Nefropatía IgA en Uruguay
Presentación clínica y evolución
Palabras clave:
GLOMERULONEFRITIS POR IGA, URUGUAYResumen
La nefropatía IgA es frecuente en Uruguay y su tratamiento conflictivo.
Objetivo: analizar la incidencia, presentación clínica, histología, tratamiento y evolución de la nefropatía IgA en Uruguay.
Material y método: se realizó un análisis retrospectivo de datos del Registro Uruguayo de Glomerulopatías (RUG) e historias clínicas con estricta confidencialidad; se registró edad, sexo, fecha de biopsia renal, presentación clínica, presión arterial (PA), proteinuria, hematuria y creatininemia (al inicio y en última evolución registrada), histología, tratamientos y evolución. Análisis estadístico uni y multivariado. Aprobado por el Comité de Ética del Hospital de Clínicas.
Resultados: se estudiaron 341 pacientes con nefropatía IgA, confirmada por histología, en el período comprendido entre el 1º de enero de 1985 y el 31 de diciembre de 2009; 65% hombres, edad media 31 ± 13 años y mediana de seguimiento de 52 meses (1-271); 14% ingresaron a diálisis y 1,2% fallecieron. La presentación clínica más frecuente fue con alteraciones urinarias asintomáticas (AUA) (42%), (mayor en el período 2000-2009, chi2 p < 0,05). Al inicio, la proteinuria era 1,7 ± 1,9 g/l; creatininemia 1,6 ± 1,8 mg/dl, y 32% tenían PA ≥ 140/90 mmHg. Se observaron semilunas en 48%. Recibieron inhibidores de la enzima convertidora de angiotensina/antagonistas de los receptores de la angiotensina II (IECA/ARAII) 56% e inmunosupresores, 52%. La PA disminuyó significativamente en la evolución. En el análisis univariado, la creatininemia inicial fue ≥ 2,5 mg/dl, proteinuria, semilunas y proliferación endocapilar se asociaron a ingreso a diálisis o fallecimiento, pero en el análisis multivariado (regresión de Cox) solo fue significativo el nivel de creatininemia. Conclusiones: la presentación clínica de nefropatía IgA ha cambiado en la última década, siendo más frecuente las AUA. La creatininemia ≥ 2,5 mg/dl se asocia a peor supervivencia renal, probable “punto de no retorno”.
Citas
(1) D’Amico G. Natural history of idiopathic IgA nephropathy: role of clinical and histological prognostic factors. Am J Kidney Dis 2000; 36:227-37.
(2) Appel GB, Waldman M. The IgA nephropathy treatment dilemma. Kidney Int 2006; 69:1939-44.
(3) Wyatt R, Julian B. IgA Nephropathy. N Engl J Med 2013; 368:2402-14.
(4) McGrogan A, Franssen CF, de Vries CS. The incidence of primary glomerulonephritis worldwide: a systematic review of the literature. Nephrol Dial Transplant 2011; 26(2): 414-30.
(5) Knoop T, Vikse BE, Svarstad E, Leh S, Reisæter AV, Biørneklett R. Mortality in patients with IgA nephropathy. Am J Kidney Dis 2013; 62(5):883-90.
(6) Goto M, Kawamura T, Wakai K, Ando M, Endoh M, Tomino Y. Risk stratification for progression of IgA nephropathy using a decision tree induction algorithm. Nephrol Dial Trasplant 2009; 24:1242-47.
(7) Floege J, Feehally J. Treatment of IgA nephropathy and Henoch-Schönlein nephritis. Nat Rev Nephrol 2013; 9(6): 320-7.
(8) Noboa O, Gadola L, Caorsi H, Garau M, González-Martíinez F, Acosta N, et al. Changes in the incidence of glomerular diseases in Uruguay during the last ten years. Abstract in ASN Meeting 2012, San Diego, USA. Obtenido de: www.asn-online.org/education/kidneyweek/archives/ Consulta: mayo de 2014.
