Академический Документы
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Культура Документы
São Paulo
2013
DEDICATÓRIA
Dedico esta tese a minha querida Mãe pelo carinho, educação e incentivo
incondicionais que me fizeram chegar até aqui.
Aos meus avós, Francisco e Clarice pelo amor e apoio moral que foram
essenciais à conquista dos meus objetivos.
Aos queridos Thallys, Thiego e Edvan, meus irmãos e amigos que sempre
estiveram comigo nos momentos mais difíceis.
AGRADECIMENTOS
Aos pacientes, que tornaram possível este estudo e que são o motivo desta
pesquisa.
Abreviatura dos títulos dos periódicos de acordo com List of Journals Indexed in Index
Medicus.
SUMÁRIO
1 INTRODUÇÃO..................................................................................................1
2 OBJETIVOS......................................................................................................4
3 MÉTODOS........................................................................................................6
3.1 Pacientes.......................................................................................................7
3.2 Desenho do Estudo.......................................................................................8
3.3 Definições de Síndrome Metabólica..............................................................9
3.4 Exames laboratoriais.....................................................................................9
3.5 Análise estatística........................................................................................11
4 RESULTADOS................................................................................................12
4.1 Dados Antropométricos, Características Clínicas e de Tratamento das
Condições Metabólicas em Pacientes e Controles............................................13
4.2 Prevalência de SM na AT............................................................................13
4.3 Testes Laboratoriais, Adipocinas e Citocinas em Pacientes e Controles....14
4.4 Características Gerais de Pacientes com e sem SM...................................14
4.5 Testes Laboratoriais, Adipocinas e Citocinas em Pacientes com e sem
SM......................................................................................................................15
4.6 Correlação entre Citocinas e Adipocinas com Dados Antropométricos e
Laboratoriais em Pacientes com e sem SM......................................................16
5 DISCUSSÃO...................................................................................................23
6 CONCLUSÕES...............................................................................................28
7 ANEXOS.........................................................................................................30
8 REFERÊNCIAS..............................................................................................66
LISTA DE ABREVIATURAS E SIGLAS
1 INTRODUÇÃO
2
que é maior que a soma dos fatores de risco associados com cada
componente individual1,2.
2 OBJETIVOS
5
com AT.
seguintes variáveis:
da AT;
3 MÉTODOS
7
3.1 Pacientes
2011.
em grupos: baixo peso (IMC < 18 kg/m 2), peso normal (IMC = 18-24,9
pressão arterial foi determinada pela média de duas medidas que foram
infecção15.
Dislipidemia foi definida como colesterol total > 200 mg/dL, colesterol
HDL < 40mg/dL, colesterol LDL > 130mg/dL, triglicérides > 150 mg/dL ou
Helsink (Anexo B)
seguintes critérios: NCEP/ATP III13, IDF12 e o novo critério proposto por IDF
e expressos em uU/mL.
elevados.
fórmula do modelo HOMA21. HOMA-IR maior que 3,4 foi considerado como
significantes.
12
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4 RESULTADOS
13
14,40 mmHg, p=0,001) e diastólica (75,90 ± 18,78 vs. 68,38 ± 11,17 mmHg,
(Tabela 2).
14
p=0,001).
controles.
àquelas sem esta comorbidade (66,66 vs. 26,26%, p=0,022). Além disso, o
aquelas sem esta complicação (44,66 vs. 16,66%; p=0,032) (Tabela 4).
sem SM
(Tabela 6).
17
IMC – Índice de massa corporal, CA- Circunferência abdominal, IAM – Infarto agudo do miocárdio, AVE –
Acidente vascular encefálico, PAS – Pressão arterial sistólica, PAD – Pressão arterial diastólica.
*N=31.
Dados expressos em média ± DP ou porcentagem.
18
Critérios IDF/AHA
0 2 (4,44) 19 (40,42)
1 14 (31,12) 13 (27,66)
2 12 (26,67) 9 (19,15)
3 10 (22,22) 4 (8,51)
4 6 (13,34) 1 (2,13)
5 1 (2,22) 1 (2,13)
IMC – Índice de massa corporal, PAS – Pressão arterial sistólica, PAD – Pressão arterial diastólica.
