Atenuação do descenso noturno na predição do início da albuminúria em diabéticos tipo 1
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2018-02-23
Autores
Silva, Bruno Alves
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Universidade Estadual Paulista (Unesp)
Resumo
A presença de albuminúria constitui fator prognóstico desfavorável nos pacientes diabéticos do tipo 1 e precede a elevação da PA de consultório em três anos. A monitorização ambulatorial de pressão arterial (MAPA) pode identificar a atenuação ou desaparecimento do descenso noturno, o que prediz o risco cardiovascular, independentemente da pressão arterial de 24 h. Entretanto, apenas um estudo avaliou o papel preditivo da atenuação do descenso noturno para o desenvolvimento da albuminúria no diabetes do tipo 1. Assim, o objetivo do corrente trabalho é de avaliar, em coorte brasileira, se o descenso noturno atenuado pode predizer o desenvolvimento de albuminúria no diabetes do tipo 1. Foi realizado estudo observacional prospectivo que visou avaliar o poder preditivo da ausência ou atenuação do descenso noturno em relação ao surgimento de albuminúria em pacientes diabéticos tipo 1 normoalbuminúricos. Os pacientes foram submetidos à MAPA e dosada a albuminúria por mais de 2 vezes. Ao cabo de um ano a albuminúria foi reavaliada. A frequência de evolução para albuminúria ente os pacientes com descenso noturno ausente/atenuado ou presente foi comparada pelo teste de Fisher. As médias de pressão arterial (PA) foram comparadas por teste "t" para amostras independentes. Foi realizada regressão linear para avaliar a associação entre descenso noturno e elevação da albuminúria no seguimento. O nível de significância foi estabelecido em 5 %. Foram avaliados 24 pacientes com idade de 24 ±8,2 anos, seis pacientes do sexo masculino. Seis pacientes tinham descenso noturno presente para PA sistólica (PAS) (média de PAS em 24 h: 119±7,5mmHg) destes, apenas um evoluiu para albuminúria. Dos 18 que tinham descenso noturno atenuado para PAS (média de PAS em 24 h: 122±8,4mmHg; p=0,36 em relação aos pacientes descenso noturno presente), 14 evoluíram para albuminúria (p=0,01). Em relação à PA diastólica (PAD), 12 pacientes tinham descenso noturno presente (média de PAD em 24 h: 72±5,2mmHg), destes, 6 evoluíram para albuminúria. Dos outros 12 que tinham descenso noturno ausente (média de PAD em 24 h: 74±5,6mmHg; p=0,31 em relação aos pacientes com descenso noturno presente), 9 evoluíram com microalbuminúria (p=0,40). A porcentagem de descenso noturno da PAS apresentou coeficiente de correlação com a variação da albuminúria de 0,40; p= 0,061. A porcentagem de descenso noturno da PAD apresentou coeficiente de correlação com a variação da albuminúria de 0,46; p=0,027. Em conclusão, a evolução para albuminúria associou-se à classificação descenso noturno atenuado para PAS, mesmo com PAS em 24 horas normal. Ou seja, a atenuação do descenso noturno para PAS precedeu o início da nefropatia diabética incipiente no diabetes do tipo 1. Estes resultados ressaltam a importância da realização da MAPA no momento do diagnóstico, e no seguimento, dos pacientes diabéticos tipo 1.
