tratamiento glomerulonefritis membranosa

Download Tratamiento Glomerulonefritis Membranosa

Post on 02-Jul-2015

5.651 views

Category:

Health & Medicine

0 download

Embed Size (px)

DESCRIPTION

enfermedad renal comun de tratamiento aun no definido

TRANSCRIPT

  • 1. Prognosis of Untreated Patients with IdiopathicMembranous Nephropathy Arrigo Schieppati, Lidia Mosconi, Annalisa Perna, Giuliano Mecca, Tullio Bertani, Silvio Garattini, andGiuseppe Remuzzi VolumeJuly 8, 1993 Number 2329:85-89

2. Probability of Adequate Renal Function in Untreated Patients withIdiopathic Membranous Nephropathy 3. Changes in the Clinical Status of Patients with Idiopathic MembranousNephropathy. 4. Prognosis of Untreated Patients with Idiopathic Membranous NephropathyProbability of Five-Year Kidney Survival According to the Degree ofProteinuria at Base Line.. 5. Prognosis of Untreated Patients with Idiopathic Membranous Nephropathy Base-Line Clinical and Laboratory Data for 100 Patients with Idiopathic Membranous Nephropathy. 6. PONTICELLI TRIAL RESULTS: 10 YEAR RENAL SURVIVAL 7. PONTICELLI TRIAL RESULTS: PERCENT ACHIEVING REMISSION 8. TRATAMIENTO INMUNOSUPRESOR PARA LA NEFROPATA MEMBRANOSAIDIOPTICA EN ADULTOS CON SNDROME NEFRTICO(REVISIN COCHRANE TRADUCIDA)SCHIEPPATI A, PERNA A, ZAMORA J, GIULIANO GA, BRAUN N, REMUZZI G La nefropata membranosa idioptica (NMI) es la forma ms comn de sndrome nefrtico en los adultos. La enfermedad tiene un curso benigno o indolente en la mayora de los pacientes, con una alta tasa de remisin espontnea completa o parcial del sndrome nefrtico, del 30% o superior. A pesar de esto, del 30% al 40% de los pacientes progresan hacia la insuficiencia renal terminal (IRT) en el lapso de cinco a 15 aos. 9. TRATAMIENTO INMUNOSUPRESOR PARA LA NEFROPATA MEMBRANOSAIDIOPTICA EN ADULTOS CON SNDROME NEFRTICO(REVISIN COCHRANE TRADUCIDA)Objetivos: Evaluar los beneficios y los daos del tratamiento inmunosupresor para la NMI en los adultos.Estrategia de bsqueda: Se realizaron bsquedas en el Registro Especializado del Grupo Cochrane de Rin (Cochrane Renal Group) (diciembre de 2003), el Registro Cochrane Central de Ensayos Controlados (CENTRAL) (The Cochrane Central Register of Controlled Trials (CENTRAL)) (la Cochrane Library Nmero 4, 2003), MEDLINE y Pre- MEDLINE (1966 a diciembre de 2003), EMBASE (1980 a diciembre de 2003), las listas de referencias de los libros de texto de nefrologa, artculos de revisin, registros de ensayos prospectivos, ensayos pertinentes y resmenes de las reuniones cientficas de nefrologa y la Internet, sin restriccin de idiomas. Se estableci contacto con los investigadores principales de los estudios controlados. 10. TRATAMIENTO INMUNOSUPRESOR PARA LA NEFROPATA MEMBRANOSAIDIOPTICA EN ADULTOS CON SNDROME NEFRTICO(REVISIN COCHRANE TRADUCIDA)Resultados principales: Se incluy un total de 18 ensayos, con 1025 pacientes. No se encontraron diferencias cuando se combinaron los datos de todas las categoras de tratamiento como un grupo y se compararon con placebo o ningn tratamiento. Glucocorticosteroides orales: no se observaron efectos beneficiosos sobre las variables principales elegidas para evaluar la eficacia. Los agentes alquilantes mostraron un efecto beneficioso significativo sobre la remisin completa (RR 2,37; IC del 95%: 1,32 a 4,25; P=0,004) pero no sobre la remisin parcial (RR 1,22; IC del 95%: 0,63 a 2,35; P=0,56) o