Acompanhamento nutricional de pacientes com doença renal crônica: do pré diálise à diálise tardia
Carregando...
Arquivos
Data
2019-02-22
Autores
Silva, Ana Luiza Leite de Moraes da
Título da Revista
ISSN da Revista
Título de Volume
Editor
Universidade Estadual Paulista (Unesp)
Resumo
A Doença Renal Crônica (DRC) é caracterizada pela perda progressiva e irreversível da função renal. Distúrbios metabólicos e condições catabólicas relacionadas à doença renal e à terapia de diálise afetam negativamente o estado nutricional de pacientes com DRC, deixando-os permanentemente propensos ao protein energy wasting (PEW). O wasting pode resultar de uma dieta inadequada, mas na doença renal, existem outros fatores que resultam nessa condição. Alterações no gasto energético desta população contribuem de forma importante para o prejuízo nutricional. Sendo assim, o objetivo do estudo foi avaliar, de modo evolutivo, o Gasto Energético de Repouso (GER) e parâmetros nutricionais de pacientes com DRC na fase pré dialítica, dialítica inicial e dialítica tardia, estudando pacientes submetidos a hemodiálise e a diálise peritoneal. Além disso, comparar os valores de GER medidos pela Calorimetria Indireta (CI) aos valores estimados pela fórmula de Harris & Benedict. Foram estudados os pacientes com taxa de filtração glomerular estimada <15ml/min/1,73m² e avaliados de acordo com Protocolo de Avaliação Nutricional e medida do GER por CI. Foram consideradas três avaliações realizadas previamente: nos pacientes em estágio 5 não dialítico, no início da diálise, após 30 dias do início da terapia dialítica e incluído no estudo atual, uma última avaliação, após 1 ano do início da diálise. Os dados foram descritos em média, desvio padrão ou mediana. Foi aplicado modelo misto em medidas repetidas com teste de Tukey ou ajustado por modelo linear generalizado e a análise de Bland & Altman para comparação dos métodos. Considerou-se nível de significância p<0,05. Foram incluídos 22 pacientes com média de idade de 66,8 ± 9,2 anos, sendo 68,1% do sexo feminino, 18,1% afrodescendentes e 59% com diabetes mellitus. Os resultados mostraram que houve redução da albumina sérica entre a primeira (3,7±0,7 g/dl) e a terceira avaliação (2,9±0,5 g/dl) na população geral, e aumento na última avaliação (3,9±0,4 g/dl), fase mais tardia da DRC. Houve também na população geral, aumento dos níveis de proteína C reativa (PCR) logo após o início da terapia dialítica (3,6±8,0 mg/dl) e durante o primeiro mês de diálise (5,8±10,0 mg/dl), com redução significante na fase tardia (1,4±1,6 mg/dl). A ingestão proteica aumentou, tanto para a população geral quanto para o grupo hemodiálise, sendo o aumento, evidenciado pelo Equivalente 3 Proteico do Aparecimento de Nitrogênio (PNA) e PNA normalizado para o peso corporal, ao comparar-se as primeiras avaliações com a última. Foi possível notar também que a ingestão proteica insuficiente no período dialítico, acompanhou a redução da Circunferência Média do Braço (CMB) e dos valores da albumina sérica, no mesmo período, e que o aumento significativo da ingestão proteica na última avaliação acompanhou a recuperação da CMB e aumento da albumina, quando comparada ao início da terapia dialítica. O PCR, clássico marcador inflamatório também apresentou variações semelhantes quando avaliado na população geral. Não houve alteração significativa do GER, mesmo após dividir os pacientes em grupos (hemodiálise e diálise peritoneal). Ao comparar os valores medidos do GER pela CI e pela fórmula de Harris & Benedict, os métodos não apresentaram concordância nesta população.
