2010-CE-24

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COMENTRIO EDITORIAL

Disfuno renal na sndrome

coronria aguda uma epidemia
para o sculo XXI? [91]
SUSANA MARTINS
UTIC-AC, Hospital de Santa Maria, Lisboa, Portugal

Rev Port Cardiol 2010; 29 (09): 1355-1362

Renal dysfunction in acute coronary

syndrome - an epidemic for the
21st century?
Palavras-chave:
Disfuno renal; Sndromes coronrias agudas;
Prognstico

Key words
Renal dysfunction; Acute coronary syndrome;
Prognosis

INTRODUO

INTRODUCTION

os ltimos anos, tem-se dado maior relevo associao deletria entre disfuno
renal e doena coronria, em particular na
presena de sndrome coronria aguda (SCA).
A disfuno renal na SCA no s um importante preditor de mau prognstico, como se
associa a aumento da morbilidade, incluindo o
acrscimo exponencial do risco hemorrgico.
A alta prevalncia de doena coronria na
doena renal deve-se no s inequvoca
associao com factores de risco clssicos, em
particular hipertenso arterial, dislipidmia,
diabetes mellitus e obesidade, mas tambm
disfuno endotelial, ao estado pro-inflamatrio, pro-trombtico e hiperhomocisteinmia. A presena de disfuno renal complica a abordagem diagnstica e a estratgia
teraputica dos doentes com SCA. Nos casos
de insuficincia renal grave os frmacos com
eliminao renal preferencial ou exclusiva
devem ser ajustados ou esto contra-indicados. Assim, os doentes com disfuno renal e
SCA tm pior prognstico, no s pela eleva-

ecent years have seen an increasing

emphasis on the harmful association
between renal dysfunction and coronary disease, particularly in the setting of acute coronary syndrome (ACS). Renal dysfunction in
ACS is a strong predictor of poor outcome and
is also associated with increased morbidity,
including an exponential rise in bleeding risk.
The high prevalence of coronary disease in
patients with renal dysfunction is related not
only to its well-known association with traditional risk factors such as hypertension, dyslipidemia, diabetes and obesity, but also to
endothelial dysfunction, proinflammatory and
prothrombotic states, and hyperhomocysteinemia. The presence of renal dysfunction complicates diagnosis and management of ACS
patients: in cases of severe renal failure, drugs
that are preferentially or exclusively eliminated by the kidneys must be adjusted or may be
contraindicated, and so the poor prognosis of
patients with ACS and renal dysfunction is
due not only to their high prevalence of risk

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da prevalncia de factores de risco, como tambm pela subutilizao das teraputicas cardioprotectoras, maior toxicidade dos frmacos
e anomalias da biologia vascular.
Em doentes com enfarte do miocrdio, a
doena renal crnica ainda que ligeira associa-se ao aumento do risco de morte. De facto,
o prognstico piora de forma progressiva com
o declnio da funo renal at a um acrscimo
at cerca de quinze vezes superior da
mortalidade em doentes com insuficincia
renal terminal comparando com indivduos
com funo renal conservada (1-7).
Todavia, na maioria dos estudos efectuados
no contexto de avaliao do impacto da
doena renal aps SCA existe a limitao de
no ser possvel diferenciar a doena renal
crnica agudizada da insuficincia renal
aguda, podendo sobrestimar o impacto da
patologia renal prvia no prognstico. Nos
doentes com SCA, o desenvolvimento de
disfuno renal ocorre com maior frequncia
exactamente num subgrupo de maior risco,
como acontece nos idosos, na presena de
maior compromisso da funo sistlica
ventricular esquerda, evoluo em classes de
Killip-Kimbal mais elevadas, localizao na
parede anterior ou anemia (8,9). De qualquer
modo, tanto a insuficincia renal aguda como
a doena renal crnica se correlacionam
fortemente, na presena de SCA, com eventos
adversos em particular com a mortalidade.
Uma vez que a mortalidade e a probabilidade de eventos adversos aps SCA na
presena de disfuno renal so elevadas, o
diagnstico precoce, a estratificao de risco e a
adopo de estratgias teraputicas adaptadas e
em tempo til reveste-se da maior importncia.
A prevalncia da disfuno renal, em particular de uma clearence da creatinina (ClCr)
<60 ml/min, varivel em doentes com SCA
de acordo com os estudos. Na presena de
enfarte agudo do miocrdio com supradesnivelamento do segmento ST foi reportada
uma prevalncia de disfuno renal de 23%
em ensaios clnicos. No contexto de SCA sem
supra-desnivelamento do segmento ST a
prevalncia encontrada variou entre 16% em
ensaios clnicos e 36% nos registos GRACE

