Impacto do risco de desnutrição pré-transplante no desfecho clínico e na sobrevida do enxerto de pacientes transplantados renais

Abstract

RESUMO Antecedentes: A prevalência de pacientes desnutridos antes do transplante e a influência da desnutrição nos desfechos do enxerto e do paciente permanecem subestimadas, embora estejam associadas a maior morbimortalidade pós-operatória. Este estudo buscou desenvolver uma ferramenta simples de triagem nutricional e avaliar o impacto do estado nutricional no desfecho clínico, sobrevida do enxerto (SE) e risco de mortalidade em pacientes transplantados renais (PTR). Métodos: Neste estudo de coorte retrospectivo incluindo 451 PTR, desenvolvemos um escore usando medidas antropométricas, clínicas e laboratoriais tomadas na avaliação pré-transplante. Os pacientes foram estratificados em 3 grupos segundo a pontuação final: G1 (0-1 ponto) = baixo risco, G2 (2-4 pontos) = risco moderado e G3 (>5 pontos) = alto risco de desnutrição. Eles foram monitorados por pelo menos 1 a 10 anos após o transplante. Resultados: Os 451 pacientes foram estratificados em G1, G2 e G3, que consistiram em 90, 292 e 69 pacientes, respectivamente. Os pacientes do G1 mantiveram os menores níveis de creatinina sérica na alta hospitalar em relação aos demais (p = 0,012). A incidência de infecção nos pacientes do G3 foi maior que nos pacientes do G1 e G2 (p = 0,030). Os pacientes do G3 apresentaram SE pior do que os pacientes do G1 (p = 0,044) e um risco quase três vezes maior de perda do enxerto (HR 2,94; IC 95% 1,084-7,996). Conclusões: PTR com maior escore de risco de desnutrição foram associados a piores desfechos e menor SE. A ferramenta de triagem nutricional é fácil de usar na prática clínica para avaliar pacientes em preparação para transplante renal.

Malnutrition before kidney transplantation: how to assess it and what is the impact?

“…Another point that draws attention is that this instrument would be most important during the first year after the transplant. During this period, there would be a higher proportion of infections and a greater impact of immunosuppression, as well observed by the authors 5 . The same authors associated the risks of malnutrition with a decrease in graft survival, but in the mediumand long-term other factors described in this study, especially infections, depend greatly on nutritional status.…”

“…There is a complex interplay between overlapping nutritional and inflammatory parameters during CKD, with a need for further assessment and interpretation of these variables, and how they relate to the identification and prevention of malnutrition, specifically 10 . Therefore, as already indicated by the authors 5 , there is the possibility of new investigations improving what, in our assessment, is quality. This current study 5 opens the way for new investigations as a way to have more validated instruments for specific purposes in the area, whether for transplant patients or not, positively impacting the intervention and ensuring better results and clinical outcomes.…”

“…This fact justifies the proposal to develop a new instrument or improve existing ones. Santos et al 5 developed and applied an assessment instrument, which was called pre-transplant malnutrition risk, to 451 patients in a retrospective cohort study. In this study, nutritional risk was obtained through the assessment of the following variables: body mass index (BMI), serum albumin levels, total cholesterol, total lymphocyte count, time on dialysis (years) and time (years) with comorbidities (diabetes mellitus and others) during the period on dialysis.…”

“…However, there is a lack of reference standards and definition of cut-off points associated with clinical and nutritional risks; therefore, periodic monitoring is the best way to detect abnormalities in nutritional status, their outcomes and impacts 4 . Santos et al 5 have recently proposed the use of a new nutritional assessment instrument to be applied before kidney transplantation. This instrument has the advantages of being easy to use and being of low cost, because it is based on the use of anthropometric variables, usual clinical data and routine laboratory results with the aim of evaluating the nutritional clinical information in a single instrument.…”

“…This can be achieved by incorporating functionality measures, identifying patients with frailty and inflammatory markers 6 . Certainly, the incorporation of these new variables would make the instrument by Santos et al 5 more complex, but it would bring the probable benefit of increasing its precision. There would also be a need for its validation by other studies and comparison with more commonly used instruments.…”