Cronoterapia e elevação de decúbito no controle de proteinúria em diabéticos com disautonomia.
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2019-10-03
Autores
Santos, Guilherme Palhares Aversa
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Universidade Estadual Paulista (Unesp)
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INTRODUÇÃO - A doença renal do diabetes (DRD) é uma importante causa de doença renal crônica (DRC), e é a segunda causa de doença renal terminal no Brasil. A hipertensão arterial (HA) constitui fator preponderante para a progressão de proteinúria na DRD. Os pacientes com esta doença apresentam elevada prevalência de alterações do ciclo sono-vigília da pressão arterial (PA), além de poderem apresentar disautonomia. No caso dos pacientes com DRD e disfunção do sistema nervoso autônomo, podem coexistir hipotensão ortostática e hipertensão arterial na posição supina (Hsup). A Hsup quando não controlada pode contribuir para progressão da proteinúria nesse grupo de pacientes. O uso da cronoterapia e da elevação da cabeceira da cama durante o sono são medidas clínicas factíveis de serem aplicadas que podem contribuir para controle da Hsup e da proteinúria nos pacientes com DRD e disautonomia. HIPÓTESE: A cronoterapia e a elevação de decúbito durante o sono podem levar à diminuição de proteinúria em pacientes com DRD, disautonomia e Hsup. OBJETIVO: Avaliar a resposta da proteinúria mediante à utilização de cronoterapia e de elevação de decúbito durante o sono, em pacientes com DRD, disautonomia e Hsup. MÉTODOS: este estudo consiste em uma série de casos, na qual nove pacientes atendidos consecutivamente com DRD, disautonomia e Hsup receberam medidas direcionadas para o controle de Hsup. Essas medidas foram a cronoterapia e a elevação da cabeceira da cama em seis graus durante o sono. Esses pacientes foram comparados com um controle histórico. Foram avaliadas variáveis clínicas e laboratoriais. O comportamento da proteinúria foi o desfecho primário avaliado. RESULTADOS: o grupo intervenção teve queda dos níveis de proteinúria de modo expressivo com as medidas direcionadas para o controle da Hsup, enquanto que no grupo controle houve aumento da proteinúria (índice proteinúria/creatinina urina g/g em amostra isolada do grupo intervenção: 8,80 ± 5,10 inicial para 2,20 ± 2,00 aos 11 meses, variação -6,60 ± 3,90; grupo controle: 3,70 ± 3,30 inicial para 5,40 ± 5,30 aos 11 meses, variação 1,70 ± 7,10), com significância estatística (p=0.008). CONCLUSÃO: as medidas direcionadas para o controle da Hsup, isto é, a cronoterapia e a elevação da cabeceira da cama em seis graus durante o sono, se associaram a queda expressiva da proteinúria nos pacientes do grupo intervenção, portadores de DRD, disautonomia e Hsup. Houve conversão de proteinúrias nefróticas em não nefróticas na maioria desses pacientes. Estudos prospectivos controlados e randomizados poderão determinar a relação de causalidade das medidas instituídas com a melhora de proteinúria nesse grupo de pacientes.