factors, but also to underuse of cardioprotective therapies, the toxicity of certain drugs,
and abnormalities of vascular biology.
In patients with myocardial infarction,
chronic renal disease, even when mild, is
associated with increased risk of death; prognosis worsens progressively in parallel with
deterioration in renal function, and mortality
in patients with end-stage renal failure is up to
15 times that of those with preserved renal
function (1-7).
However, most studies assessing the
impact of renal disease after ACS are limited
by their failure to differentiate between exacerbation of chronic renal disease and acute
renal failure, and may overestimate the effect
of prior renal pathology on prognosis. In ACS
patients, renal dysfunction is more likely to
develop in higher-risk groups such as the elderly and those with more severe left ventricular systolic dysfunction, higher Killip class,
anterior wall infarction or anemia(8, 9). Both
acute renal failure and chronic renal disease
are strongly correlated in ACS with adverse
events, particularly death.
Since mortality and the risk for adverse
events after ACS are so high in the presence of
renal dysfunction, prompt diagnosis, risk
stratification and adoption of appropriate therapeutic strategies are essential.
The prevalence of renal dysfunction in
ACS patients, as measured by creatinine
clearance (CrCl) of <60 ml/min, varies
according to the study. In patients with STsegment elevation myocardial infarction, a
prevalence of renal dysfunction of 23% has
been reported in clinical trials. In non-ST-segment elevation ACS the prevalence ranged
between 16% in clinical trials and 36% and
44% in the GRACE and CRUSADE registries, respectively (10-12). These figures reflect
the restrictive selection criteria in randomized
clinical trials, as well as the use of serum creatinine rather than CrCl or glomerular filtration rate (GFR) to determine renal function.
Even in unselected populations included in
registries, the reported prevalences may
underestimate the level of renal dysfunction,
since some patients have impaired renal func-

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Susana Martins
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ou 44% no CRUSADE (10-12). Estes valores

reflectem os critrios restritivos de seleco
dos doentes em ensaios clnicos aleatorizados
e a determinao da funo renal em funo
do nvel de creatinina srica e no da ClCr ou
taxa de filtrao glomerular. Mesmo nas
populaes no seleccionadas includas nos
registos, os valores de prevalncia encontrados podem subestimar a presena da disfuno renal, uma vez que alguns doentes
apresentam compromisso da funo renal
apesar de valores de taxa de filtrao
glomerular normal, em particular na presena
de baixo ndice de massa corporal, idade
avanada ou no sexo feminino.
Recentemente, foram publicados resultados do registo americano ACTION (Acute
Coronary Treatment and Intervention Outcomes Network registry) que envolveu 49491
doentes com SCA (15). A taxa de filtrao
glomerular foi estimada de acordo com
equao da Modification of Diet in Renal
Disease (MDRD) em relao com o uso da
teraputica imediata (< 24 horas) e precoce (<
48 horas), coronariografia, hemorragias major
e mortalidade hospitalar. No total, 30,5% e
42,9% dos doentes com SCA com e sem
supradesnivelamento ST, respectivamente,
apresentavam disfuno renal. Independentemente do tipo de SCA, verificou-se que
os doentes com doena renal progressivamente mais grave tiveram maiores taxas de
mortalidade. As taxas ajustadas para eventos
adversos foram marcadamente superiores nos
doentes com pior funo renal, com odds ratio
para morte quarto a oito vezes superior no
estdio 5 da doena renal crnica, comparativamente com doentes sem disfuno renal (15).
Por outro lado, os pacientes com disfuno
renal mais grave foram menos medicados com
teraputicas recomendadas incluindo aspirina, clopidogrel, bloqueadores beta, estratgias
de reperfuso ou revascularizao e tiveram
maiores taxas de hemorragia (15). Os dados
deste registo contemporneo reforam outros
estudos prvios, demonstrando-se que a
presena de disfuno renal se associa a
subtratamento e maiores taxas de mortalidade
nas SCA (15).

