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Função renal após nefrectomia

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Função renal após nefrectomia

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Função renal após nefrectomia

  1. 1. Função Renal ApósNefrectomiaParcialvs Radical<br />Lucas Nogueira<br />Coordenador - Grupo de Uroncologia<br />Hospital das Clínicas - UFMG<br />
  2. 2. Epidemiologia<br />Cerca de 3% das neoplasiasmalignas (EUA)<br />Estimativa2010:<br />57.760 novoscasos<br />12.980 óbitos<br />Aumentodaincidênciaedamortalidade (1971)<br />Incidência – 5 x<br />Mortalidade – 2 x<br /> 7.1 / 105 em 1980 10.9 / 105 em 2002<br />Jemal A, Siegel R, Ward E, Hao Y, Xu J, Murray T, Thun MJ. Cancer statistics, 2009.<br /> CA Cancer J Clin2009:59:225-49<br />
  3. 3. Detecção IncidentalMSKCC = 70% (2009)<br />
  4. 4. Renal Cortical TumorsMedian Tumor Size (3.3 cm in 2009)MSKCC<br />
  5. 5. “Tumores Renais Pequenos”“Small Renal Mass - SRM”<br />Incidência das lesões entre 3 e 4 cm cresceu de 1 para 3.3/105<br /><ul><li>Benignos – 20%
  6. 6. AML
  7. 7. Oncocitoma
  8. 8. Adenoma metanéfrico
  9. 9. CistoHemorrágico
  10. 10. Alguns tumores com histologia favorável e comportamento indolente</li></li></ul><li>Tendência à Preservação Renal<br />Sucesso no câncer de mama e sarcoma de partes moles<br />Diagnósticosemestágiosmaisprecoces<br />Tumoresbenignos<br />Agressividade<br />Doençametastática<br />Avanços no conhecimento molecular / histológicodaneoplasia.<br />Eficáciaoncológica – T1a/b<br />Evidência dos efeitosdeletériosda IRC<br />Função renal empacientesportadores de ca renal<br />Efeitos do tratamentocirúrgiconafunção renal<br />
  11. 11. F.P, 74 anos, fem<br />Epigastralgialeve, HAS emuso de enalapril<br />Creatinina 1,3 <br />Tabagista<br />Exameimagememcontrole habitual.<br />
  12. 12. 6,9 x 5,4 cm – T1b<br />
  13. 13.
  14. 14.
  15. 15. Função Renal / Câncer<br />Conceitoquepacientessubmetidos a NRad, apesar do aumento de escóriasnãoestariamemrisco de efeitos a longoprazopelopapelcompensador do rim contralateral. <br />Dados referentes a doadoresrenais – doadoresnãoapresentavamriscoaumentado de IRC requerendodiáliseouóbito.<br />Najaraian JS et al.<br />Lancet, 1992<br />
  16. 16. Função Renal / Câncer<br />Doadoresrenaisrepresentam a populaçãoportadora de Ca Renal ?<br />Selecionados<br />“Screening” para co-morbidades<br />Idade < 40 anos<br />Najaraian JS et al.<br />Lancet, 1992<br />
  17. 17. “Evaluation of Nonneoplasic Pathology in Tumor Nephrectomy Specimens”<br />Análise do tecidonãoafetadoporneoplasiaem 110 pacientessubmetidos a nefrectomiaparatratamento de Ca Renal. <br />Apenas 10% apresentavamausência de alteraçõeshistológicas<br />Demais:<br />Nefropatiadiabética<br />Esclerose vascular<br />Alteracõesmesenquimais<br />Hipertrofiaglomerular<br />Glomeruloesclerosedifusa<br />Bijol V et al.<br />Am J Patho, 2006<br />