(9) Levey AS, Stevens LA. Estimating GFR using the CKD Epidemiology Collaboration (CKD-EPI) creatinine equation: more accurate GFR estimates, lower CKD prevalence estimates, and better risk predictions. Am J Kidney Dis 2010; 55(4): 622-7.
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(14) Bjørneklett R, Vikse BE, Bostad L, Leivestad T, Iversen BM. Long-term risk of ESRD in IgAN; validation of Japanese prognostic model in a Norwegian cohort. Nephrol Dial Transplant 2012; 27(4):1485-91.
(15) Lee H, Kim DK, Oh KH, Joo KW, Kim YS, Chae DW, et al. Mortality of IgA nephropathy patients: a single center experience over 30 years. PLoS One 2012; 7(12):e51225.
(16) Maixnerova D, Bauerova L, Skibova J, Rysava R, Reiterova J, Merta M, et al. The retrospective analysis of 343 Czech patients with IgA nephropathy—one centre experience. Nephrol Dial Transplant 2012; 27(4):1492-8.
(17) Shi SF, Wang SX, Jiang L, Lv JC, Liu LJ, Chen YQ, et al. Pathologic predictors of renal outcome and therapeutic efficacy in IgA nephropathy: validation of the oxford classification. Clin J Am Soc Nephrol 2011; 6(9):2175-84.
(18) Herzenberg AM, Fogo AB, Reich HN, Troyanov S, Bavbek N, Massat AE, et al. Validation of the Oxford classification of IgA nephropathy. Kidney Int 2011; 80(3):310-7.
(19) Berthoux F, Mohey H, Laurent B, Mariat C, Afiani A, Thibaudin L. Predicting the risk for dialysis or death in IgA nephropathy. J Am Soc Nephrol 2011; 22:752-61.
(20) Shimizu A, Takei T, Moriyama T, Itabashi M, Uchida K, Nitta K. Clinical and pathological studies of IgA nephropathy presenting as a rapidly progressive form of glomerulonephritis. Inter Med 2013; 52 (22):2489-94.
(21) VALIGA-European validation study of the Oxford classification of IgA nephropathy. Obtenido de: www.era-edta.org/images/VALIGA.pdf Consulta: mayo de 2014.
(22) Lv J, Shi S, Xu D, Zhang H, Troyanov S, Cattran DC, Wang H. Evaluation of the Oxford Classification of IgA nephropathy: a systematic review and meta-analysis. Am J Kidney Dis 2013; 62(5):891-9.
(23) Kidney Disease Improving Global Outcome. KDIGO Clinical Practice Guideline for Glomerulonephritis. Kidney Int Suppl 2012; 2:139-274.
(24) Lv J, Yang Y, Zhang H, Chen W, Pan X, Guo Z, et al. Prediction of outcomes in crescentic IgA nephropathy in a multicenter cohort study. J Am Soc Nephrol 2013; 24(12):2118-25.
(25) Tumlin JA, Lohavicha V, Hennigar R. Crescentic, proliferative IgA nephropathy: clinical and histological response to methylprednisolone and intravenous cyclophosphamide. Nephrol Dial Transplant 2003; 18(7):1321-9.
(26) Toronto Glomerulonephritis Registry, Reich HN, Troyanov S, Scholey JW, Cattran DC. Remission of proteinuria improves prognosis in IgA nephropathy. J Am Soc Nephrol 2007; 18:3177-83.
(27) Komatsu H, Fujimoto S, Sato Y, Hara S, Yamada K, Morita S, et al. “Point of no return (PNR)” in progressive IgA nephropathy: significance of blood pressure and proteinuria management up to PNR. J Nephrol 2005; 18(6):690-5.
(28) Gutiérrez E, Zamora I, Ballarín JA, Arce Y, Jiménez S, Quereda C et al. Grupo de Estudio de Enfermedades Glomerulares de la Sociedad Española de Nefrología (GLOSEN) Long-term outcomes of IgA nephropathy presenting with minimal or no proteinuria. J Am Soc Nephrol 2012; 23(10):1753-60.