tion despite having normal GFR, particularly

those with a low body mass index, the elderly,
and women.
In the recently published Acute Coronary
Treatment and Intervention Outcomes Network
(ACTION) registry (15), involving 49,491 ACS
patients, GFR was calculated by the
Modification of Diet in Renal Disease
(MDRD) equation in relation to use of immediate (first 24 hours) therapies and early (first
48 hours) coronary angiography, major bleeding events and in-hospital mortality. The
prevalence of renal dysfunction in patients
with and without ST-segment elevation was
30.5% and 42.9%, respectively. Patients with
more severe kidney disease had higher rates
of death, regardless of type of ACS. Adjusted
rates of adverse outcomes were markedly
higher among patients with worse renal function, with odds ratios for death being 4 to 8
times higher among those with stage 5 chronic kidney disease than among those without
renal dysfunction (15).
In addition, patients with more severe
renal dysfunction were less likely to receive
recommended therapies including aspirin,
clopidogrel or beta-blockers, were less likely
to undergo reperfusion or revascularization,
and had higher rates of bleeding (15). The data
from this up-to-date registry corroborate those
of other studies showing renal dysfunction is
associated with undertreatment and higher
mortality rates (15).
The appropriate use of established therapies for ACS in patients with renal failure is
essential to improve their prognosis. The latest European Society of Cardiology (ESC)
guidelines for the diagnosis and treatment of
non-ST-segment elevation acute coronary syndromes stress the importance of routine calculation of CrCl and/or GFR in all patients (13).
Drug therapy must be carefully evaluated in
patients with renal dysfunction, particularly
certain anticoagulants, which may need to be
adjusted or might be contraindicated (13). Since
40% of enoxaparin, for example, is eliminated
by the kidneys, dosage should be adjusted
according to CrCl. The OASIS-5 study showed
a lower risk of bleeding complications with

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O uso apropriado das teraputicas estabelecidas nas SCA nos doentes com insuficincia renal essencial para a melhoria do
prognstico. As recomendaes mais recentes
da Sociedade Europeia de Cardiologia relativamente aos SCA sem supra-desnivelamento
do segmento ST destacam a importncia da
avaliao por rotina da ClCr ou taxa de
filtrao glomerular em todos os doentes (13).
Em doentes com disfuno renal recomendada uma avaliao cuidadosa da teraputica
farmacolgica, em particular o ajuste da dose
de algumas teraputicas anti-coagulantes ou
mesmo a sua no utilizao (13). Uma vez que
a enoxaparina tem cerca de 40% de
eliminao renal, a dose deve ser ajustada em
funo da ClCr. O estudo OASIS-5 revelou
menor taxa de complicaes hemorrgicas
com o fondaparinux comparativamente com a
enoxaparina, mesmo em doentes com disfuno renal (13). A heparina no fraccionada
deve ser utilizada preferencialmente nos
doentes com ClCr <30 ml/min, em doses
ajustadas ao valor alvo de APTT (50 a 70 s).
No que diz respeito utilizao dos
antagonistas das glicoproteinas IIb/IIIa, em
particular o eptifibatide e tirofibam,
recomendado o ajusto das doses para valores
de ClCr < 50 e 30 ml/min, respectivamente,
ainda que a presena de disfuno renal se
associe a maior risco hemorrgico.
Nos doentes com SCA a utilizao de doses
excessivas teraputicas anti-trombticas demonstrou ser um importante preditor de morbilidade, em particular de eventos hemorrgicos e mortalidade, como foi reportado no
registo CRUSADE (14).
Os doentes com patologia renal crnica
tm mais doena cardiovascular prvia
conhecida e maior gravidade da doena
aterosclertica na apresentao por SCA, o
que em parte poder contribuir para o pior
prognstico. No registo ACTION comprovouse que com o agravamento da disfuno renal,
os doentes tinham maior probabilidade de ter
hipertenso arterial, Diabetes Mellitus, histria
prvia de SCA, insuficincia cardaca congestiva e acidente vascular cerebral. Por outro
lado, na presena de doena renal crnica,