  18. 18. MSKCC1989-2005Lancet Oncol 2006; 7: 735–40. 2006.<br />662 pacientes, Cr (<1.4 mg/dl) e rim contra-lateral normais, submetidos a NP(409)ouNrad (290)paratumoresmenoresque 4 cm.<br />PreOp RFG <br /><ul><li>> 60 ml/min 1.73 m2 - (74%)
  19. 19. > 45 ml/min 1.73 m2 - (98%).</li></li></ul><li>Chronic Kidney DiseaseLevey et al Ann. Int. Med. 139:137-147, 2003.<br />Estabelecidaclassificação com 5 graus de função renal.<br />RFG estimado – “abbreviated MDRD study equation”:<br />eGFR(mL/min per 1.73 m2) = 186 x (Scr)-1.154 x (age)-0.203 x (0.742 if female) x (1.210 if African American)<br />www.nephron.com/MDRD_GFR.cgi<br />
  20. 20.
  21. 21. “Chronic kidney disease is an independent risk factor for serious cardiovascular comorbidites and death.<br />Go AS et al., N Engl J Med 2004<br />
  22. 22.
  23. 23. N Engl J Med 2004<br />
  24. 24.
  25. 25. “ImpactodaNefrectomianaFunção Renal”Mayo Clinic<br />Design:<br />328 pacientes<br />submetidos a nefrectomia radical (164) eparcial (164) com<br />rim contra-lateral normal, entre 1966 e1999 (70%realizadas<br />nadécada de 90).<br />Resultados: <br />Ausência de diferençanasobrevida global, recorrênciatumoralemetástases - 10anos.<br />Diferençasignificativanafunção renal (NP vs NR)<br />Creatinina> 2 mg/dL 11.6 % vs22.4 % <br />Proteinúria 34.5 % vs55.2 %<br />Lau WKO et al. Mayo Clin Proc 75:1236-1242, 2000<br />
  26. 26. Chronic Kidney Disease: NSS versus RNMayo Clinic Experience (N=328)<br />10 %<br />Lau WKO et al. Mayo Clin Proc 75:1236-1242, 2000<br />
  27. 27. “Impact on Renal Function: PN versus RN”MSKCC (N=290)<br />Tumores <= 4.0 cm<br /> NR (173)vs PN (117)<br />Comparação IRC em 10 anos (Creat> 2 mg/dl)<br />Controladoparafatores de risco: <br /> diabetes, HAS, ASA score,idade, creatininapré-op, história de tabagismo.<br />5,2 %<br /> Urology 59:816-820, 2002 <br />
  28. 28. MSKCC1989-2005Lancet Oncol 2006; 7: 735–40. 2006.<br />662 pacientes, Cr (<1.4 mg/dl) e rim contra-lateral normais, submetidos a NP(409)ouNrad (290)paratumoresmenoresque 4 cm.<br />PosOp:livre de RFG em 3 anos: <br />< 60 ml/min 1.73 m2 - (80 vs 35%)<br />< 45 ml/min 1.73 m2 - (93,5 vs 58,8%)<br />
  29. 29. 34,7 %<br />45 %<br />Lancet, 2006<br />
  30. 30.
  31. 31. Nrad 1,4 x NP<br />
  32. 32. Nrad 1,38 x NP<br />
  33. 33. 7 %<br />1009 pacientes<br />J Urol, 2010<br />
  34. 34. 7 %<br />J Urol, out 2010<br />
  35. 35.
  36. 36. 1228 pacientes<br />J Urol, 2011<br />
  37. 37.
  38. 38.
  39. 39. F.P, 74 anos, fem<br />Boa Evoluçãopósoperatória – alta 2 DPO<br />Carcinoma de CélulasRenaisConvencional<br />Fuhrman 3 – MargensNegativas<br />Função renal:<br />15 dias - 34 mL/min per 1.73 m2<br />60 dias - 37 mL/min per 1.73 m2<br />180 dias – 40 mL/min per 1.73 m2<br />
  40. 40. MSKCC<br />T1a<br />T1b<br />
  41. 41.
  42. 42.
  43. 43. “Primum non nocere” <br />“First, do no harm” <br />
  44. 44. OBRIGADO !!!<br />lucasnog@globo.com<br />

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