(29) Praga M, Gutiérrez E, González E, Morales E, Hernández E. Treatment of IgA nephropathy with ACE inhibitors: a randomized and controlled trial. J Am Soc Nephrol 2003; 14(6):1578-83.
(30) Coppo R, Peruzzi L, Amore A, Piccoli A, Cochat P, Stone R, et al. IgACE: a placebo-controlled, randomized trial of angiotensin-converting enzyme inhibitors in children and young people with IgA nephropathy and moderate proteinuria. J Am Soc Nephrol 2007; 18:1880-8.
(31) Locatelli F, Pozzi C, Andrulli S. IgA nephritis: ACE inhibitors, steroids, both or neither? Nephrol Dial Transplant 2006; 21(12):3357-61.
(32) Manno C, Torres DD, Rossini M, Pesce F, Schena FP. Randomized controlled clinical trial of corticosteroids plus ACE-inhibitors with long-term follow-up in proteinuric IgA nephropathy. Nephrol Dial Transplant 2009; 24(12):3694-701.
(33) TESTING Study Group, Lv J, Xu D, Perkovic V, Ma X, Johnson DW, Woodward M, et al. Corticosteroid therapy in IgA nephropathy. J Am Soc Nephrol 2012; 23(6):1108-16.
(34) Floege J, Eitner F. Current therapy for IgA nephropathy. J Am Soc Nephrol 2011; 22:1785-94.
(35) Eitner F, Ackermann D, Hilgers RD, Floege J. Supportive Versus Immunosuppressive Therapy of Progressive IgA Nephropathy (STOP) IgAN trial: rationale and study protocol. J Nephrol 2008; 21:284-9.
(36) Pozzi C, Andrulli S, Pani A, Scaini P, Roccatello D, Fogazzi G, et al. IgA nephropathy with severe chronic renal failure: a randomized controlled trial of corticosteroids and azathioprine. J Nephrol 2013; 26(1):86-93.
(37) Pozzi C, Andrulli S, Pani A, Scaini P, Del Vecchio L, Fogazzi G, et al. Addition of azathioprine to corticosteroids does not benefit patients with IgA nephropathy. J Am Soc Nephrol 2010; 21(10):1783-90.
(38) Ballardie FW, Roberts IS. Controlled prospective trial of prednisolone and cytotoxics in progressive IgA nephropathy. J Am Soc Nephrol 2002; 13(1):142-8.
(39) Le W, Liang S, Hu Y, Deng K, Bao H, Zeng C, Liu Z. Long-term renal survival and related risk factors in patients with IgA nephropathy: results from a cohort of 1155 cases in a Chinese adult population. Nephrol Dial Transplant 2012; 27 (4):1479-85.
(2) Appel GB, Waldman M. The IgA nephropathy treatment dilemma. Kidney Int 2006; 69:1939-44.
(3) Wyatt R, Julian B. IgA Nephropathy. N Engl J Med 2013; 368:2402-14.
(4) McGrogan A, Franssen CF, de Vries CS. The incidence of primary glomerulonephritis worldwide: a systematic review of the literature. Nephrol Dial Transplant 2011; 26(2): 414-30.
(5) Knoop T, Vikse BE, Svarstad E, Leh S, Reisæter AV, Biørneklett R. Mortality in patients with IgA nephropathy. Am J Kidney Dis 2013; 62(5):883-90.
(6) Goto M, Kawamura T, Wakai K, Ando M, Endoh M, Tomino Y. Risk stratification for progression of IgA nephropathy using a decision tree induction algorithm. Nephrol Dial Trasplant 2009; 24:1242-47.
(7) Floege J, Feehally J. Treatment of IgA nephropathy and Henoch-Schönlein nephritis. Nat Rev Nephrol 2013; 9(6): 320-7.
(8) Noboa O, Gadola L, Caorsi H, Garau M, González-Martíinez F, Acosta N, et al. Changes in the incidence of glomerular diseases in Uruguay during the last ten years. Abstract in ASN Meeting 2012, San Diego, USA. Obtenido de: www.asn-online.org/education/kidneyweek/archives/ Consulta: mayo de 2014.