la remisin completa o parcial (RR 1,55; IC del 95%: 0,72 a 3,34; P=0,27). El tratamiento con ciclofosfamida result en una tasa significativamente inferior de interrupciones debidas a eventos adversos en comparacin con el clorambucil (RR 2,34; IC del 95%: 1,25 a 4,39; P=0,008). No hubo pruebas de diferencias clnicamente pertinentes a favor de la ciclosporina y no hubo datos suficientes sobre los agentes antiproliferativos 11. TRATAMIENTO INMUNOSUPRESOR PARA LA NEFROPATA MEMBRANOSAIDIOPTICA EN ADULTOS CON SNDROME NEFRTICO (REVISIN COCHRANE TRADUCIDA)Conclusiones: Esta revisin no logr mostrar efectos a largo plazo del tratamiento inmunosupresor sobre la supervivencia de los pacientes o la supervivencia renal. Hubo un mayor nmero de interrupciones debidas a eventos adversos en los grupos con tratamiento inmunosupresor. Dentro de la clase de agentes alquilantes no hay pruebas slidas que apoyen la eficacia de la ciclofosfamida en comparacin con el clorambucil. Por otro lado, la ciclofosfamida present menos efectos secundarios que resultaban en el retiro del paciente en comparacin con el clorambucil. 12. BAJO RIESGORIESGO MODERADO BAJO RIESGOPROTEINURIA 4 8 g/DIA PROTEINURIA < 4g/DIAPROTEINURIA > 8g/DIAFUNCION RENAL NORMAL FUNCION RENAL ALTERADAFUNCION RENAL NORMAL RESTRICCION PROTEINAS RESTRICCION PROTEINAS RESTRICCION PROTEINAS DIETA DIETADIETA IECA O ARA POR HTA O IECA O ARA POR HTA OIECA O ARA POR HTA O PROTEINURIA PROTEINURIAPROTEINURIA ESTATINAS SI DISLIPIDEMIA ESTATINAS SI DISLIPIDEMIAESTATINAS SI DISLIPIDEMIA CONTROL EN 6 MESESCORTICOIDES + AGENTES CITOTOXICOSPROTEINURIA DE RANGO NEFROTICO PERSISTENTE +PRESENCIA DE FACTORES DEPOBRE PRONOSTICO PROTEINURIA DE RANGO NEFROTICO PERSISTENTEDETERIORO FUNCION RENAL ESTEROIDES ALTERNANDO CON DROGAS CITOTOXICASCsAMMF FK506FUNCION RENAL DETERIORADA 13. LES DROGAS: aines, sales oro, penicilamina, captopril INFECCIONES: Hep B, C, HIV, otras, Exposiciones crnicas solventes. CANCER: pulmn, colon, estomago, rin, prstata, ovario, vejiga, linfoma, otros. 14. Creatinina >=1.2 en mujeres y >= 1.4 en hombres con proteinuria rango nefrtico. Proteinuria >8 g/24 h por mas 6 meses. Biopsia renal con 10% fibrosis intersticial y proteinuria rango nefrtico. Otros: masculino, hipertensin, edad > 50 aos. 15. PRESENCIA FACTORES PROGRESIONSINOTERAPIATERAPIACONSERVADORA CONSERVADORAINMUNOSUPRESION 16. CONTROL DE PRESION ARTERIAL: pas 120 O MENOS. IECA AUN SI HAY NORMOTENSION, ARA O BLOQUEADORES CALCIO NO DIHIDROPIRIDINICOS. RESTRICCION EN DIETA: PROTEINAS 0,7 0,8 g/K/dia. ADICIONAR: 1 g PROTEINAS POR CADA g/PROTEINURIA > 3g/DIA. SAL : 100 120 mEq /DIA. 17. CONTROL LIPIDOS: EVITAR ESTROGENOS. DEJAR DE FUMAR. NO AINES. AAS. ACIDO FOLICO. ANTIOXIDANTES : VIT C 200 mg/DIA. EVITAR SOBREINGESTA HIDRICA. 18. CICLOFOSFAMIDA + PREDNISONA. CLORAMBUCIL + PREDNISONA. AZATHIOPRINA + PREDNISONA. CICLOSPORINA + PREDNISONA?. MICOFENOLATO + PREDNISONA?. 