Estado clínico-nutricional, controle metabólico, inflamação e estresse oxidativo em indivíduos submetidos à hemodiálise
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2018-02-23
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Universidade Federal de Viçosa
Resumo
A doença renal crônica (DRC), caracterizada pela perda lenta, progressiva e irreversível das funções renais, bem como a hemodiálise (HD), tratamento substitutivo na DRC terminal, tem alta morbimortalidade e impacto socioeconômico relevante. Ademais, desnutrição, desordens metabólicas, inflamação e estresse oxidativo são fatores importantes que contribuem para esse cenário. Assim, este estudo teve como objetivo avaliar a associação entre estado clínico-nutricional, controle metabólico, inflamação e estresse oxidativo em indivíduos submetidos à HD. Participaram do estudo 85 indivíduos com idade superior a 18 anos (56 H/ 29 M, idade 62±14 anos), dos quais foram coletados dados sociodemográficos, indicadores antropométricos e de composição nutricional, estado nutricional por avaliação subjetiva global modificada (ASGm). Dados laboratoriais e de prescrição medicamentosa também foram obtidos dos prontuários e incluíram: Kt/V, número de medicamentos prescritos, GPID e valores de concentrações séricas de creatinina, ureia, taxa de remoção da ureia (TRU), potássio, cálcio, fósforo, paratormônio (PTH), albumina, ferro, capacidade latente e total de ligação do ferro, ferritina, saturação da transferrina, colesterol, triglicerídeos, proteína C reativa (PCR), IL-6, oxido nítrico (ON), Capacidade antioxidante (CAT), MDA, SOD. O consumo alimentar foi avaliado por meio do recordatório alimentar e o questionário de frequência de consumo alimentar semi-quantitativo (QFCA).Como resultados as principais causas da DRC na amostra estudada foram nefroesclerose hipertensiva e diabetes mellitus (DM). Quanto ao estado nutricional, a ASGm identificou 10,6% dos indivíduos na categoria adequado e 89,5% com risco nutricional/desnutrição leve. Em um primeiro momento observou que aqueles indivíduos com maior óxido nítrico (ON) (> 4,32 μmol/L) tiveram menores valores para escore ASGm (melhor estado nutricional), menor ferro sérico e triacilglicerol, acima das recomendações. Os mesmos ainda tiveram menor consumo de cobre, manganês, vitamina E, ɷ3 e ɷ6, quando comparado ao grupo com menor ON, porém ambos atingiram valores satisfatórios para consumo segundo recomendações nutricionais. Em modelo de regressão múltipla, as concentrações de ferritina, triacilglicerol, IL6 e SOD representaram uma variação de 54,8% nas concentrações de ON, sendo que as concentrações de triacilglicerol e SOD foram preditores independentes para variação de ON. Outro achado relevante do presente estudo, foi que aqueles indivíduos com diabetes tiveram menor escore ferro (p=0,001), KtV (p=0,050), e maiores valores de saturação de Fe (p=0,034), creatinina (p=0,003), PTH (p=0,046). Os mesmos ainda tiveram menor ingestão de fibra (p=0,019), zinco (p=0,001), vitamina A (p=0,002) quando comparados aos não diabéticos. Em modelo de regressão múltipla, a ocorrência de diabetes se associou positivamente com concentrações ferro e saturação de ferro, bem como negativamente com os valores de creatinina, KtV, ureia pré-diálise, CATs (p<0,05). E quando analisou o consumo alimentar observamos um maior consumo para maioria dos nutrientes (calorias totais, gorduras, fibra, vitaminas do complexo B, C e E e minerais K, Mg, Zn e Cu) analisados entre os homens, adultos, alfabetizados e valores adequados de creatinina (p<0,05). Ademais, aqueles indivíduos com excesso de peso tiveram menor consumo para macro e micronutrientes, comparados aos normopeso e com magreza (p<0,05) Em modelo de regressão múltipla, a escolaridade, atividade física, IMC e creatinina foram preditores independentes para variações na ingestão calórica dos macronutrientes (carboidrato, proteínas, lipídeos / kg de peso, p<0,001). Diante do exposto concluímos que este estudo transversal mostrou uma significativa associação de ON com marcadores de metabolismo lipídico e de ferro, bem como com marcadores inflamatórios (IL6 e IL10) e estresse oxidativo (SOD) em pacientes em HD, indicando seu importante papel como mediador de risco cardiometabólico. Ainda nessa população com baixas concentrações de ON, foi encontrado um consumo adequado de nutrientes com propriedade antioxidante (Cu, Se, Mn, vitamina C,E e ω3), assim como de vitaminas do complexo B além de uma distribuição adequada de gordura corporal e proteínas plasmáticas que parecem modular uma ação protetora nesta população. E ao considerarmos a presença do diabetes no indivíduo em HD foi associado positivamente com controle metabólico (creatinina, ferro, Kt/V, uréia e PTH), sem, contudo indicar desnutrição, sendo que a maior ingestão de antioxidante da dieta entre ambos os grupos e menor CATs indica menor risco de estresse oxidativo nesta população. Ademais, os pacientes em HD com excesso de peso também merecem atenção com ênfase na ingestão de micronutrientes, evitando a presença de uma desnutrição oculta, que pode contribuir para os agravos metabólicos comuns à DRC, sem contudo excluir a possibilidade de sub-relato entre estes pacientes.