(9) Levey AS, Stevens LA. Estimating GFR using the CKD Epidemiology Collaboration (CKD-EPI) creatinine equation: more accurate GFR estimates, lower CKD prevalence estimates, and better risk predictions. Am J Kidney Dis 2010; 55(4): 622-7.
(10) Barratt J, Feehally J. IgA nephropathy. J Am Soc Nephrol 2005; 16:2088-97.
(11) Coppo R, D’Amico G. Factors predicting progression of IgA nephropathies. J Nephrol 2005; 18:503-12.
(12) Working Group of the International IgA Nephropathy Network and the Renal Pathology Society, Cattran DC, Coppo R, Cook HT, Feehally J, Roberts IS, Troyanov S, et al. The Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and classification. Kidney Int 2009; 76:534-45.
(13) Working Group of the International IgA Nephropathy Network and the Renal Pathology Society, Roberts IS, Cook HT, Troyanov S, Alpers CE, Amore A, Barratt J, et al. The Oxford classification of IgA nephropathy: pathology definitions, correlations, and reproducibility. Kidney Int 2009; 76:546-56.
(14) Bjørneklett R, Vikse BE, Bostad L, Leivestad T, Iversen BM. Long-term risk of ESRD in IgAN; validation of Japanese prognostic model in a Norwegian cohort. Nephrol Dial Transplant 2012; 27(4):1485-91.
(15) Lee H, Kim DK, Oh KH, Joo KW, Kim YS, Chae DW, et al. Mortality of IgA nephropathy patients: a single center experience over 30 years. PLoS One 2012; 7(12):e51225.
(16) Maixnerova D, Bauerova L, Skibova J, Rysava R, Reiterova J, Merta M, et al. The retrospective analysis of 343 Czech patients with IgA nephropathy—one centre experience. Nephrol Dial Transplant 2012; 27(4):1492-8.
(17) Shi SF, Wang SX, Jiang L, Lv JC, Liu LJ, Chen YQ, et al. Pathologic predictors of renal outcome and therapeutic efficacy in IgA nephropathy: validation of the oxford classification. Clin J Am Soc Nephrol 2011; 6(9):2175-84.
(18) Herzenberg AM, Fogo AB, Reich HN, Troyanov S, Bavbek N, Massat AE, et al. Validation of the Oxford classification of IgA nephropathy. Kidney Int 2011; 80(3):310-7.
(19) Berthoux F, Mohey H, Laurent B, Mariat C, Afiani A, Thibaudin L. Predicting the risk for dialysis or death in IgA nephropathy. J Am Soc Nephrol 2011; 22:752-61.
(20) Shimizu A, Takei T, Moriyama T, Itabashi M, Uchida K, Nitta K. Clinical and pathological studies of IgA nephropathy presenting as a rapidly progressive form of glomerulonephritis. Inter Med 2013; 52 (22):2489-94.
(21) VALIGA-European validation study of the Oxford classification of IgA nephropathy. Obtenido de: www.era-edta.org/images/VALIGA.pdf Consulta: mayo de 2014.
(22) Lv J, Shi S, Xu D, Zhang H, Troyanov S, Cattran DC, Wang H. Evaluation of the Oxford Classification of IgA nephropathy: a systematic review and meta-analysis. Am J Kidney Dis 2013; 62(5):891-9.
(23) Kidney Disease Improving Global Outcome. KDIGO Clinical Practice Guideline for Glomerulonephritis. Kidney Int Suppl 2012; 2:139-274.
(24) Lv J, Yang Y, Zhang H, Chen W, Pan X, Guo Z, et al. Prediction of outcomes in crescentic IgA nephropathy in a multicenter cohort study. J Am Soc Nephrol 2013; 24(12):2118-25.
(25) Tumlin JA, Lohavicha V, Hennigar R. Crescentic, proliferative IgA nephropathy: clinical and histological response to methylprednisolone and intravenous cyclophosphamide. Nephrol Dial Transplant 2003; 18(7):1321-9.
