Injúria Renal Aguda após Tomografia Computadorizada: Uma metanálise (AYCOCK, 2017)

Injúria Renal Aguda após Tomografia Computadorizada: Uma metanálise (AYCOCK, 2017)

Um dos grandes dilemas do médico é a utilização do contraste para a realização de tomografia computadorizada em pacientes com lesões renais prévia. Portanto para abrir nosso blog trago o resumo da apresentação de nossa residente sobre o tema.

Hoje iremos discutir uma revisão sistemática.

PICOTS:

P= Idosos com lesão renal aguda prévia a infusão de contraste

I= Realização de Tomografia Computadorizada com contraste

C= Realização de Tomografia Computadorizada sem contraste

O= Necessidade de diálise; mortalidade; aumento do tempo de internação hospitalar; anafilaxia

T= Redução da acurácia do diagnóstico de patologias que exigem uso de contraste na TC

S= revisão sistemática com metanálise;

Pergunta Condutora

Em pacientes idosos portadores de lesão renal aguda prévia a infusão de contraste, qual o risco de piorar a função renal e evoluir com necessidade de diálise após a administração de contraste para realização de TC, comparando com o não uso de contraste?

Estratégia de Busca:

Medline/Pubmed

“Acute kidney injury”[Mesh] AND “Tomography”[Mesh] AND “Contrast“[Mesh] AND “Elderly”[Mesh]”
Resultado Medline: 174 estudos: 05 revisões sistemáticas e 23 ensaios clínicos (data: 11 outubro/2018)

Biblioteca Cochrane

“Acute kidney injury”[Mesh] AND “Tomography”[Mesh] AND “Contrast“[Mesh] AND “Elderly”[Mesh]”
Resultado: 526 ensaios clínicos; 0 revisões sistemáticas. (data: 13 outubro/2018)

Epistemonikos

“Acute kidney injury”[Mesh] AND “Tomography”[Mesh] AND “Contrast“[Mesh] AND “Elderly”[Mesh]”

Resultado: 3.782 estudos: 1.262 revisões sistemáticas e 2.220 ensaios clínicos (data: 13 outubro/2018)

 

Sumário da Evidência:

Os estudos utilizados na metanálise foram observacionais e, em sua maioria retrospectivos, os quais já apresentam vieses inerentes. Porém, devido à natureza antiética de se realizar um estudo controlado randomizado com o intuito apenas de avaliar os malefícios do uso do contraste intravenoso, somente estudos observacionais foram usados. Apesar disso, os estudos desta metanálise foram relativamente semelhantes em relação às características avaliadas, e apresentaram de baixo a moderado risco de vieses de acordo com a ferramenta aplicada para avaliação de estudos de coorte do CLARITY Groupe, um grupo formado por pesquisadores em Medicina Baseada em Evidências do McMaster University. Não houve conflito de interesse.

Uma das limitações que comprometeram, em parte, a qualidade da metanálise foi a ausência de dados sobre os pacientes, como idade, presença de comorbidades e função renal prévia.

Os desfechos avaliados foram a IRA, a mortalidade e a terapia de substituição renal, os quais são críticos e importantes, com magnitudes de 0,938, 0,998 e 0,825, respectivamente. Porém, observamos inconsistência moderada e imprecisão nos resultados, com intervalos de confiança que variavam significativamente, ora apresentando aumento do risco de desenvolvimento do desfecho, ora reduzindo esse risco. Concluímos então que não há associação dos desfechos analisados em relação ao uso ou não uso do contraste durante a realização de TC.

Aplicabilidade:

A tomografia computadorizada com contraste é um exame importante para o diagnóstico de várias condições clínicas e está cada vez mais disponível no sistema público de saúde, o que torna viável a intervenção. Entretanto, como as características dos pacientes dos estudos não são detalhadas com clareza, não se pode generalizar os achados e, deve-se, individualizar as escolhas de cada paciente, ponderando suas expectativas, perspectivas e desejos.

Conclusão Clínica:

Diante da avaliação desta Metanálise de estudos observacionais de Ryan Aycock et al como melhor evidência atual, publicada no Jornal do Colégio Americano de Médicos Emergencistas, em Agosto de 2017, observa-se que não há associação do risco de desenvolvimento de LRA, mortalidade e necessidade de Terapia de Substituição Renal em pacientes que realizaram TC com contraste em relação aos que realizaram TC sem contraste, com uma qualidade de moderada a boa. Porém, existe imprecisão nos estudos analisados, além das limitações desses tipos de estudos da revisão, com moderado risco de vieses. Além disso, o estudo não especifica as características dos pacientes e, portanto, não podemos generalizar os achados da metanálise espeficicamente para o nosso paciente.

Referências: Aycock R, et al. Acute Kidney Injury After Computed Tomography:

A Meta-analysis (Annals of Emergency Medicine). American College of Emergency Physicians 2017 Aug.

Avaliador:

Priscila Rodrigues de Paula

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