fondaparinux compared to enoxaparin, even in

patients with renal failure (13). Unfractionated
heparin should be used in patients with CrCl
of <30 ml/min in doses adjusted to target
aPTT (50-70 s). For glycoprotein IIb/IIIa
inhibitors, particularly eptifibatide and
tirofiban, dose adjustment is recommended for
CrCl <50 and <30 ml/min, respectively, even
though the presence of renal dysfunction
increases bleeding risk.
Excess dosing of antithrombotic agents in
ACS patients has been shown to be a strong
predictor of morbidity, particularly bleeding
events, and mortality, as reported in the CRUSADE registry (14).
Patients with chronic renal disease have
higher rates of pre-existing cardiovascular
disease and more severe cardiovascular disease on presentation with ACS, which may
contribute to their poorer outcomes (15). In the
ACTION registry, with progressively more
severe renal dysfunction, patients were more
likely to have hypertension, diabetes, prior
ACS, congestive heart failure, and stroke.
Additionally, patients with chronic renal disease were less likely to be current smokers
and had lower body mass index, possibly
reflecting more general body wasting (15).
The findings from the ACTION registry, as
well as from other registries, indicate underutilization of known cardioprotective therapies and more frequent errors in dosing in this
group, which may further contribute to their
poor outcomes (15). Renal patients are as a rule
less often included in randomized clinical trials, and consequently there have been few
studies on therapies in the context of chronic
kidney disease and dialysis. The higher rate of
complications in individuals with chronic kidney disease, particularly bleeding related to
antiplatelet and antithrombotic drugs, may
limit the efficacy of established treatment.
Data from the ACTION registry confirm the
high rate of bleeding from stage 3 renal disease onward, which may be related to intrinsic
platelet dysfunction as well as excessive dosing (15).
The ESC guidelines recommend that
patients with non-ST segment elevation ACS

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constatou-se menor prevalncia de fumadores

activos e menores ndices de massa corporal,
podendo traduzir maior estado consumptivo(15).
Os dados reportados no registo ACTION,
tal como noutros prvios, indicam a subutilizao das teraputicas cardioprotectoras
conhecidas, erros mais frequentes nas dosagens, o que tambm poder influenciar o
prognstico adverso (15). Os doentes nefrolgicos so, por norma, os menos includos nos
ensaios clnicos aleatorizados pelo que
poucas teraputicas foram estudadas na
presena de doena renal crnica e na
dilise. A maior taxa de complicaes nos
indivduos com doena renal crnica,
particularmente o ex-cesso de hemorragias
relacionados com a medicao anti-plaquetria e anti-trombtica, pode limitar a eficcia
das intervenes estabelecidas. Os dados do
registo ACTION confirmam o excesso de
hemorragia, sobretudo a partir do estdio 3
da doena renal crnica, atribuvel disfuno plaquetria intrnseca e excesso de dosagem(15).
As recomendaes sugerem que os doentes
com SCA sem supradesnivelamento segmento
ST e ClCr <60 ml/min devem ser submetidos
a avaliao invasiva e revascularizao logo
que possvel, uma vez que o riscos de eventos
isqumicos futuros elevado (13). Outro aspecto
crucial, prende-se com a utilizao das
medidas apropriadas para evitar ou minimizar
a nefropatia induzida por contraste (NIC) com
a hidratao adequada, utilizao de NAcetilcistena, limitao da quantidade de
contraste utilizado (dose mxima de contraste
estimada em 5 ml x peso em kg a dividir pela
creatinina srica em mg/dl) e a preferncia
para os compostos iso-osmolares no momento
da coronariografia.
Mas de facto, existe menor recurso a procedimentos invasivos na presena de disfuno
renal. No registo ACTION verificou-se menor
recurso a cateterismo cardaco, interveno
coronria percutnea ou cirurgia de revascularizao miocrdica nos estadios 4 e 5 da doena renal crnica, sobretudo na ausncia de supradesnivelamento segmento ST (15).
O recurso teraputica com anti-agregan-

and CrCl of <60 ml/min should undergo invasive evaluation and revascularization whenever possible, since the risk of further ischemic
events is high (13). Another important point is
the need for measures to avoid or minimize
contrast-induced nephropathy, including adequate hydration, administration of N-acetylcysteine, reducing the quantity of contrast
(maximum dose calculated as 5 ml x weight in
kg divided by serum creatinine in mg/dl), and
the use of iso-osmolar compounds during
coronary angiography.
However, invasive procedures are less
likely to be used in the presence of renal dysfunction. In the ACTION registry, cardiac
catheterization, percutaneous coronary intervention, and coronary artery bypass grafting
were less used in stage 4 and 5 chronic kidney
disease, particularly in non-ST-segment elevation ACS (15).
Use of antiplatelets, beta-blockers, ACE
inhibitors and statins is lower among ACS patients with renal dysfunction, as are non-pharmacological measures such as dietary and
exercise counseling, and referral to cardiac
rehabilitation.
Against this background, the article by
Loureno et al. in this issue of the Journal is
of considerable current interest, dealing as it
does with important issues and raising relevant questions.
The aim of the study was to evaluate
patients hospitalized for ACS who also presented renal dysfunction, identifying baseline
clinical characteristics, treatment options and
prognosis. It also assessed the impact of renal
dysfunction as an independent predictor of
mortality and major adverse cardiovascular
events (MACE). This observational, longitudinal, prospective and continuous study included 1039 consecutive patients admitted for
ACS to a single center and compared two
groups according to estimated glomerular filtration rate (eGFR): 60 ml/min (group A) and
<60 ml/min (group B), over a mean follow-up
of 12 months. Group B patients were older and
more frequently female, and presented a higher prevalence of cardiovascular risk factors
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tes plaquetrios, beta-bloqueadores, inibidores da enzima de converso da angiotensina

