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Authors
Abstract(s)
Introdução: A prevalência da doença renal crónica (DRC) tem aumentado ao longo dos
anos, sendo considerada uma das mais impactantes doenças não comunicáveis mundiais.
Com a progressão desta patologia, uma das alterações observadas corresponde aos
distúrbios minerais e ósseos, que apresentam um significativo impacto prognóstico. O
diagnóstico destes distúrbios pode ser realizado através de métodos invasivos e não
invasivos.
Objetivo: Avaliar o papel dos métodos de diagnóstico não invasivos (biomarcadores e
exames de imagem) e invasivos (biópsia óssea) nos distúrbios minerais e ósseos associados
à DRC (DMO-DRC), com o intuito de melhorar o diagnóstico e prognóstico.
Material e Métodos: Foram incluídos registos cujo foco de estudo foram os DMO-DRC e
os exames complementares de diagnóstico não invasivo ou invasivo. Foi realizada pesquisa
em duas bases de dados, Pubmed/Medline e Embase, e utilizado software Endnote para
organizar os registos. A equipa de revisores realizou de forma independente um screening
de títulos e abstracts e por último uma leitura completa dos artigos potencialmente
elegíveis. A ferramenta NIH (National Heart, Lung, and Blood Institute) permitiu avaliar a
qualidade dos estudos.
Resultados: Foram incluídos 49 estudos: 8 com doentes em estadio 1-5, 30 com doentes
em diálise, 3 com transplantados renais e 8 com categorias mistas. Foram obtidos dados
referentes a 10 biomarcadores e encontradas correlações entre os biomarcadores e a
capacidade diagnóstica de DMO-DRC e eventos adversos associados. De relevo, a
paratormona (PTH) correlacionou-se com o turnover ósseo em doentes dialisados e
transplantados, e com a doença óssea adinâmica (DOA), em dialisados. A paratormona
intacta (iPTH), também se correlacionou com o turnover ósseo, nomeadamente na
identificação de DOA nos doentes dialisados e categoria mista. A fosfatase alcalina óssea
correlacionou-se com o turnover ósseo e perda de massa óssea ao longo dos estadios da DRC
tendo sido útil na diferenciação da DOA na fase pré-dialítica. Já a fosfatase alcalina total
(FAT) correlacionou-se com o turnover ósseo em hemodialisados. Foi evidenciada
correlação entre biomarcadores FGF-23, OPG, FA (níveis elevados) e PTH e iPTH (níveis
elevados ou diminuídos) e eventos adversos como mortalidade aumentada. A iPTH e a
esclerostina demonstraram correlação com as calcificações vasculares em hemodialisados,
iPTH reduzida foi associada a aumento das calcificações no arco aórtico, em população de
categoria mista e de estadio 3-4. Dos exames de imagem analisados, em dialisados, a tomografia por emissão de positrões com 18F-Fluoreto de Sódio (18F-NaF PET)
possibilitou diferenciar pacientes com baixo turnover ósseo de não baixo turnover, a
quantitative computed tomography evidenciou capacidade na avaliação de perda óssea na
anca e o trabecular bone score apresentou menor valor em doentes em diálise
comparativamente a indivíduos saudáveis.
Discussão: Nesta revisão foi evidenciada a capacidade diagnóstica e prognóstica dos
biomarcadores, e relação com eventos adversos e calcificações vasculares. Os exames de
imagem demonstraram utilidade como método diagnóstico não invasivo. Apesar dos
resultados obtidos estes carecem ainda de maior validação em estudos subsequentes.
Conclusão: Os resultados obtidos estimulam a criação de algoritmos auxiliadores de
diagnóstico e de decisão terapêutica, através da conjugação de scores de calcificação e
biomarcadores, bem como a própria combinação de biomarcadores, com objetivo final de
obtenção de um diagnóstico preciso, precoce e instituição tratamento adequado.
