O papel do NGAL urinário como preditor prognóstico e diagnóstico da lesão renal aguda associada à sepse em pacientes idosos admitidos na unidade de terapia intensiva
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2016-12-16
Autores
Rocha, Érica Pires da [UNESP]
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Universidade Estadual Paulista (Unesp)
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Introdução: O idoso se apresenta como principal grupo etário acometido pela lesão renal aguda (LRA) por possuir diversos fatores de risco para o seu desenvolvimento como a nefroesclerose senil, a presença de comorbidades, o uso de medicamentos nefrotóxicos e a susceptibilidade à sepse. Além disso, conforme se envelhece, perde-se massa muscular e por isso a creatinina plasmática basal do idoso pode ser mais baixa que o normal de modo a mascarar o aumento patológico decorrente de lesão renal e assim levar ao subdiagnóstico ou diagnóstico tardio, o que justifica a busca por biomarcadores de lesão mais precoce, como o NGAL. Não há estudos que avaliaram a LRA em pacientes sépticos e idosos admitidos em unidade de terapia intensiva (UTI). Objetivo: Este estudo teve como objetivo principal avaliar a eficácia do NGAL urinário (u) como predito diagnóstico e prognóstico da LRA associada à sepse em pacientes idosos em UTI. Pacientes e métodos: Foram estudados de modo prospectivos pacientes idosos admitidos com sepse ou que evoluíram com sepse em três UTIs do HC-FMB (UNESP) durante o período de 01 de outubro de 2014 a 20 de novembro de 2015. A avaliação de função renal foi realizada diariamente por meio da dosagem da creatinina sérica e verificação de débito urinário. A dosagem do NGALu foi realizada nas primeiras 48h do diagnóstico de sepse (amostra 1) e entre 48 e 96h (amostra 2). Os resultados foram apresentados utilizando estatística descritiva e área sob a curva ROC para determinar a capacidade do NGALu discriminar o diagnóstico e prognóstico da LRA. Todos os resultados dos testes de hipótese foram discutidos no nível de 5% de significância (p<0.05). Resultados: Foram incluídos 75 pacientes idosos sépticos, sendo que 47 (62,7%) desenvolveram LRA. Na regressão logística foram identificados como fatores associados à LRA a presença de DRC (OR= 0,051, IC=0,017-0,601, p=0,045), menor PAM à admissão (OR=0,816, IC=0,130– 0,472; p=0,047) e maior NGALur1 (OR= 2,002, IC=1,205-3,325, p=0,007). O NGAL u apresentou-se como excelente preditor diagnóstico de LRA, com área sob a curva >0,95, e sensibilidade e especificidade superiores a 0,89, antecipando o diagnóstico de LRA em 2,1±0,3 dias. Os fatores associados ao óbito na regressão logística foram a presença de LRA (OR= 2,14, IC= 1,421–3,982, p=0,04), a doença pulmonar obstrutiva crônica (OR=9,376, IC=1,790 – 49,1, p= 0,008) e o uso de droga vasoativa (OR= 2,066, IC=0,987 – 1,021, p=0,04). A acurácia do NGALu1 e 2 como preditor de óbito foi intermediária, com área sob a curva de 0,61 e 0,62; sensibilidade entre 0,65 e 0,77 e especificidade inferior a 0,6. Conclusão: O NGAL u mostrou-se excelente preditor de LRA em pacientes idosos sépticos em UTI, podendo antecipar o diagnóstico de LRA em 2,1 dias.