(26) Toronto Glomerulonephritis Registry, Reich HN, Troyanov S, Scholey JW, Cattran DC. Remission of proteinuria improves prognosis in IgA nephropathy. J Am Soc Nephrol 2007; 18:3177-83.
(27) Komatsu H, Fujimoto S, Sato Y, Hara S, Yamada K, Morita S, et al. “Point of no return (PNR)” in progressive IgA nephropathy: significance of blood pressure and proteinuria management up to PNR. J Nephrol 2005; 18(6):690-5.
(28) Gutiérrez E, Zamora I, Ballarín JA, Arce Y, Jiménez S, Quereda C et al. Grupo de Estudio de Enfermedades Glomerulares de la Sociedad Española de Nefrología (GLOSEN) Long-term outcomes of IgA nephropathy presenting with minimal or no proteinuria. J Am Soc Nephrol 2012; 23(10):1753-60.
(29) Praga M, Gutiérrez E, González E, Morales E, Hernández E. Treatment of IgA nephropathy with ACE inhibitors: a randomized and controlled trial. J Am Soc Nephrol 2003; 14(6):1578-83.
(30) Coppo R, Peruzzi L, Amore A, Piccoli A, Cochat P, Stone R, et al. IgACE: a placebo-controlled, randomized trial of angiotensin-converting enzyme inhibitors in children and young people with IgA nephropathy and moderate proteinuria. J Am Soc Nephrol 2007; 18:1880-8.
(31) Locatelli F, Pozzi C, Andrulli S. IgA nephritis: ACE inhibitors, steroids, both or neither? Nephrol Dial Transplant 2006; 21(12):3357-61.
(32) Manno C, Torres DD, Rossini M, Pesce F, Schena FP. Randomized controlled clinical trial of corticosteroids plus ACE-inhibitors with long-term follow-up in proteinuric IgA nephropathy. Nephrol Dial Transplant 2009; 24(12):3694-701.
(33) TESTING Study Group, Lv J, Xu D, Perkovic V, Ma X, Johnson DW, Woodward M, et al. Corticosteroid therapy in IgA nephropathy. J Am Soc Nephrol 2012; 23(6):1108-16.
(34) Floege J, Eitner F. Current therapy for IgA nephropathy. J Am Soc Nephrol 2011; 22:1785-94.
(35) Eitner F, Ackermann D, Hilgers RD, Floege J. Supportive Versus Immunosuppressive Therapy of Progressive IgA Nephropathy (STOP) IgAN trial: rationale and study protocol. J Nephrol 2008; 21:284-9.
(36) Pozzi C, Andrulli S, Pani A, Scaini P, Roccatello D, Fogazzi G, et al. IgA nephropathy with severe chronic renal failure: a randomized controlled trial of corticosteroids and azathioprine. J Nephrol 2013; 26(1):86-93.
(37) Pozzi C, Andrulli S, Pani A, Scaini P, Del Vecchio L, Fogazzi G, et al. Addition of azathioprine to corticosteroids does not benefit patients with IgA nephropathy. J Am Soc Nephrol 2010; 21(10):1783-90.
(38) Ballardie FW, Roberts IS. Controlled prospective trial of prednisolone and cytotoxics in progressive IgA nephropathy. J Am Soc Nephrol 2002; 13(1):142-8.
(39) Le W, Liang S, Hu Y, Deng K, Bao H, Zeng C, Liu Z. Long-term renal survival and related risk factors in patients with IgA nephropathy: results from a cohort of 1155 cases in a Chinese adult population. Nephrol Dial Transplant 2012; 27 (4):1479-85.
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2015-03-31
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1.
Gadola L, Cabrera J, Acosta Marichal N, Panuncio A, Aunchaina MH, Coria V, et al. Nefropatía IgA en Uruguay: Presentación clínica y evolución. Rev. Méd. Urug. [Internet]. 31 de marzo de 2015 [citado 27 de julio de 2024];31(1):15-26. Disponible en: https://revista.rmu.org.uy/index.php/rmu/article/view/220
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