DESARROLLO Y PROGRESIÓN DE LA NEFROPATÍA DIABÉTICA EN DIABETES TIPO 2: UN ENFOQUE DESDE LOS ESTUDIOS CLÍNICOS

Carlos Yesid Coronado Suescún

Resumen


INTRODUCCIÓN: El 28% de los pacientes diabéticos atendidos en cuidado primario tiene enfermedad renal crónica. La nefropatía diabética es causa del 40% de los ingresos a programa crónico de diálisis en Colombia. En los últimos años se han realizado grandes ensayos clínicos sobre nefropatía diabética. La presente revisión actualiza la información que estos estudios han aportado sobre el desarrollo y progresión de la nefropatía secundaria a diabetes tipo 2 en términos de ingesta proteica, presión arterial y control glucémico.

METODOLOGÍA: Se desarrolló una estrategia de búsqueda tipo “snowball” partiendo de una revisión no sistemática de la literatura. Para la búsqueda se utilizó la base de datos MEDLINE incluyendo artículos con el término MeSH “diabetic nephropathy” publicados entre el 2010 y 2013 en el Idioma Español o Inglés.

RESULTADOS:El control intensivo de la glucemia no siempreconduce a mejores desenlaces, la HbA1c <6% se asocia con mayor mortalidad.Varios autores sugieren que la meta de HbA1c debería ser individualizada teniendo en cuenta laduración de la diabetes,la presencia de complicaciones microvasculares y macrovasculares, y la expectativa de vida. Recientemente se ha propuesto un modelo de efecto dual y dinámico de la HbA1c en el que la tasa de filtración glomerular actual tiene relación negativa con la HbA1c previa y relación positiva con la HbA1c actual.

Las guías recomiendan reducciones en presión diastólica hasta 80-85 mm Hg. Los estudios actuales no constituyen soporte para recomendar una presión sistólica menor de 130 mm Hg.

No existe evidencia conclusiva que vincule la restricción proteica con una menor tasa de progresión de la nefropatía diabética.


Palabras clave


Diabetes Mellitus, Nefropatías Diabéticas, Insuficiencia Renal Crónica

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Referencias


Rodriguez-Poncelas A, Garre-Olmo J, Franch-Nadal J, Diez-Espino J, Mundet-Tuduri X, Barrot-De la Puente J, et al. Prevalence of chronic kidney disease in patients with type 2 diabetes in Spain: PERCEDIME2 study. BMC Nephrol. 2013;14(46):1-8.

Rtiz E, Orth SR. Nephropathy in patients with type 2 diabetes mellitus. N Engl J Med. 1999;341:1127-33.

Retnakaran R, Cull C, Thorne KI. Risk factors for renal dysfunction in type 2 diabetes: UK. Prospective Diabetes Study 74. Diabetes. 2006;55:1832-9.

Schargrodsky H, Hernández R, Champagne BM, Silva H, Vinueza R, Silva Ayçaguer LC, et al. CARMELA: assessment of cardiovascular risk in seven Latin American cities. Am J Med. 2008;121(1):58-65.

Sanabria M, Muñoz J, Trillos C, Hernández G, Latorre C, Díaz C, et al. Dialysis outcomes in Colombia (DOC) study: A comparison of patient survival on peritoneal dialysis vs hemodialysis in Colombia. Kidney International. 2008;73:S165-72.

Chicaiza L. Fallas del mercado de la salud en Colmbia: el caso de la insuficiencia renal crónica. Revista de Economía Institucional. 2005;7(12):191-208.

Cooper ME. Pathogenesis, prevention, and treatment of diabetic nephropathy. Lancet. 1998;352:213-9.

Alcázar R, Ríos E. Nefropatía diabética. En: Avendaño H, coordinador. Nefrología Clínica. 3ª ed.Madrid: Editorial Médica Panamericana;2008. p. 406-20.

DeFronzo RA. Diabetic nephropathy: etiologic and therapeutic considerations. Diabetes Rev. 1995;3:510-64.

Macisaac RJ, Jerums G. Albuminuric and non-albuminuric pathways to renal impairment in diabetes. Minerva Endocrinol. 2005;30(3):161-77

UK Prospective Diabetes Study (UKDPS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). . Lancet. 1998(352):854-65.

Adler A, Stevens R, Manley S, Bilous R, Cull C, Holman R. Development and progression of nephropaty in type 2 diabetes: The United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney int. 2003;63:225-32.