Background: The elderly is the main age group affected by acute kidney injury (AKI). There are several risk factors for its development as renal structural and functional degeneration, comorbidities, use of nephrotoxic drugs and susceptibility to sepsis. Besides that, in the process of ageing there is loss of muscular mass and therefore, the basal plasmatic creatinine levels of the elderly can be lower than the normal values, masking an increase in kidney injury pathologies, leading to delayed or late diagnosis, justifying the search for biomarkers of early injury biomarkers, such as NGAL. There are no studies that assessed AKI in elderly septic patients admitted to Intensive Care Units (ICUs). Objective: This study aimed to evaluate the efficacy of urinary NGAL (u) as predictor of diagnosis and prognosis in elderly septic patients admitted to ICUs. Patients and Methods: We prospectively studied elderly patients with sepsis admitted to ICUs from October 2014 to November 2015. Assessment of renal function was performed daily by serum creatinine and urine output. The dosage of NGALu was performed within the first 48 hours of the diagnosis of sepsis (NGAL 1) and between 48 and 96 hours (NGAL 2). The results were presented using descriptive statistics and area under the receiver operating characteristic curve (AUC-ROC) by comparing AKI patients with all non-AKI patients and by comparing survivor patients with those nonsurvivor patients. In all tests, differences were considered significant at 5%. Results: Seventy-five septic elderly patients were included, 47 (62.7%) developed AKI. In logistic regression were identified as factors associated with AKI the presence of chronic kidney injury (OR = 0.051, CI = 0.017 to 0.601, p = 0.045), lower mean blood pressure at admission (OR = 0.816, CI = 0,130- 0.472; p = 0.047) and higher NGALur1 (OR = 2.002, CI = 1.205 to 3.325, p = 0.007). The NGAL u was excellent predictor of AKI diagnosis (AUC-ROC > 0.95, and sensitivity and specificity greater than 0.89), anticipating the AKI diagnosis in 2.1 ± 0.3 days. Factors associated with mortality in the logistic regression were the presence of AKI (OR = 2.14, CI = 1.421 to 3.982, p = 0.04), chronic obstructive pulmonary disease (OR = 9.376, CI = 1.790 to 49.1, p = 0.008) and vasoactive drugs (OR = 2.066, CI = 0.987 to 1.021, p = 0.04). The accuracy of NGALu1 and 2 as predictors of death was intermediate, with AUC-ROC of 0.61 and 0.62; sensitivity between 0.65 and 0.77 and a specificity lower than 0.6. Conclusion: The uNGAL was excellent predictor of AKI in septic elderly patients in ICUs and can anticipate the diagnosis of AKI in 2.1 days.
Background: The elderly is the main age group affected by acute kidney injury (AKI). There are several risk factors for its development as renal structural and functional degeneration, comorbidities, use of nephrotoxic drugs and susceptibility to sepsis. Besides that, in the process of ageing there is loss of muscular mass and therefore, the basal plasmatic creatinine levels of the elderly can be lower than the normal values, masking an increase in kidney injury pathologies, leading to delayed or late diagnosis, justifying the search for biomarkers of early injury biomarkers, such as NGAL. There are no studies that assessed AKI in elderly septic patients admitted to Intensive Care Units (ICUs). Objective: This study aimed to evaluate the efficacy of urinary NGAL (u) as predictor of diagnosis and prognosis in elderly septic patients admitted to ICUs. Patients and Methods: We prospectively studied elderly patients with sepsis admitted to ICUs from October 2014 to November 2015. Assessment of renal function was performed daily by serum creatinine and urine output. The dosage of NGALu was performed within the first 48 hours of the diagnosis of sepsis (NGAL 1) and between 48 and 96 hours (NGAL 2). The results were presented using descriptive statistics and area under the receiver operating characteristic curve (AUC-ROC) by comparing AKI patients with all non-AKI patients and by comparing survivor patients with those nonsurvivor patients. In all tests, differences were considered significant at 5%. Results: Seventy-five septic elderly patients were included, 47 (62.7%) developed AKI. In logistic regression were identified as factors associated with AKI the presence of chronic kidney injury (OR = 0.051, CI = 0.017 to 0.601, p = 0.045), lower mean blood pressure at admission (OR = 0.816, CI = 0,130- 0.472; p = 0.047) and higher NGALur1 (OR = 2.002, CI = 1.205 to 3.325, p = 0.007). The NGAL u was excellent predictor of AKI diagnosis (AUC-ROC > 0.95, and sensitivity and specificity greater than 0.89), anticipating the AKI diagnosis in 2.1 ± 0.3 days. Factors associated with mortality in the logistic regression were the presence of AKI (OR = 2.14, CI = 1.421 to 3.982, p = 0.04), chronic obstructive pulmonary disease (OR = 9.376, CI = 1.790 to 49.1, p = 0.008) and vasoactive drugs (OR = 2.066, CI = 0.987 to 1.021, p = 0.04). The accuracy of NGALu1 and 2 as predictors of death was intermediate, with AUC-ROC of 0.61 and 0.62; sensitivity between 0.65 and 0.77 and a specificity lower than 0.6. Conclusion: The uNGAL was excellent predictor of AKI in septic elderly patients in ICUs and can anticipate the diagnosis of AKI in 2.1 days.
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Palavras-chave
Idoso, Lesão Renal Aguda, Preditor, NGAL, Sepse