Dados expressos em média ± DP ou porcentagem.
21
TABELA 6 – Correlação entre citocinas, dados antropométricos e testes laboratoriais em pacientes com arterite de Takayasu (AT)
com e sem síndrome metabólica (SM) de acordo com os critérios IDF/AHA
IL12 IL1a IL6 TNFα
Pacientes com Pacientes com AT Pacientes com Pacientes com AT Pacientes com AT Pacientes com Pacientes com AT Pacientes com
AT com SM sem SM AT com SM sem SM com SM AT sem SM com SM AT sem SM
r p r p r p r p r p r p r p r p
Idade 0,01 0,982 0,07 0,702 -0,08 0,799 -0,14 0,477 0,14 0,660 -0,16 0,407 0,25 0,418 0,12 0,516
IMC 0,01 0,995 -0,14 0,487 0,03 0,920 -0,27 0,176 -0,49 0,104 -0,25 0,203 -0,43 0,160 -0,16 0,408
CA -0,29 0,355 -0,19 0,367 0,38 0,219 -0,06 0,747 -0,40 0,190 -0,29 0,146 -0,51 0,090 -0,03 0,883
PAS -0,01 0,993 0,32 0,186 -0,04 0,914 0,36 0,133 0,03 0,928 -0,09 0,716 0,15 0,713 0,47 0,040
PAD -0,54 0,160 0,06 0,796 -0,36 0,378 0,01 0,981 0,01 0,979 -0,13 0,586 0,07 0,865 0,01 0,985
CT -0,22 0,490 0,05 0,800 -0,01 0,963 -0,31 0,110 -0,12 0,697 -0,24 0,220 0,30 0,337 -0,05 0,771
HDL-c -0,24 0,445 0,05 0,771 -0,01 0,972 -0,01 0,939 -0,02 0,943 -0,06 0,738 0,26 0,399 -0,25 0,206
LDL-c -0,27 0,394 0,07 0,746 -0,03 0,935 -0,30 0,136 -0,22 0,498 -0,18 0,379 -0,43 0,159 0,09 0,678
Triglicérides 0,29 0,350 -0,15 0,451 -0,01 0,964 -0,16 0,426 0,14 0,656 -0,22 0,275 0,13 0,665 -0,14 0,490
Glicose -0,18 0,570 0,05 0,793 -0,21 0,500 -0,34 0,080 -0,23 0,461 -0,21 0,295 0,09 0,766 -0,14 0,468
Insulina 0,32 0,307 -0,13 0,498 0,47 0,116 -0,13 0,590 -0,12 0,710 0,01 0,948 -0,28 0,367 -0,26 0,186
HOMA-IR 0,22 0,488 -0,11 0,579 0,39 0,206 -0,15 0,439 -0,21 0,492 -0,02 0,897 -0,26 0,413 -0,21 0,283
Adiponectina 0,09 0,802 0,16 0,444 -0,16 0,636 0,07 0,742 -0,07 0,833 -0,05 0,794 0,37 0,266 -0,29 0,151
Resistina 0,12 0,728 0,04 0,845 -0,17 0,614 0,60 0,001 -0,10 0,771 0,09 0,646 0,49 0,126 -0,08 0,700
VHS -0,03 0,927 -0,18 0,386 -0,15 0,640 0,02 0,912 0,40 0,202 0,25 0,229 -0,02 0,956 0,02 0,939
PCR -0,22 0,501 -0,15 0,470 -0,11 0,733 0,00 0,997 0,57 0,050 0,04 0,845 0,08 0,803 0,13 0,551
IL-12 – Interleucina 12; IL1a – Interleucina IL1a; IL6 – Interleucina 6; TNFα – Tumor necrosis factor alfa; IMC – Índice de massa corporal, CA- Circunferência abdominal; PAS – Pressão
arterial sistólica; PAD – Pressão arterial diastólica; CT – Colesterol total; HDL-c – High density lipoprotein; LDL-c – Low density lipoprotein; HOMA-IR - Homeostatic model assessment of
Insulin resistance; VHS – Velocidade de hemossedimentação; PCR – Proteína C reativa.