INTRODUCTION- Diabetes kidney disease (DKD) is an important cause of chronic kidney disease (CKD), and is the second leading cause of end-stage renal disease in Brazil. Arterial hypertension (AH) is a preponderant factor for the progression of proteinuria in DKD. Patients with this disease present a high prevalence of changes in the sleep-wake cycle of blood pressure (BP), and may present with dysautonomia. In the case of patients with DKD and dysfunction of the autonomic nervous system, orthostatic hypotension and supine arterial hypertension (Hsup) may coexist. Hsup when uncontrolled may contribute to progression of proteinuria in this group of patients. The use of chronotherapy and sleeping head up are feasible clinical measures that can contribute to control of Hsup and proteinuria in patients with DKD and dysautonomia. HYPOTHESIS: Chronotherapy and elevation of decubitus during sleep may lead to decreased proteinuria in patients with DKD, dysautonomia and Hsup. OBJECTIVE: To evaluate the proteinuria response through the use of chronotherapy and elevation of decubitus during sleep in patients with DKD, dysautonomia and Hsup. METHODS: This study consists of a series of cases, in which nine patients consecutively attended with DKD, dysautonomia and Hsup received measures aimed at the control of Hsup. These measures were chronotherapy and sleeping head up in six degrees. These patients were compared with a historical control. Clinical and laboratory variables were evaluated. The behavior of proteinuria was the primary endpoint evaluated. RESULTS: The intervention group had an expressive decrease in proteinuria levels with the measures aimed at Hsup control, while in the control group there was an increase in proteinuria (proteinuria / creatinine urine g / g in a sample isolated from the intervention group: 8,80 ± 5,10 initial to 2.20 ± 2.00 at 11 months, variation -6.60 ± 3.90; control group: 3,70 ± 3,30 initial to 5,40 ± 5,30 at 11 months, variation 1,70 ± 7,10), with statistical significance (p = 0.008). CONCLUSION: the measures aimed at the control of Hsup, that is, chronotherapy and the elevation of the head of the bed in six degrees during sleep, were associated with an expressive decrease of proteinuria in the patients of the intervention group, with DRD, dysautonomia and Hsup . There was conversion of nephrotic proteinuria to non-nephrotic in most of these patients. Prospective controlled and randomized studies may determine the causal relationship of the measures instituted with the improvement of proteinuria in this group of patients.
INTRODUCTION- Diabetes kidney disease (DKD) is an important cause of chronic kidney disease (CKD), and is the second leading cause of end-stage renal disease in Brazil. Arterial hypertension (AH) is a preponderant factor for the progression of proteinuria in DKD. Patients with this disease present a high prevalence of changes in the sleep-wake cycle of blood pressure (BP), and may present with dysautonomia. In the case of patients with DKD and dysfunction of the autonomic nervous system, orthostatic hypotension and supine arterial hypertension (Hsup) may coexist. Hsup when uncontrolled may contribute to progression of proteinuria in this group of patients. The use of chronotherapy and sleeping head up are feasible clinical measures that can contribute to control of Hsup and proteinuria in patients with DKD and dysautonomia. HYPOTHESIS: Chronotherapy and elevation of decubitus during sleep may lead to decreased proteinuria in patients with DKD, dysautonomia and Hsup. OBJECTIVE: To evaluate the proteinuria response through the use of chronotherapy and elevation of decubitus during sleep in patients with DKD, dysautonomia and Hsup. METHODS: This study consists of a series of cases, in which nine patients consecutively attended with DKD, dysautonomia and Hsup received measures aimed at the control of Hsup. These measures were chronotherapy and sleeping head up in six degrees. These patients were compared with a historical control. Clinical and laboratory variables were evaluated. The behavior of proteinuria was the primary endpoint evaluated. RESULTS: The intervention group had an expressive decrease in proteinuria levels with the measures aimed at Hsup control, while in the control group there was an increase in proteinuria (proteinuria / creatinine urine g / g in a sample isolated from the intervention group: 8,80 ± 5,10 initial to 2.20 ± 2.00 at 11 months, variation -6.60 ± 3.90; control group: 3,70 ± 3,30 initial to 5,40 ± 5,30 at 11 months, variation 1,70 ± 7,10), with statistical significance (p = 0.008). CONCLUSION: the measures aimed at the control of Hsup, that is, chronotherapy and the elevation of the head of the bed in six degrees during sleep, were associated with an expressive decrease of proteinuria in the patients of the intervention group, with DRD, dysautonomia and Hsup . There was conversion of nephrotic proteinuria to non-nephrotic in most of these patients. Prospective controlled and randomized studies may determine the causal relationship of the measures instituted with the improvement of proteinuria in this group of patients.
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diabetes melito, doença renal crônica, doença renal do diabetes, nefropatia diabética, hipertensão arterial, hipertensão supina, proteinúria, cronoterapia, doenças do sistema nervoso autônomo, ritmo sono-vigília da pressão arterial