Chronic kidney disease (CKD), characterized by slow, progressive and irreversible loss of renal function, as well as hemodialysis (HD), a substitute treatment in terminal CKD, has high morbidity and mortality and a relevant socioeconomic impact. In addition, malnutrition, metabolic disorders, inflammation and oxidative stress are important factors contributing to this scenario. Thus, this study aimed to evaluate the association between clinical-nutritional status, metabolic control, inflammation and oxidative stress in subjects submitted to HD. A total of 85 individuals over the age of 18 (56 H / 29 M, age 62 ± 14 years) were included in the study, from which sociodemographic data, anthropometric indicators and nutritional composition, nutritional status and modified global subjective assessment (ASGm) were collected. Laboratory data and drug prescription were also obtained from the medical records and included: Kt / V, number of drugs prescribed, GPID and serum concentrations of creatinine, urea, urea removal rate (TRU), potassium, calcium, phosphorus, parathyroid hormone (PTH), albumin, protein, globulin, hemoglobin, hematocrit, leukocytes, iron, latent and total binding capacity of iron, ferritin, transferrin saturation, alkaline phosphatase, glutamic-pyruvic transaminase (TGP), cholesterol, triglycerides, aluminum, C-reactive protein (CRP), IL- 6, nitric oxide (ON), antioxidant capacity (CAT), MDA, SOD. Dietary intake was assessed using the food recall and the semi-quantitative food consumption questionnaire (QFCA). As results the main causes of CKD in the sample studied were hypertensive nephrosclerosis and diabetes mellitus (DM). Regarding nutritional status, ASGm identified 10.6% of the individuals in the appropriate category and 89.5% with nutritional risk / mild malnutrition. At first, it was observed that those individuals with higher nitric oxide (ON) (> 4.32 μmol / L) had lower values for ASGm score (better nutritional status), lower serum iron and triacylglycerol, above the recommendations. They also had lower consumption of copper, manganese, vitamin E, ɷ3 and ɷ6, when compared to the group with lower ON, but both reached satisfactory values for consumption according to nutritional recommendations. In a multiple regression model, concentrations of ferritin, triacylglycerol, IL6 and SOD represented a 54.8% variation in NO concentrations, and triacylglycerol and SOD concentrations were independent predictors for ON variation. Another relevant finding of the present study was that those individuals with diabetes had lower values for iron (p = 0.001), KtV (p = 0.050), and higher values of Fe saturation (p = 0.034), creatinine (p = 0.003) ), and PTH (p = 0.046). (P = 0.063), sodium (p = 0.003), thiamine (p = 0.004), vitamin E (p = 0.045), ɷ3 (p = 0.048) and ɷ6 (p = 0.047), when compared to non-diabetics. In a multiple regression model, the occurrence of diabetes was positively associated with iron concentrations and iron saturation, as well as negatively with creatinine, KtV, pre- dialysis urea, CATs (p <0.05). When we analyzed food consumption we observed a higher intake for most of the nutrients (total calories, fat, fiber, B, C and E complex vitamins and minerals K, Mg, Zn and Cu) analyzed among men, adults, literacy and values of creatinine (p <0.05). In the multiple regression model, schooling, physical activity, BMI and creatinine were independent predictors for variations in intake (p <0.05) macronutrients (carbohydrate, proteins, lipids / kg of body weight, p <0.001). In view of the above, we conclude that this cross-sectional study showed a significant association of ON with markers of lipid and iron metabolism, as well as with inflammatory markers (IL6 and IL10) and oxidative stress (SOD) in HD patients, indicating their important role as mediator of cardiometabolic risk. Also in this population with low NO concentrations, adequate intake of nutrients with antioxidant properties (Cu, Se, Mn, vitamin C, E and ω3), as well as B vitamins and an adequate distribution of body fat and plasma proteins that appear to modulate a protective action in this population. And considering the presence of diabetes in the individual in HD was positively associated with metabolic control (creatinine, iron, Kt / V, urea and PTH), but did not indicate malnutrition, and the lower dietary antioxidant intake and lower CATs indicated higher risk of oxidative stress in relation to non-diabetics. In addition, patients with overweight HD also deserve attention with an emphasis on micronutrient intake.