Dados expressos como coeficientes de correlação (r) calculados usando o teste de correlação de Pearson.
23
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DISCUSSÃO
24
nível educacional (> 9 anos), pertencer a uma faixa etária mais jovem e
associadas (VAA), a prevalência de SM foi maior que nos pacientes com AT 32.
Desde que as pacientes com AT avaliados neste estudo eram mais jovens
pareados por IMC pode explicar a CA similar; em segundo lugar, quase metade
em vasculites32.
que tem sido associado com concentrações baixas de adiponectina, foi similar
Por outro lado, a resistina - uma adipocina induzida por várias citocinas
reumáticas como LES37 e AR, sendo que nesta última patologia esta citocina
26
níveis de adiponectina eram mais baixos no primeiro grupo. Este achado deve-
subgrupos.
com muitos estudos em outras doenças reumáticas, incluído LES 27,42,43, AR44,45
e VAA32. Além do mais, estes achados podem estar relacionados com baixas
observamos que a doença (AT) e seu tratamento não parecem ser um gatilho
principal desta síndrome em pacientes com AT, reforçado pelo achado de uma
subdiagnosticado na AT.
presença de SM. Todavia, foi encontrada correlação positiva entre PCR e IL-6
presença de SM.
6 CONCLUSÕES
29
tratamento;
7 ANEXOS
31
_______________________________________________________________________________________
1 – O objetivo deste estudo é avaliar nos pacientes com diagnóstico de arterite de Takayasu a ocorrência
de hipertensão (pressão alta), dislipidemia (problemas de colesterol), diabetes (alteração no açúcar do
sangue), obesidade
33
2 – Será aplicado questionário contendo idade, tempo de estudo, profissão, salário, presença no paciente
e na sua família de hipertensão (pressão alta), dislipidemia (problemas de colesterol), diabetes (alteração
no açúcar do sangue), obesidade, uso de remédios, fumo, bebida, atividade física. Serão realizadas
medidas de pressão, cintura, quadril, altura e peso
4 – Existem mínimos riscos para o participante do estudo como sangramentos e hematomas no local da
coleta.
5 – A partir dos resultados desta pesquisa poderemos conhecer quais as chances dos pacientes com
arterite de Takayasu de ter problemas do coração e morrer.
6 – Em qualquer etapa do estudo, você terá acesso aos profissionais responsáveis pela pesquisa para
esclarecimento de eventuais dúvidas. O principal investigador é o Dr Thiago Ferreira da Silva. que pode
ser encontrado no endereço Av. Dr. Enéas de Carvalho Aguiar, 255 - Cerqueira César - CEP: 05403-
000, São Paulo-SP Telefone(s) 11-3069-6000. Se você tiver alguma consideração ou dúvida sobre a
ética da pesquisa, entre em contato com o Comitê de Ética em Pesquisa (CEP) – Rua Ovídio Pires de
Campos, 225 – 5º andar – tel: 3069-6442 ramais 16, 17, 18 ou 20, FAX: 3069-6442 ramal 26 – E-mail:
cappesq@hcnet.usp.br
7 – Você pode suspender a autorização a qualquer momento e deixar de participar do estudo, sem
qualquer prejuízo à continuidade de seu tratamento na Instituição;
8 –As informações obtidas serão analisadas em conjunto com outros pacientes, não sendo divulgado a
identificação de nenhum paciente;
12 - Compromisso do pesquisador de utilizar os dados e o material coletado somente para esta pesquisa.
Acredito ter sido suficientemente informado a respeito das informações que li ou que foram lidas para
mim, descrevendo o estudo Prevalância de síndrome metabólica em pacientes com arterite de Takayasu
Eu discuti com o Dr. Thiago Ferreira da Silva sobre a minha decisão em participar nesse estudo.
Ficaram claros para mim quais são os propósitos do estudo, os procedimentos a serem realizados, seus
desconfortos e riscos, as garantias de confidencialidade e de esclarecimentos permanentes. Ficou claro
também que minha participação é isenta de despesas e que tenho garantia do acesso a tratamento
hospitalar quando necessário. Concordo voluntariamente em participar deste estudo e poderei retirar o
meu consentimento a qualquer momento, antes ou durante o mesmo, sem penalidades ou prejuízo ou
perda de qualquer benefício que eu possa ter adquirido, ou no meu atendimento neste Serviço.