Gall MA, Hougaard P, Borch-Johnsen K, Parving HH. Risk factors for development of incipient and overt diabetic nephropathy in patients with non-insulin dependent diabetes mellitus: prospective, observational study. BMJ. 1997;314:783-8.

Ravid M, Brosh D, Ravid-Safran D, Levy Z, Rachmani R. Main risk factors for nephropathy in type 2 diabetes mellitus are plasma cholesterol levels, mean blood pressure, and hyperglycemia. Arch Intern Med. 1998;158(9):998-1004.

Nelson RG, Bennett P, Beck G, Tan M, Knowler W, Mitch W, et al. Development and progression of renal disease in Pima indians with non-insulin-dependent diabetes mellitus. N Engl J Med. 1996;335:1636-42.

Ismail-Beigi F, Craven T, Banerji MA, Basile J, Celles J, Cohen RM et al. Effect of intensive treatment of hyperglycaemia on microvascular outcomes in type 2 diabetes: an analysis of the ACCORD randomised trial. Lancet. 2010;376:419-30.

ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560-72.

Agrawal L, Azad N, Emanuele N, BahnG, Kaufman D, Moritz T et al. Observation on Renal Outcomes in the Veterans Affairs Diabetes Trial. Diabetes Care. 2011;34(9):2090-94.

Gerstein HC, Miller M, Byington RP, Goff DC Jr, Bigger JT, Buse JB. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):25-45-59.

Miller ME, Bonds DE, Gerstein HC, Seaquist ER, Bergenstal RM, Calles-Escandon J, et al. The effects of baseline characteristics, glycaemia treatment approach, and glycated haemoglobin concentration on the risk of severe hypoglycaemia: post hoc epidemiological analysis of the ACCORD study. BMJ. 2010;340:b5444.

Perkovic V, Heerspink HL, Chalmers J, Woodward M, Jun M, Li Q, MacMahon S, et al. Intensive glucose control improves kidney outcomes in patients with type 2 diabetes. Kidney Int. 2013;83(3):517-23.

Duckworth WC, Abraira C, Moritz TE, Davis SN, Emanuele N, Goldman S, et al. The duration of diabetes affects the response to intensive glucose control in type 2 subjects: the VA Diabetes Trial. J Diabetes Complications. 2011;25(6):355-61.

American Diabetes Association. Standards of Medical Care in diabetes-2013. Diabetes Care. 2013;26(Suppl 1):S11-66.

Shurraw S, Tonelli M. Intensive glycemic control in type 2 diabetics at high cardiovascular risk: do the benefits justify the risk? Kidney Int. 2013;83:346-48.

DCCT/EDIC Research Group, de Boer IH, Sun W, Cleary PA, Lachin JM, Molitch ME, Steffes MW,. Intensive diabetes therapy and glomerular filtration rate in type 1 diabetes. N Engl J Med. 2011;22365(25):2366-76.

Lee CL, Li T, Lin SY, Wang JS, Lee IT, Tseng LN. Dynamic and dual effects of glycated hemoglobin on estimated glomerular filtration rate in type 2 diabetic outpatients. Am J Nephrol. 2013;38(1):19-26.

Magee GM, Bilous RW, Cardwell CR, Hunter SJ, Kee F, Fogarty DG. Is hyperfiltration associated with the future risk of developing diabetic nephropathy? A meta-analysis. Diabetologia. 2009;52(4):691-7.

Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB,. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345(12):851-60.

Hypertension in Diabetes Study (HDS): I. Prevalence of hypertension in newly presenting type 2 diabetic patients and the association with risk factors for cardiovascular and diabetic complications. J Hypertens. 1993;11:309.

Buse JB, Ginsberg H, Bakris GL, Clark NG, Costa F, Eckel R, et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation. 2007;30(1):162-72.

Hansson L, Zanchetti A, Carruthers SG, Dahlöf B, Elmfeldt D, Julius S, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet. 1998;351:1755-62.

McBrien K, Rabi DM, Campbell N, Barnieh L, Clement F, Hemmelgarn BR, et al. Intensive and Standard Blood Pressure Targets in Patients With Type 2 Diabetes Mellitus: Systematic Review and Meta-analysis. Arch Intern Med. 2012;172(17):1296-303.