Chronic kidney disease (CKD), characterized by slow, progressive and irreversible loss of renal function, as well as hemodialysis (HD), a substitute treatment in terminal CKD, has high morbidity and mortality and a relevant socioeconomic impact. In addition, malnutrition, metabolic disorders, inflammation and oxidative stress are important factors contributing to this scenario. Thus, this study aimed to evaluate the association between clinical-nutritional status, metabolic control, inflammation and oxidative stress in subjects submitted to HD. A total of 85 individuals over the age of 18 (56 H / 29 M, age 62 ± 14 years) were included in the study, from which sociodemographic data, anthropometric indicators and nutritional composition, nutritional status and modified global subjective assessment (ASGm) were collected. Laboratory data and drug prescription were also obtained from the medical records and included: Kt / V, number of drugs prescribed, GPID and serum concentrations of creatinine, urea, urea removal rate (TRU), potassium, calcium, phosphorus, parathyroid hormone (PTH), albumin, protein, globulin, hemoglobin, hematocrit, leukocytes, iron, latent and total binding capacity of iron, ferritin, transferrin saturation, alkaline phosphatase, glutamic-pyruvic transaminase (TGP), cholesterol, triglycerides, aluminum, C-reactive protein (CRP), IL- 6, nitric oxide (ON), antioxidant capacity (CAT), MDA, SOD. Dietary intake was assessed using the food recall and the semi-quantitative food consumption questionnaire (QFCA). As results the main causes of CKD in the sample studied were hypertensive nephrosclerosis and diabetes mellitus (DM). Regarding nutritional status, ASGm identified 10.6% of the individuals in the appropriate category and 89.5% with nutritional risk / mild malnutrition. At first, it was observed that those individuals with higher nitric oxide (ON) (> 4.32 μmol / L) had lower values for ASGm score (better nutritional status), lower serum iron and triacylglycerol, above the recommendations. They also had lower consumption of copper, manganese, vitamin E, ɷ3 and ɷ6, when compared to the group with lower ON, but both reached satisfactory values for consumption according to nutritional recommendations. In a multiple regression model, concentrations of ferritin, triacylglycerol, IL6 and SOD represented a 54.8% variation in NO concentrations, and triacylglycerol and SOD concentrations were independent predictors for ON variation. Another relevant finding of the present study was that those individuals with diabetes had lower values for iron (p = 0.001), KtV (p = 0.050), and higher values of Fe saturation (p = 0.034), creatinine (p = 0.003) ), and PTH (p = 0.046). (P = 0.063), sodium (p = 0.003), thiamine (p = 0.004), vitamin E (p = 0.045), ɷ3 (p = 0.048) and ɷ6 (p = 0.047), when compared to non-diabetics. In a multiple regression model, the occurrence of diabetes was positively associated with iron concentrations and iron saturation, as well as negatively with creatinine, KtV, pre- dialysis urea, CATs (p <0.05). When we analyzed food consumption we observed a higher intake for most of the nutrients (total calories, fat, fiber, B, C and E complex vitamins and minerals K, Mg, Zn and Cu) analyzed among men, adults, literacy and values of creatinine (p <0.05). In the multiple regression model, schooling, physical activity, BMI and creatinine were independent predictors for variations in intake (p <0.05) macronutrients (carbohydrate, proteins, lipids / kg of body weight, p <0.001). In view of the above, we conclude that this cross-sectional study showed a significant association of ON with markers of lipid and iron metabolism, as well as with inflammatory markers (IL6 and IL10) and oxidative stress (SOD) in HD patients, indicating their important role as mediator of cardiometabolic risk. Also in this population with low NO concentrations, adequate intake of nutrients with antioxidant properties (Cu, Se, Mn, vitamin C, E and ω3), as well as B vitamins and an adequate distribution of body fat and plasma proteins that appear to modulate a protective action in this population. And considering the presence of diabetes in the individual in HD was positively associated with metabolic control (creatinine, iron, Kt / V, urea and PTH), but did not indicate malnutrition, and the lower dietary antioxidant intake and lower CATs indicated higher risk of oxidative stress in relation to non-diabetics. In addition, patients with overweight HD also deserve attention with an emphasis on micronutrient intake.
Descrição
Palavras-chave
Hemodiálise - Pacientes - Nutrição - Análise, Inflamação, Hemodiálise, Stress oxidativo, Sindrome metabólica
Citação
EPIFÂNIO, Andreza de Paula Santos. Estado clínico-nutricional, controle metabólico, inflamação e estresse oxidativo em indivíduos submetidos à hemodiálise. 2018. 158 f. Tese (Doutorado em Ciência da Nutrição) - Universidade Federal de Viçosa, Viçosa. 2018.