34
-------------------------------------------------
-------------------------------------------------------------------------
Declaro que obtive de forma apropriada e voluntária o Consentimento Livre e Esclarecido deste paciente
ou representante legal para a participação neste estudo.
-------------------------------------------------------------------------
De: manuscripts@jrheum.com
Data: 22 de julho de 2013 16:27:16 BRT
Para: rosamariarp@yahoo.com
Assunto: The Journal of Rheumatology - Decision on Manuscript ID 2013-0162.R1
22-Jul-2013
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36
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Original article
Pereira
Brazil.
ABSTRACT
death in these conditions. The aim of this study is to determine the prevalence
of MetS in Takayasu Arteritis patients (TA) and its association with risk factors
PAI-1 (p>0.05). Further analysis of TA patients with and without MetS revealed
regarding disease duration, activity, glucocorticoid use, resistin and PAI-1 levels
in these two groups of TA patients (p>0.05). Patients with and without MetS
showed no differences respect to cytokines levels (IL-12, IL-1a, IL-6 and TNFα).
IL-6 had a positive Pearson correlation with CRP only in TA patients with MetS
disease status. Further longitudinal studies are necessary to observe the impact
of controlling this modifiable risk factor in the quality of life and survival of TA
patients.
INTRODUCTION
that imply an additional cardiovascular morbidity that is greater than the sum of
ranges from 14 to 62.8%, and coronary heart disease is the leading cause of
vasculitis, although the causal factors have not yet been fully elucidated 5,6. In
the carotid artery were about ten times more often than age-matched, sex-
matched controls6.
Adipose tissue seems to have an important role in this process with the
etiology, predominantly affecting the aorta and its major branches and
levels of HDL cholesterol associated with disease activity10, but there are no
METHODS
Sao Paulo, Brazil from August 2009 to July 2011. Exclusion criteria were:
of the Hospital with similar age, weight and educational level were selected as
exclusion criteria for healthy controls. Data were obtained by retrospective chart
review (until December 1999) and from an ongoing electronic database protocol
established in January 2000, that was carried out for all patients at 1- to 6-
anthropometric data (weight, height, body mass index and waist circumference),
obesity among ethnic South and Central Americans12. Body mass index (BMI)
was calculated based on the formula: weight/height 2 (kg/m2) and patients were
classified in groups: underweight (BMI < 18 kg/m 2), normal weight (BMI = 18-
24.9 kg/m2), overweight (BMI = 25-29.9 kg/m2) and obese (BMI ≥ 30 kg/m2).
that were recorded 5 min apart after subjects had rested supine for 10 min, and
applied in order to estimate the 10-year risk for CAD and expressed as a
percentage13.
high erythrocyte sedimentation rate (ESR) (> 20 mm/1st hour) and/or C-reactive
Dyslipidemia was defined as plasma total cholesterol > 200 mg/dL, high-
activity at least 3h/ week for at least 2 months13. The local ethic committee
approved the study and written informed consent was obtained from patients
and controls.
the following criteria were used: National Cholesterol Education Program / Adult
(IDF)12 and the new criteria proposed in partnership IDF and the American
the IDF/AHA definition were performed due to its proposal to harmonize those
previous criteria.
43
after a 12-hour overnight fast. Glucose, TSH, free T4 and insulin were also
reported as uU/mL.
calibration was performed using the calibrators supplied by the kit, and cut-off
because all samples had triglyceride level <400 mg/dL19: VLDL cholesterol
levels using the triglyceride level/5 ratio (TG/5)20, and LDL cholesterol levels
IR) was used for the evaluation of insulin resistance. HOMA-IR was calculated
according to the formulas in the HOMA model21 HOMA-IR exceeding 3.4 was
Statistical analysis.
RESULTS
As expected both groups had a comparable age, weight and BMI. The
antihypertensive drugs (p<0.001) and statins (p<0.001) than the control group.
