382952057152.6315043204217.6482891680.04125227270.13966726330.1393103051

    214.176470588216.85882352942.68235294122.71764705881.6529411765-1.0647058824153.4235294118128.7235294118-24.70.01711764710.02229411760.0051764706

    04.96255093325.79299780165.03726553972.12815509721.34588151741.5564146204137.3975142125130.8741548655107.3929874340.01764540430.02032782790.0147869676

    Non-progressorsProgressorsNon-progressorsProgressors

    high3.920.1888888889low-2.95714285712.6823529412

    BV/TV2.39102488496.0976315985BV/TV8.88647983235.0372655397

    Non-progressorsProgressorsNon-progressorsProgressors

    OV/BV-0.76-0.5OV/BV2.8857142857-1.0647058824

    7.17760405713.06349473643.51303694421.5564146204

    Non-progressorsProgressorsNon-progressorsProgressors

    Mlt161.733.6555555556Mlt-162.9-24.7

    120.8501551509217.648289168146.7631084435107.392987434

    Non-progressorsProgressorsNon-progressorsProgressors

    BFR/BS-0.12480.0751111111BFR/BS0.10971428570.0051764706

    0.10195930560.13931030510.10419167320.0147869676

  • Fatores de risco cumulativo para DCV na DRC ICCAc. Vascular cerebralHVED. CoronarianaD. Vascular perifricaIAMEspecfico da uremiaanemiahiperpara P TFG PCRTradicionais modificaveisHADislipidemiaFumoTradicionais no modificaveisidadesexoHist. familiarDMHiperglicemiaMANEJO

  • DCV vs. DRCMetasParar fumarPA < 130/80 mmHgLDL < 100mg/dlTG < 130mg/dlHbA1c < 7%Perder pesoAspirinaExerccioDietaAJKD 2007;49(2 Suppl2):S28

  • DCV vs. DRCInvestigaoAJKD 2007;49(2 Suppl2):S30Teste esforoEco / Cintilografia - estresse farmacolgicoCATE

  • NEJM 2005;353:2643Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes.Nathan DM, et all 42% risco 57% riscoDCV vs. DRC

  • Sada do plano

    Morte (antes do Tx ou dilise)

    Transplantado

    Iniciou dilise

    Nenhum dos anteriores

    FG, 60-89Proteinria (-)(n=14.202) 14,9

    10,2

    0,01

    0,06

    74,82 FG= 60-89Proteinria (+)(n=1.741) 16,2

    19,5

    0,2

    0,9

    63,33FG= 30-59

    (n=11.278) 10,3

    24,3

    0,2

    1,1

    64,24FG= 15-28

    (n= 777) 6,6

    45,7

    2,3

    17,6

    27,8Estgios da DRCArch Intern Med. 2004;164:659 n=27.997, 2 medidas Cl

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