Abordagem terapêutica da

Litíase

Mauricio Carvalho

Nenhum financiamento ou

conflito de interesse

• Participação em estudos clínicos e/ou

experimentais subvencionados pela indústria;

• Ser palestrante em eventos patrocinados pela

indústria;

• Ser membro do conselho consultivo ou

diretivo da indústria;

• Participar de comitês normativos de estudos

científicos patrocinados pela indústria;

• Receber apoio institucional da indústria;

• Ter ações da indústria;

• Preparo de textos científicos em periódicos

patrocinados pela indústria

1) Tratamento da cólica renal no Pronto-Socorro;2) Tratamento e eliminação da pedra já formada;3) Tratamento da causa, para prevenir novos

cálculos.

HIPEROXALÚRIA

HIPERPARAT. 1o

HIPERCALCEMIA

(5%)

RENAL

ÓSSEA

INTESTINAL

NORMOCALCEMIA

(95%)

HIPERCALCIÚRIA HIPOCITRATÚRIA

Oxalato de cálcio

Tópicos

• Citrato

– Farmacológico

– Dietético

• Tiazídicos

• Hiperuricosuria x cálculos OxCa

• Nutrição na nefrolitíase

– Novos alvos e objetivos

Terapia com Citrato

Farmacológica

Dietética

Citrato

Estudo Paciente Eficácia Observações

1993

Barcelo

citrato

Cálcio N

+ K-Cit

1990

Butz

Não

selecionado

+ Follow-up

1ano/Na-K-

Cit

1994

Hofbauer

Não

selecionado

_ Sem poder /

Na-K-Cit

1997

Ettinger

Não

selecionado

+ RR 0,35 /

K-Mg-Cit

Barcelo P, Wuhl O, Servitge E, Rousaud A, Pak CYC:J Urol 1993; 150: 1761

Randomized double-blind study of potassium citrate in idiopathic

hypocitraturic calcium nephrolithiasis.

24

31

Adverse reactions to potassium citrate were mild. Only 2 patients in the KCit group and 1 in

the placebo group withdraw from the study.

Citrato

Intolerância gastrointestinal

• 60 mEq de Kcit por dia ↑ citrato urinário ~ 400

mg/dia e o ↑ pH em 0,7 unidadesPak CYC, and Resnick MI: Urol Clin North Am 27: 243–253, 2000

• Taxa de abandono de tratamento –

– 3 meses a 3 anos – 25%

• Potencial ulcerogênico. Complicações GI

– Epigastralgia

– Náuseas, vômitos ,diarréia

– Flatulência, obstipação

• Risco de hipercalemia

– Quando usado concomitante a espironolactona ou

amilorida

Tiazídicos

Tiazídicos diminuem a recorrência

FL Coe et al, Kidney Int, 1988

Randomized clinical trials of thiazide treatment in

hypercalciuric stone formers

Abridged

title

Unprocessed bran and

intermittent thiazide in

prevention of recurrent

stones16

Thiazide for calcium

urolithiasis in patients

with hypercalciuria17

Randomized

prospective study of

indapamide in preventing

calcium stone

recurrences18

The role of thiazides

in the prophylaxis of

recurrent calcium

lithiasis19

Year 1987 1992 1993 2006

Exposures Group A: n: 18; Bran (40 g/d).

Group B n: 14; Bran (40 g/d) +

thiazide (50 mg twice a day)

Group A: n: 93

No specific therapy; Group

B: 82: TrichlormeTZD

(4 mg/d)

Group A: n:25; diet and fluid.

Group B: n:25; diet and fluid +

INDA (2.5 mg/d). Group C: n:25;

diet and fluid + INDA (2.5 mg/d)

+ ALOP (300 mg/d)

Group A: n: 17; no specific

therapy; Group B: n: 21;

HCT (50 mg/d) Group C: n:

14; HCT (50 mg/d) +

potassium citrate (20 mL

Eq/d)

Outcomes Stone/year per patient;

stone-free patients (%)

mean urinary excretion of

lithogenic factors

Stone formation rate

(stones/patient/y)

Stone-free patients (%)

Reduction in stone

formation; Remission rate

Total number of newly

formed stones

Stone formation rate

(stones/patient/y);

stone-free patients (%);

reduction in calciuria and

oxaluria

Stone-free patients (%)

Conclusion Thiazide + bran superior.

3/11 (27%) stones compared

with the 11/17 (65%) in the

bran group.

Stones/patient/year

lower in the thiazide

group (0.13 versus

0.31), with statistically

significant difference.

Urinary calcium decreased

to 50% of the

pretreatment values;

stone rate improved more

in the two drugs Tx groups

Recurrence of 19% (4

cases) and 7% (1 case)

in groups B-C,

respectively compared

to 59% (10 cases) of

group A, p=0.003

MAP Pachaly, CP Baena e M Carvalho.

Therapy of nephrolithiasis: where is the evidence from clinical trials?

Thiazides

• Intestinal calcium absorption may ↓ during long-term

thiazide administration

• During the first few days of administration, there is

frequently a slight rise in total serum calcium

• 20 to 30% increase in UMg excretion which is evident

during the initial period of administration

• A marked ↑ of approximately 50% in zinc excretion

• A marked ↓ in UOx excretion occurred with the

administration of 50 mg of hydrochlorothiazide daily

• HCT dose employed is 50 mg, twice daily (↓ Uca 150

mg/day)

Diminuição da solubilidade do OxCa

pelo ácido úrico

(Salting-out)

Hiperuricosuria x cálculos OxCa

60 pts; Hiperuricosuria; Normocalciuria; Alopurinol 100mg X 3/dia

Borghi et al. N Engl J Med 2002; 346:77

Cálcio x Nefrolitíase

Nutrição na nefrolitíase

Novos alvos e objetivos

DASH Score and Stone Risk

0,2

0,4

0,6

0,8

1,0

Q1 Q2 Q3 Q4 Q5

HPFS

NHS I

NHS II

Re

lative

Ris

k

DASH Score

P trend <

0.001

17 21 24 27 31

J Am Soc Nephrol. 2009

Oct; 20(10): 2253–2259.