The current systolic (129 ± 20.65 vs. 105.02 ± 14.40 mmHg, p=0.001) and
diastolic (75.90 ± 18.78 vs. 68.38 ± 11.17 mmHg, p=0.021) blood pressure was
NCEP/ATP III criteria (p=0.003) and IDF criteria (p=0.025) (Table 2). TA
E (p=0.029) and CRP (p < 0.001) compared to healthy subjects. Before statin
use TA patients presented higher LDL-c levels (148.60 ± 40.33 vs. 113.14 ±
49.59 mg/dl, p=0,001). With regard to adipokines, resistin levels were higher in
patients (22.55 ± 12.62 vs. 15.94 ± 10.11 ng/ml, p=0.018) compared to the
control group whereas no difference was observed for adiponectin and PAI-1
(Table 3).
patients without this comorbidity (66.66 vs. 26.26%, p=0.022). In addition the
former group had larger waist circumference (90.52 ± 7.84 vs. 77.40 ± 7.45 cm,
Framingham scores ≥ 1 than those without this complication (44.66 vs. 16.66%;
LDL-c, insulin, HOMA-IR > 3.4 and apolipoprotein B in MetS patients compared
(glucose, HDL-c, triglycerides) were also higher in patients with this condition
levels than those without this complication (20.37 ± 21.16 vs. 38.64 ± 22.62
g/ml, p=0.022) while no differences were found with respect to resistin and
remission, current and cumulative dose of prednisone, current and previous use
Comparing TA patients with and without MetS, we have not found any
patients with MetS also showed a positive Pearson correlation between resistin
CRP only in TA patients with MetS (r=0.57; p=0.050). TA patients without MetS
well between TNFa and systolic blood pressure (r=0.47; p=0.040) (Table 6).
DISCUSSION
premenopausal women matched for age and BMI parameters with healthy
healthy controls of the present study24,25. It may be explained by the fact of our
healthy control group had a high level of education (> 9 years), were younger
The observed prevalence is also higher than the reported for systemic
MetS was higher than TA patients32. Since TA patients evaluated herein were
factors besides age are possible involved in the prevalence of this metabolic
arterial hypertension.
and HDLc. This observation could be explained by several factors: first, the
matched BMI between patients and controls may explain the similar WC;
second, the statin use in almost half of TA patients could explain similar levels
regarding MetS and other vasculitis also revealed that fewer criteria were
fulfilled for the diagnosis of MetS comparing patients and controls, suggesting
that some conditions are more relevant for the diagnosis of this comorbidity in
vasculitis32.
observe any difference between patients and controls, and this finding is almost
certainly related to the fact that patients and controls had similar BMI, weight
diabetes, another risk factor that has been associated with elevated adiponectin
disease (BD)36, showed higher resistin levels than healthy controls but no
serum were also found in patients with other rheumatic disease such as SLE 37
and RA, and in the latter disease this cytokine was correlated with C-reactive
protein (CRP) and disease activity38. Accordingly, CRP levels observed herein
adiponectin levels in the former group. This finding is probably due to a higher
Sanjari et al. also identified that lower levels of adiponectin was a good
TA patients with and without MetS showed similar resistin levels probably
this study and this find is in agreement with most studies in other rheumatic
50
diseases, including SLE27,42,43, RA44,45 and AAV32. Furthermore these finds may
present study. It may, however, give clues to how inflammation and metabolic
observed that disease and its treatment did not seem to be a major trigger for
also in women with MetS39. In addition, these patients also had a higher
were found. However we found a positive correlation between CRP and IL-6
levels only in TA patients with MetS. As many authors have shown IL-6 as an
important marker for disease activity46,47, these data may denote an indirect
MetS.
controlling this modifiable risk factor in the quality of life and survival of TA
patients.
52
ACNOWLEDGMENT
CONFLICT OF INTEREST
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Antihypertensive therapy,
2 (4.26) < 0.001
n 24 (53.34)
BMI – Body mass index, SBP – Systolic blood pressure; DBP – Diastolic blood pressure.
Data are expressed in mean ± SD or percentage
61
IDF/AHA Criteria
0 2 (4.44) 19 (40.42)
1 14 (31.12) 13 (27.66)
2 12 (26.67) 9 (19.15)
3 10 (22.22) 4 (8.51)
4 6 (13.34) 1 (2.13)
5 1 (2.22) 1 (2.13)
Current use of
Previous use of
BMI – Body mass index, SBP – Systolic blood pressure; DBP – Diastolic blood pressure
Data are expressed in mean ± SD or percentage.
