Análise comparativa da progressão e tratamento multidisciplinar da doenca renal crônica entre pacientes em tratamento conservador e transplantados renais

Abstract

Introduction. Traditional complications and risk factors for chronic kidney disease (CKD) progression, typically present in predialysis patients (PDP), are also observed in kidney transplant recipients (KTR). Their study in KTR is relevant, due to the lack of improvement in long-term graft survival. Multidisciplinary approach, established as the best model of assistance for PDP, is poorly described regarding treatment of CKD among KTR. Objective. To compare coverage of treatment of complications and risk factors for CKD progression, kidney and patient survival, and progression rate of CKD, between a group of PDP and one of KTR, both followed by a multidisciplinary team. Patients and Methods. Retrospective cohort study, with 101 KTR followed at a universitary hospital and 101 PDP selected by propensity score method, using semestral data from medical records regarding a period of 12 to 60 months of follow-up. We compared patient and kidney function survival, glomerular filtration rate (GFR) decline, prevalence of complications and risk factors related to CKD progression, percentage of patients without treatment of those, percentage of medical visits without treatment of the same conditions throughout follow-up, and percentage of medical visits within treatment goals. Variation of GFR, estimated by the CKD-Epi formula, was determined using a mixed generalized linear model; survival of kidney function free of dialysis and patient survival were determined by Kaplan-Meier curves, and differences regarding treatment were compared through odds ratio or relative risk, as appropriate. Results. Both cohorts had comparable GFR and CKD category distribution, and comparable prevalence of diabetes and cardiovascular comorbidities, but KTR were younger (43.4±12.5 vs. 50.2±13.5 years, p<0.001) and had a longer follow-up (55.7±12.1 vs. 31.6±11.5 months, p<0.001). Differences in systolic and diastolic blood pressure, and in proteinuria >1g/day at the beginning of the study, higher among PDP, did not persist throughout follow-up. Anemia was more common (38.6% vs 15.8%, RR 2.43, CI 1.46-4.06, p <0.001) and more often treated among KTR (73.9% vs 11.3%, OR 0.15, CI 0.1-0.23, p <0.001), but the number of patients without treatment of anemia during follow-up was similar between groups. Untreated hypercholesterolemia was less common in KTR (15.7% vs 22.9%, OR 0.68, CI 0.52-0.89, p=0.005), but untreated hyperphosphatemia (56.1% vs 30.0%, RR 1.86, CI 1.01-3.44, p=0.044) and untreated hyperuricemia (60.4% vs 35.4%, RR 1.7, CI 1.31-2.21, p<0.001) were more common in this cohort. Percentage of medical visits with patients within most treatment goals was similar between groups, with exception of diastolic blood pressure (83.4% vs 77.3%, RR 0.92, CI 0.88-0.97, p=0.002) and hypertrigliceridemia (67.7% vs 58.2%, OR 0.85, CI 0.78-0.93, p<0.001), more often controlled in PDP, and proteinuria (92.7% vs. 83.5%, RR 1.1, CI 1.05-1.16, p<0.001) and LDL cholesterol, more often controlled in KTR. Patient survival and GFR slope (0.81 mL/min/year in KTR vs 1.07 mL/min/year in PDP, p=0.48, CI -0.04–0.08) were similar between groups, but PDP progressed more often to dialysis (9.9% vs 6.9%, p<0.001). Conclusion. Differences in prevalence of some complications could be explained by a large number of incident patients in the PDP group and by adverse effects of immunosuppressive medication in KTR. We observed a good performance by the multidisciplinary model for treatment of CKD-related complications in KTR in comparison to PDP, suggesting that this model of assistance can contribute to improve the quality of clinical follow-up of KTR.