e estatinas menor no contexto de SCA na
disfuno renal (15), tal como o aconselhamento
sobre medidas no farmacolgicas, dieta,
exerccio e reabilitao cardaca.
Neste contexto, o artigo presente de C.
Loureno e colaboradores trata de um tema de
grande impacto e actualidade, descrevendo
aspectos muito relevantes e levantando questes com inequvoco interesse.
O objectivo do estudo foi analisar a populao de doentes hospitalizados num nico
centro por SCA que apresentava disfuno
renal, identificando as caractersticas clnicas
basais, o seu tratamento e prognstico. Foi
tambm analisado o impacto da disfuno
renal como preditor de mortalidade e de
eventos cardiovasculares. Trata-se de um
estudo observacional, longitudinal, prospectivo e contnuo, que incluiu 1039 doentes
consecutivamente admitidos num nico
centro por SCA. Foram comparados dois
grupos de acordo com os valores da taxa de
filtrao glomerular estimada (TFGe): TFGe
>60 ml/min (Grupo A) e TFGe <60 ml/min
(Grupo B), seguidos durante cerca de 12
meses. Os doentes do grupo B eram mais
idosos e mais frequentemente do sexo
feminino, apresentaram maior prevalncia de
factores de risco e de antecedentes de doena
cardiovascular, bem como doena coronria
mais severa. A apresentao clnica mais
frequente foi SCA sem supradesnivelamento
de ST, a glicemia e a frequncia cardaca eram
mais elevadas na admisso e a fraco de
ejeco do ventrculo esquerdo (FEVE)
inferior. No seguimento clnico verificou-se
que as taxas de sobrevida e sobrevida livre de
eventos cardiovasculares major foram significativamente inferiores neste grupo. A anlise multivariada revelou que uma TFGe <30
ml/min foi preditora independente de mortalidade intra-hospitalar e que uma TFGe <60
ml/min foi preditora independente de eventos
cardacos major no seguimento clnico.
O artigo apresenta como principal limitao, mas incontornvel, o facto de se referir
populao de doentes admitidos num nico

more severe coronary artery disease. Their

clinical presentation was more often non-STsegment elevation ACS, and they more often
had higher blood glucose and heart rate on
admission, and lower left ventricular ejection
fraction. During clinical follow-up, survival
and MACE-free rates were significantly lower
in this group. Multivariate analysis showed
that eGFR of <30 ml/min was an independent
predictor of in-hospital mortality, and that
eGFR of <60 ml/min was an independent predictor of MACE during follow-up.
The studys main limitation, inevitably, was
that it examined patients admitted to a single
center. Furthermore, as the authors acknowledge, there are no data on the duration of renal
dysfunction (and hence the percentage of
patients with chronic kidney disease cannot
be estimated), nor on the use of dialysis,
which should be borne in mind when considering the conclusions of the study.
The article provides data that are crucial to
understanding the increased risk of patients
with renal dysfunction and ACS and prompts
reflection on current practices. More than a
third (35%) of the study population had eGFR
<60 ml/min as calculated by the Modification
of Diet in Renal Disease equation. Patients
with renal dysfunction were less frequently
treated with an invasive strategy; when coronary angiography was performed, they were
less often revascularized, and when they were,
they were less likely to undergo complete
revascularization or implantation of drug-eluting stents.
The authors stress the need to identify
patients with renal dysfunction on admission
for ACS, to estimate GFR, even in patients
with normal or only slightly elevated serum
creatinine, and to recognize renal dysfunction
as a marker of particularly poor outcome. The
study showed that moderate to severe dysfunction in ACS patients was an independent predictor of mortality and adverse events.
However, it also showed that these patients
are undertreated, which may contribute to
their poor prognosis. Early identification of
these high-risk patients is important so that
the procedures recommended in the interna-