64
TABLE 6 – Correlation between citokynes, anthropometrical data and laboratorial tests in TA patients with and without
MetS according to IDF/AHA criteria
IL12 IL1a IL6 TNFα
TA patients with TA patients without TA patients with TA patients without TA patients with TA patients without TA patients with TA patients
MetS MetS MetS MetS MetS MetS MetS without MetS
r p r p r p r p r p R p r p r p
Age 0.01 0.982 0.07 0.702 -0.08 0.799 -0.14 0.477 0.14 0.660 -0.16 0.407 0.25 0.418 0.12 0.516
BMI 0.01 0.995 -0.14 0.487 0.03 0.920 -0.27 0.176 -0.49 0.104 -0.25 0.203 -0.43 0.160 -0.16 0.408
WC -0.29 0.355 -0.19 0.367 0.38 0.219 -0.06 0.747 -0.4 0.190 -0.29 0.146 -0.51 0.090 -0.03 0.883
SBP -0.01 0.993 0.32 0.186 -0.04 0.914 0.36 0.133 0.03 0.928 -0.09 0.716 0.15 0.713 0.47 0.040
DBP -0.54 0.160 0.06 0.796 -0.36 0.378 0.01 0.981 0.01 0.979 -0.13 0.586 0,07 0.865 0.01 0.985
TC -0.22 0.490 0.05 0.800 -0.01 0.963 -0.31 0.110 -0.12 0.697 -0.24 0.220 0.30 0.337 -0.05 0.771
HDL -0.24 0.445 0.05 0.771 -0.01 0.972 -0.01 0.939 -0.02 0.943 -0.06 0.738 0.26 0.399 -0.25 0.206
LDL -0.27 0.394 0.07 0.746 -0.03 0.935 -0.30 0.136 -0.22 0.498 -0.18 0.379 -0.43 0.159 0.09 0.678
Triglycerides 0.29 0.350 -0.15 0.451 -0.01 0.964 -0.16 0.426 0.14 0.656 -0.22 0.275 0.13 0.665 -0.14 0.490
Glucose -0.18 0.570 0.05 0.793 -0.21 0.500 -0.34 0.080 -0.23 0.461 -0.21 0.295 0.09 0.766 -0.14 0.468
Insulin 0.32 0.307 -0.13 0.498 0.47 0.116 -0.13 0.590 -0.12 0.710 0.01 0.948 -0.28 0.367 -0.26 0.186
HOMA-IR 0.22 0.488 -0.11 0.579 0.39 0.206 -0.15 0.439 -0.21 0.492 -0.02 0.897 -0.26 0.413 -0.21 0.283
Adiponectin 0.09 0.802 0.16 0.444 -0.16 0.636 0.07 0.742 -0.07 0.833 -0.05 0.794 0.37 0.266 -0.29 0.151
Resistin 0.12 0.728 0.04 0.845 -0.17 0.614 0.60 0.001 -0.10 0.771 0.09 0.646 0.49 0.126 -0.08 0.700
ESR -0.03 0.927 -0.18 0.386 -0.15 0.640 0.02 0.912 0.40 0.202 0.25 0.229 -0.02 0.956 0.02 0.939
CRP -0.22 0.501 -0.15 0.470 -0.11 0.733 0.00 0.997 0.57 0.050 0.04 0.845 0.08 0.803 0.13 0.551
BMI – Body mass index, WC – Waist circumference; SBP – Systolic blood pressure; DBP – Diastolic blood pressure; TC – Total cholesterol; HDL-c – High density lipoprotein; LDL-c
– Low density lipoprotein; HOMA-IR - Homeostatic model assessment of Insulin resistance; ESR – Erythrocyte sedimentation rate; CRP – C reactive protein; IL-12 – Interleukin 12;
IL1a – Interleukin IL1a; IL6 – Interleukin 6; TNFα – Tumor necrosis factor alfa.Data are expressed as correlation coefficients (r) calculated using Pearson’s correlation test.
66 uma
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