The presence of albuminuria constitutes an unfavorable prognosis in type 1 diabetic patients and precedes an increase in office BP in three years. Ambulatory blood pressure monitoring (ABPM) can identify an attenuation or disappearance of noc-turnal descent, which predicts cardiovascular risk, regardless of blood pressure of 24 h. There is no type 1 diabetes. Thus, the objective of the current evaluation work, in a Brazilian cohort, whether the attenuated nocturnal decline may predict the devel-opment of albuminuria in type 1 diabetes. A prospective observational study was carried out to evaluate the predictive power of the absence or attenuation of the noc-turnal descent in relation to the appearance of albuminuria in type 1 diabetic normoalbuminuric patients. The patients were submitted to ABPM and dosed albu-minuria by more than 2 times. After one year and albuminuria for reassessment. The frequency of progression to albuminuria in patients with absent / attenuated or pre-sent nocturnal descent was compared by Fisher's test. Blood pressure (BP) averag-es were compared by "t" test for independent samples. Linear regression was per-formed to evaluate an association between nocturnal descent and elevated albumi-nuria at follow-up. The level of significance was set at 5%. Twenty-four patients, aged 24 ± 8.2 years, six male patients were evaluated. Six pa-tients had a nocturnal decrease in systolic BP (SBP) (mean SBP in 24 h: 119 ± 7.5 mmHg), only one had progressed to albuminuria. Of the 18 patients who had an at-tenuated nocturnal decrease in SBP (mean SBP at 24 h: 122 ± 8.4 mmHg, p = 0.36 in relation to the patients present at night), 14 developed albuminuria (p = 0.01). In relation to the diastolic BP (DBP), 12 patients had nocturnal decrease present (mean DBP in 24 h: 72 ± 5.2 mmHg), of these, 6 evolved into albuminuria. Of the 12 others who had a nocturnal descent absent (mean PAD at 24 h: 74 ± 5.6 mmHg, p = .31 compared to patients with nocturnal decrease), 9 developed microalbuminuria (p = 0.40). The percentage of nocturnal SBP decrease had a correlation coefficient with albuminuria variation of 0.40; p = 0.061. The percentage of nocturnal decrease in DBP presented a correlation coefficient with albuminuria variation of 0.46; p = 0.027. In conclusion, the progression to albuminuria was associated with an attenuated nocturnal descent for SBP, even with SBP at normal 24 hours. That is, attenuation of nocturnal descent into SBP preceded the onset of incipient diabetic nephropathy in type 1 diabetes. These results suggest that ABPM should be performed at the time of diagnosis and follow-up of type 1 diabetic patients.
The presence of albuminuria constitutes an unfavorable prognosis in type 1 diabetic patients and precedes an increase in office BP in three years. Ambulatory blood pressure monitoring (ABPM) can identify an attenuation or disappearance of noc-turnal descent, which predicts cardiovascular risk, regardless of blood pressure of 24 h. There is no type 1 diabetes. Thus, the objective of the current evaluation work, in a Brazilian cohort, whether the attenuated nocturnal decline may predict the devel-opment of albuminuria in type 1 diabetes. A prospective observational study was carried out to evaluate the predictive power of the absence or attenuation of the noc-turnal descent in relation to the appearance of albuminuria in type 1 diabetic normoalbuminuric patients. The patients were submitted to ABPM and dosed albu-minuria by more than 2 times. After one year and albuminuria for reassessment. The frequency of progression to albuminuria in patients with absent / attenuated or pre-sent nocturnal descent was compared by Fisher's test. Blood pressure (BP) averag-es were compared by "t" test for independent samples. Linear regression was per-formed to evaluate an association between nocturnal descent and elevated albumi-nuria at follow-up. The level of significance was set at 5%. Twenty-four patients, aged 24 ± 8.2 years, six male patients were evaluated. Six pa-tients had a nocturnal decrease in systolic BP (SBP) (mean SBP in 24 h: 119 ± 7.5 mmHg), only one had progressed to albuminuria. Of the 18 patients who had an at-tenuated nocturnal decrease in SBP (mean SBP at 24 h: 122 ± 8.4 mmHg, p = 0.36 in relation to the patients present at night), 14 developed albuminuria (p = 0.01). In relation to the diastolic BP (DBP), 12 patients had nocturnal decrease present (mean DBP in 24 h: 72 ± 5.2 mmHg), of these, 6 evolved into albuminuria. Of the 12 others who had a nocturnal descent absent (mean PAD at 24 h: 74 ± 5.6 mmHg, p = .31 compared to patients with nocturnal decrease), 9 developed microalbuminuria (p = 0.40). The percentage of nocturnal SBP decrease had a correlation coefficient with albuminuria variation of 0.40; p = 0.061. The percentage of nocturnal decrease in DBP presented a correlation coefficient with albuminuria variation of 0.46; p = 0.027. In conclusion, the progression to albuminuria was associated with an attenuated nocturnal descent for SBP, even with SBP at normal 24 hours. That is, attenuation of nocturnal descent into SBP preceded the onset of incipient diabetic nephropathy in type 1 diabetes. These results suggest that ABPM should be performed at the time of diagnosis and follow-up of type 1 diabetic patients.
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Palavras-chave
Diabetes Mellitus,, microalbuminúria, descenso noturno, Diabetes Mellitus, microalbuminuria, nocturnal decrease, diabetic nephropathy