Chronic Kidney Disease (CKD) is characterized by progressive and irreversible loss of renal function. Metabolic disorders and catabolic conditions related to renal disease and dialysis therapy negatively affect the nutritional status of patients with CKD, leaving them permanently prone to protein energy wasting (PEW). The wasting may result from an inadequate diet, but in kidney disease, there are other factors that result in this condition. Changes in the energy expenditure of this population contribute significantly to the nutritional damage. Therefore, the objective of the study was to evaluate, in an evolutionary way, Resting Energy Expenditure (REE) and nutritional parameters of patients with CKD in the pre dialysis, early dialysis and late dialysis phases, studying patients undergoing hemodialysis and peritoneal dialysis. In addition, we compared the REE values measured by Indirect Calorimetry (IC) to the values estimated by the Harris & Benedict equations. Patients with an estimated glomerular filtration rate <15ml / min / 1.73m² and evaluated according to the Nutrition Assessment Protocol and REE measurement by IC were studied. Three previous evaluations were considered: in the non-dialytic stage 5, at the beginning of dialysis, 30 days after the start of dialysis therapy and included in the current study, a final evaluation, one year after the start of dialysis. Data were described on average, standard deviation or median. A mixed model was applied in repeated measurements with Tukey's test or adjusted by generalized linear model and the Bland & Altman analysis for comparison of the methods. Significance level was considered p <0.05. Twenty-two patients with mean age of 66.8 ± 9.2 years were included, 68.1% were female, 18.1% were African-descendants, and 59% were diabetes mellitus. The results showed that serum albumin was reduced between the first (3.7 ± 0.7 g/dl) and the third evaluation (2.9 ± 0.5 g/dl) in the general population, and an increase in the last evaluation (3.9 ± 0, 4 g/dl), the later phase of CKD. There was also an increase in C-reactive protein (CRP) levels in the general population shortly after the initiation of dialysis therapy (3.6 ± 8.0 mg/dl) and during the first month of dialysis (5.8 ± 10.0 mg/dl), with significant reduction in the late phase (1.4 ± 1.6 mg/dl). Protein intake increased for both the general population and the hemodialysis group - evidenced by the Nitrogen Appearance Protein Equivalent (PNA) and normalized PNA for body weight- when 6 comparing the first evaluations with the latter. It was also possible to observe that the insufficient protein intake during the dialysis period accompanied the reduction in the Mean Arm Circumference (BMC) and serum albumin values in the same period, and that the significant increase in protein intake in the last evaluation followed the recovery of BMC and increased albumin, when compared to the beginning of dialysis therapy. Importantly, CRP is a classic inflammatory marker also showed similar variations when evaluated in the general population. There was no significant change in REE, even after dividing patients into groups (hemodialysis and peritoneal dialysis). When comparing GER values by CI and the Harris & Benedict equations, the methods did not show agreement in this population.
Chronic Kidney Disease (CKD) is characterized by progressive and irreversible loss of renal function. Metabolic disorders and catabolic conditions related to renal disease and dialysis therapy negatively affect the nutritional status of patients with CKD, leaving them permanently prone to protein energy wasting (PEW). The wasting may result from an inadequate diet, but in kidney disease, there are other factors that result in this condition. Changes in the energy expenditure of this population contribute significantly to the nutritional damage. Therefore, the objective of the study was to evaluate, in an evolutionary way, Resting Energy Expenditure (REE) and nutritional parameters of patients with CKD in the pre dialysis, early dialysis and late dialysis phases, studying patients undergoing hemodialysis and peritoneal dialysis. In addition, we compared the REE values measured by Indirect Calorimetry (IC) to the values estimated by the Harris & Benedict equations. Patients with an estimated glomerular filtration rate <15ml / min / 1.73m² and evaluated according to the Nutrition Assessment Protocol and REE measurement by IC were studied. Three previous evaluations were considered: in the non-dialytic stage 5, at the beginning of dialysis, 30 days after the start of dialysis therapy and included in the current study, a final evaluation, one year after the start of dialysis. Data were described on average, standard deviation or median. A mixed model was applied in repeated measurements with Tukey's test or adjusted by generalized linear model and the Bland & Altman analysis for comparison of the methods. Significance level was considered p <0.05. Twenty-two patients with mean age of 66.8 ± 9.2 years were included, 68.1% were female, 18.1% were African-descendants, and 59% were diabetes mellitus. The results showed that serum albumin was reduced between the first (3.7 ± 0.7 g/dl) and the third evaluation (2.9 ± 0.5 g/dl) in the general population, and an increase in the last evaluation (3.9 ± 0, 4 g/dl), the later phase of CKD. There was also an increase in C-reactive protein (CRP) levels in the general population shortly after the initiation of dialysis therapy (3.6 ± 8.0 mg/dl) and during the first month of dialysis (5.8 ± 10.0 mg/dl), with significant reduction in the late phase (1.4 ± 1.6 mg/dl). Protein intake increased for both the general population and the hemodialysis group - evidenced by the Nitrogen Appearance Protein Equivalent (PNA) and normalized PNA for body weight- when 6 comparing the first evaluations with the latter. It was also possible to observe that the insufficient protein intake during the dialysis period accompanied the reduction in the Mean Arm Circumference (BMC) and serum albumin values in the same period, and that the significant increase in protein intake in the last evaluation followed the recovery of BMC and increased albumin, when compared to the beginning of dialysis therapy. Importantly, CRP is a classic inflammatory marker also showed similar variations when evaluated in the general population. There was no significant change in REE, even after dividing patients into groups (hemodialysis and peritoneal dialysis). When comparing GER values by CI and the Harris & Benedict equations, the methods did not show agreement in this population.
Descrição
Palavras-chave
Doença renal crônica, Gasto energético, Avaliação nutricional, Diálise, Chronic kidney disease, Energy expenditure, Nutritional assessment