19. Prognosis of Untreated Patients with Idiopathic Membranous NephropathyResults Twenty-four (65 percent) of the 37 patients followed for at least five years had complete or partial remission of proteinuria; in 6 others (16 percent), end-stage renal disease developed, and they required dialysis. As calculated by the Kaplan-Meier method, the estimated probability (the standard error of the estimate) of retaining adequate kidney function was 88 5 percent after five years and 73 7 percent after eight years. The prognosis was poorer in men and in patients over 50 years of age, but not in patients with the nephrotic syndrome, hypertension, or hypercholesterolemia. Conclusions Most untreated patients with idiopathic membranous nephropathy maintain renal function for prolonged periods and are likely to have spontaneous remission. These results do not support the use of glucocorticoids and immunosuppressive drugs in patients with idiopathic membranous nephropathy. 20. METHYLPREDNISOLONE PLUS CHLORAMBUCIL AS COMPARED WITH METHYLPREDNISOLONE ALONE FOR THE TREATMENT OF IDIOPATHIC MEMBRANOUS NEPHROPATHYAuthor(s): PONTICELLI C, ZUCCHELLI P, PASSERINI P, CESANA B Source: NEW ENGLAND JOURNAL OF MEDICINE Volume: 327 Issue: 9 Pages: 599-603 Published: AUG 27 1992 Background and Methods. Treatment with methylprednisolone and chlorambucil may protect renal function and increase the chance of remission of the nephrotic syndrome in patients with idiopathic membranous nephropathy. To determine whether similar results might be obtained with methylprednisolone alone, we compared the effects of methylprednisolone and chlorambucil with those of methylprednisolone alone in 92 patients with the nephrotic syndrome caused by idiopathic membranous nephropathy. The patients were randomly assigned to receive either alternating one- month courses of methylprednisolone and then chlorambucil for a total of six months (group 1) or methylprednisolone alone for six months at the same cumulative dosage (group 2). 21. METHYLPREDNISOLONE PLUS CHLORAMBUCIL AS COMPARED WITH METHYLPREDNISOLONE ALONE FOR THE TREATMENT OF IDIOPATHIC MEMBRANOUS NEPHROPATHYAuthor(s): PONTICELLI C, ZUCCHELLI P, PASSERINI P, CESANA B Source: NEW ENGLAND JOURNAL OF MEDICINE Volume: 327 Issue: 9 Pages: 599-603 Published: AUG 27 1992 Results. Four of the 45 patients in group 1 (9 percent) and 1 of the 47 in group 2 (2 percent) stopped treatment because of side effects. At one, two, and three years, the percentage of patients who did not have the nephrotic syndrome was significantly higher in group 1 than in group 2. It was 58, 54, and 66 percent, respectively, in group 1, as compared with 26, 32, and 40 percent in group 2 (P = 0.002, 0.029, and 0.011). By year 4, the difference was no longer statistically significant: 62 percent of the patients in group 1 and 42 percent of those in group 2 did not have the nephrotic syndrome (P = 0.102). The patients in group 1 were in remission longer than those in group 2 (P = 0.008). Conclusions. In patients with the nephrotic syndrome caused by idiopathic membranous nephropathy, treatment with methylprednisolone and chlorambucil for six months induces an earlier remission of the nephrotic syndrome than methylprednisolone alone, but the difference may diminish with time. 22. CHARACTERISTIC GROUP 1GROUP 2PNo. of cases46 47 Age (yr)37.2 12.438.0 13.60.77 range16 to 66 18 to 64 Gender ratio 27:1930:17 0.67 Disease duration (mo) 11.7 6.2 10.8 7.9 0.48 Serum creatinine1.17 0.221.21 0.310.48 (mg/dl)MDRD GFR (ml/min) 84 2289 260.32Serum albumin (g/dl)2.42 0.812.34 0.580.58 Serum cholesterol 306.4 88.2 336.7 99.6 0.12 (mg/dl)Proteinuria (g/d)5.91 2.2 6.11 2.50.68 23. Kaplan-Meier plots showing probabilities of dialysis-free survival (A), survival without reaching either end point (B), complete remission (C), and c

Recommended

View more >