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centro. Tal como os autores reconhecem no

h informao relativa durao da disfuno
renal, no sendo por isso possvel estimar a
percentagem de doentes que apresentavam
efectivamente doena renal crnica, nem
sobre utilizao de eventuais tcnicas
dialticas, pelo que as concluses devem ter
em linha de conta estas particularidades da
anlise.
O Artigo de C. Loureno e colaboradores
revela-nos dados cruciais para a compreenso
do aumento do risco nos doentes com
disfuno renal e SCA, possibilitando uma
reflexo mais precisa da nossa realidade. Mais
de um tero dos doentes analisados (35%)
tinham valores da taxa de filtrao glomerular
estimada < 60 ml/min, de acordo com clculo
atravs da equao de Modificao da Dieta
na Doena Renal. Os doentes com disfuno
renal foram mais raramente submetidos a uma
estratgia invasiva precoce, nas situaes em
que foi realizada angiografia coronria, foram
menos frequentemente revascularizados e
quando tal aconteceu, as taxas de revascularizao completa e de uso de stents farmacolgicos foram inferiores. O presente estudo
enfatiza a necessidade de identificar, na
admisso por SCA, a presena de disfuno
renal, a necessidade de estimar a taxa de
filtrao glomerular, mesmo em doentes com
creatinina srica normal ou apenas discretamente elevada e de a encarar como um marcador de prognstico particularmente adverso.
Neste estudo, a disfuno renal moderada a
severa em doentes com SCA foi preditora
independente de mortalidade e de eventos
adversos. Contudo, verificou-se que estes
doentes so sub-tratados, o que poder em
parte explicar o seu mau prognstico.
importante a identificao precoce destes
doentes de alto risco, de forma a poder tratlos recorrendo mais frequentemente aos
procedimentos aconselhados nas recomendaes internacionais.
So ainda necessrios mais ensaios clnicos aleatorizados para testar as teraputicas
estabelecidas ou novos frmacos para as SCA
em doentes com disfuno renal. No passado,
os doentes diabticos e do sexo feminino eram

tional guidelines can be more consistently

implemented.
More randomized clinical trials are
required to test established therapies as well
as new drugs for ACS in patients with renal
dysfunction. In the past, for a variety of reasons, diabetic patients and women were often
excluded from randomized studies, but it has
since been shown that they benefit as much
or even more from the therapies under
analysis. The same may occur in the future for
patients with renal dysfunction, as the era of
therapeutic nihilism gives way to evidencebased diagnosis and management that could
reduce the risk in this population.
The incidence of renal dysfunction is likely to rise steadily over the course of this century, due to its association with diabetes,
hypertension and dyslipidemia, which makes
the development of aggressive and effective
primary prevention measures even more
urgent.
The challenge is considerable: on one hand
to reduce the incidence of renal dysfunction
through education and prevention, and on the
other to ensure that patients with renal dysfunction and ACS are stratified promptly and
treated appropriately, while developing new
therapies that can improve their dismal prognosis.
The article by Loureno et al. has investigated the problem and helped to define its
extent; the solution now depends on us all.

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muitas vezes excludos dos estudos aleatorizados, por diversas razes, mas a histria
veio a provar que beneficiavam tanto ou mais
com as teraputicas testadas. Porventura, no
futuro poder-se- afirmar o mesmo relativamente aos doentes com disfuno renal. A
era do niilismo teraputico poder dar lugar
a estratgias de diagnstico e a abordagens
teraputicas bem fundamentadas que podero
reduzir o risco desta populao.
A incidncia da disfuno renal ir
provavelmente aumentar de forma paulatina ao
longo deste sculo, em particular devido sua
associao com a diabetes, hipertenso arterial e
dislipidmia pelo que medidas agressivas e
eficazes de preveno primria so urgentes.
O desafio enorme, por um lado reduzir a
incidncia da disfuno renal atravs da edu-

cao e preveno, por outro estratificar precocemente, providenciar tratamentos mais adequados nos doentes com disfuno renal e SCA
e porventura desenvolver novas teraputicas
que possam minimizar o mau prognstico.
O artigo de Carolina Loureno e colaboradores abordou e ajudou a definir a extenso do
problema, parte da soluo depender de todos ns.
Pedido de Separatas:
Address for Reprints:
Susana Martins
UTIC - Arsnio Cordeiro
Hospital de Santa Maria, Piso 6
1600-028 Lisboa
e-mail: la63@sapo.pt

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