Howard BV, Roman MJ, Devereux RB, Fleg JL, Galloway JM, Henderson JA, et al. Effect of lower targets for blood pressure and LDL cholesterol on atherosclerosis in diabetes: the SANDS randomized trial. JAMA. 2008;299(14):1678-89.

Schrier RW, Estacio RO, Esler A, Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int. 2002;61(3):1086-97.

Ravid M, Brosh D, Levi Z, Bar-Dayan Y, Ravid D, Rachmani R. Use of enalapril to attenuate decline in renal function in normotensive, normoalbuminuric patients with type 2 diabetes mellitus. A randomized, controlled trial. Ann Intern Med. 1998;128:982-88.

Ravid M, Savin H, Jutrin I, Bental T, Katz B, Lishner M, et al. Long-term stabilizing effect of angiotensin-converting enzyme inhibition on plasma creatinine and on proteinuria in normotensive type II diabetic patients. Ann Int Med. 1993;118:577-81.

Mancia G, Fagard R, Narkiewicz K, Redón J, Zanchetti A, Böhm M. 2013 ESH/ESC Guidelines for the management of arterial hypertension: the Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2013;31(7):1281-357.

López-Jaramillo P, Sánchez R, Díaz M, Cobos L, Bryce L, Parra-Carrillo J, et al. Consenso latinoamericano de hipertensión en pacientes con diabetes tipo 2 y síndrome metabólico. Acta Med Colomb. 2013;38:154-72.

Sega R, Faccetti R, Bombelli M, Cesana G, Corrao G, Grassi G, et al. Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population: follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation. 2005;111(14):1777-83.

Staessen JA, Asmar R, De Buyzere M, Imai Y, Parati G, Shimada K, et al. Task Force II: blood pressure measurement and cardiovascular outcome. Blood Press Monit. 2001;6(6):355-70.

Hodgkinson J, Mant J, Martin U, Guo B, Hobbs FD, Deeks JJ,. Relative effectiveness of clinic and home blood pressure monitoring compared with ambulatory blood pressure monitoring in diagnosis of hypertension: systematic review. BMJ. 2011;342:d3621.

Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et al. 2007 ESH-ESC Practice Guidelines for the Management of Arterial Hypertension: ESH-ESC Task Force on the Management of Arterial Hypertension. J Hypertens. 2007;25(9):1751-62.

Afsar B, Sezer S, Elsurer R, Ozdemir FN. Is HOMA index a predictor of nocturnal nondipping in hypertensives with newly diagnosed type 2 diabetes mellitus? Blood Press Monit. 2007;12(3):133-9.

Ayala DE, Moyá A, Crespo JJ, Castiñeira C, Domínguez-Sardiña M, et al. Circadian pattern of ambulatory blood pressure in hypertensive patients with and without type 2 diabetes. Chronobiol Int. 2013;30:99-115.

Pistrosch F, Reissmann E, Wildbrett J, Koehler C, Hanefeld M. Relationship between diurnal blood pressure variation and diurnal blood glucose levels in type 2 diabetic patients. Am J Hypertens. 2007;20(5):541-5.

Cardoso CR, Leite NC, Muxfeldt ES, Salles GF. Thresholds of ambulatory blood pressure associated with chronic complications in type 2 diabetes. Am J Hypertens. 2012;25(1):82-8.

Hermida RC, Ayala DE, Mojón A, Fernández JR. Ambulatory blood pressure thresholds for diagnosis of hypertension in patients with and without type 2 diabetes based on cardiovascular outcomes. Chronobiol Int. 2013;30(1-2):132-44.

Thilly N. Low-protein diet in chronic kidney disease: from questions of effectiveness to those of feasibility. Nephrol Dial Transplant. 2013;28:2203-5.

Klahr S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW,. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of Diet in Renal Disease Study Group. N Engl J Med. 1994;330(13):877-84.

Waugh NR, Robretson AM. Protein restriction for diabetic renal disease. Cochrane Database Syst Rev. 2007(4):CD002181.

Pan Y, Guo LL, Jin Hm. Low-protein diet for diabetic nephropathy: a meta-analysis of randomized controlled trials. Am J Clin Nutr 2008;88(3):660-6.

Nezu U, Kamiyama H, Kondo Y, Sakuma M, Morimoto T, Ueda S. Effect of low-protein diet on kidney function in diabetic nephropathy: meta-analysis of randomised controlled trials. BMJ Open. 2013;3:e002934.


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