Introduction: The prevalence of chronic kidney disease (CKD) has increased over the years, being considered one of the most impacting non-communicable diseases worldwide. With the progression of this pathology, one of the changes observed corresponds to mineral and bone disorders, which have a significant prognostic impact. The diagnosis of these disorders can be performed through invasive and non-invasive methods. Objective: Evaluate the role of non-invasive (biomarkers and imaging techniques) and invasive (bone biopsy) diagnostic methods in chronic kidney disease-mineral and bone disorder (CKD-MBD), in order to improve diagnosis and prognosis. Material and Methods: Articles whose focus of study were CKD-BMD and complementary non-invasive or invasive diagnostic tests were included. Research was carried out in two databases, Pubmed/Medline and Embase, and Endnote software was used to organize and compile the records. The team of reviewers independently performed a screening of titles and abstracts and finally a complete reading of potentially eligible articles. The NIH tool (National Heart, Lung, and Blood Institute) allowed to evaluate the quality of the studies. Results: 49 studies were included: 8 with stage 1-5 patients, 30 with dialysis patients, 3 with kidney transplant recipients and 8 with mixed categories. Data were obtained for 10 biomarkers and correlations were found between the biomarkers and the diagnostic capacity of CKD-MBD and associated adverse events. Importantly, parathyroid hormone (PTH) was correlated with bone turnover in dialyzed and transplanted patients, and with adynamic bone disease (ABD) in dialyzed patients. Intact parathyroid hormone (iPTH) was also correlated with bone turnover, namely in the identification of ABD in dialyzed patients and mixed category. Bone alkaline phosphatase correlated with bone turnover and bone mass loss throughout the stages of CKD and was useful in differentiating ABD in the predialysis phase. On the other hand, total alkaline phosphatase (tALP) was correlated with bone turnover in hemodialysis patients. Correlation between biomarkers FGF-23, OPG, FA (elevated values) and PTH and iPTH (elevated or decreased values) and adverse events such as increased mortality was evidenced. iPTH and sclerostin were correlated with vascular calcifications in hemodialysis patients, reduced iPTH was associated with increased aortic arch calcifications in a mixed category and stage 3-4 population. Of the imaging exams analyzed in dialysates, positron emission tomography with 18F-Sodium Fluoride (18F-NaF PET) made it possible to differentiate patients with low bone turnover from non-low bone turnover, quantitative computed tomography showed ability to assess bone loss in the hip and the trabecular bone score showed a lower value in dialysis patients compared to healthy individuals. Discussion: In this systematic review, the diagnostic and prognostic capacity of the biomarkers was evidenced, as well as their relationship with adverse events and vascular calcifications. Imaging tests proved to be useful as a non-invasive diagnostic method. Despite the results obtained, these still lack further validation in subsequent studies. Conclusion: The results obtained stimulate the creation of algorithms to aid diagnosis and therapeutic decision, through the combination of calcification scores and biomarkers, as well as the combination of biomarkers, with the final objective of obtaining an accurate, early diagnosis and institution of adequate treatment.
Introduction: The prevalence of chronic kidney disease (CKD) has increased over the years, being considered one of the most impacting non-communicable diseases worldwide. With the progression of this pathology, one of the changes observed corresponds to mineral and bone disorders, which have a significant prognostic impact. The diagnosis of these disorders can be performed through invasive and non-invasive methods. Objective: Evaluate the role of non-invasive (biomarkers and imaging techniques) and invasive (bone biopsy) diagnostic methods in chronic kidney disease-mineral and bone disorder (CKD-MBD), in order to improve diagnosis and prognosis. Material and Methods: Articles whose focus of study were CKD-BMD and complementary non-invasive or invasive diagnostic tests were included. Research was carried out in two databases, Pubmed/Medline and Embase, and Endnote software was used to organize and compile the records. The team of reviewers independently performed a screening of titles and abstracts and finally a complete reading of potentially eligible articles. The NIH tool (National Heart, Lung, and Blood Institute) allowed to evaluate the quality of the studies. Results: 49 studies were included: 8 with stage 1-5 patients, 30 with dialysis patients, 3 with kidney transplant recipients and 8 with mixed categories. Data were obtained for 10 biomarkers and correlations were found between the biomarkers and the diagnostic capacity of CKD-MBD and associated adverse events. Importantly, parathyroid hormone (PTH) was correlated with bone turnover in dialyzed and transplanted patients, and with adynamic bone disease (ABD) in dialyzed patients. Intact parathyroid hormone (iPTH) was also correlated with bone turnover, namely in the identification of ABD in dialyzed patients and mixed category. Bone alkaline phosphatase correlated with bone turnover and bone mass loss throughout the stages of CKD and was useful in differentiating ABD in the predialysis phase. On the other hand, total alkaline phosphatase (tALP) was correlated with bone turnover in hemodialysis patients. Correlation between biomarkers FGF-23, OPG, FA (elevated values) and PTH and iPTH (elevated or decreased values) and adverse events such as increased mortality was evidenced. iPTH and sclerostin were correlated with vascular calcifications in hemodialysis patients, reduced iPTH was associated with increased aortic arch calcifications in a mixed category and stage 3-4 population. Of the imaging exams analyzed in dialysates, positron emission tomography with 18F-Sodium Fluoride (18F-NaF PET) made it possible to differentiate patients with low bone turnover from non-low bone turnover, quantitative computed tomography showed ability to assess bone loss in the hip and the trabecular bone score showed a lower value in dialysis patients compared to healthy individuals. Discussion: In this systematic review, the diagnostic and prognostic capacity of the biomarkers was evidenced, as well as their relationship with adverse events and vascular calcifications. Imaging tests proved to be useful as a non-invasive diagnostic method. Despite the results obtained, these still lack further validation in subsequent studies. Conclusion: The results obtained stimulate the creation of algorithms to aid diagnosis and therapeutic decision, through the combination of calcification scores and biomarkers, as well as the combination of biomarkers, with the final objective of obtaining an accurate, early diagnosis and institution of adequate treatment.
Description
Keywords
Biomarcadores Ósseos Biópsia Óssea Diagnóstico Dmo-Drc Prognóstico