Uma alternativa é a substituição da carne vermelha por outras fontes proteicas.
Uma dieta onde a carne vermelha foi substituída por frango, rica em ácidos graxos poli-insaturados, foi capaz de diminuir a EUA em pacientes com DM2 micro e macroalbuminúricos.126–
127
R23 – DEVE SER CONSIDERADO o limite de ingestão de sódio em até 1,5 g/dia, ou de sal, em até 3,75 g/dia, quando houver hipertensão arterial.
Classe IIa Nível B
Ao serem feitas recomendações dietoterápicas para pacientes com DRD, deve-se levar em consideração que, em sua maioria, existe hipertensão associada. Assim, limitar a ingestão de sal deve ser um objetivo a ser atingido.
A diminuição de sal na dieta potencializa o efeito anti-hipertensivo dos fármacos.128 Além disso, o efeito renal e cardiovascular dos BRAs são potencializados quando associados à restrição da ingestão de sal.129
A restrição de sal deve estar incluída em um padrão de dieta do tipo DASH (Dietary Approaches to Stop Hypertension), isto é, com elevado consumo de frutas, vegetais e produtos lácteos magros. Em pacientes com DM2, esse padrão de dieta está associado a menores valores de pressão arterial. Essa dieta, entretanto, não é recomendada para pacientes em diálise.130
Quadro 2. Resumo das recomendações.
RECOMENDAÇÕES CLASSE NÍVEL
R1 – É RECOMENDADO que o primeiro rastreamento da DRD seja feito logo após o diagnóstico de DM2 e após cinco anos do
diagnóstico em pessoas com DM1, a partir de 11 anos de idade.
I B
R2 – É RECOMENDADO o rastreamento anual por meio da
dosagem de albumina urinária ou relação albumina/creatinina em amostra de urina, junto com o cálculo da TFG estimada pela CKD-EPI a partir da creatinina sérica.
I B
R3 – É RECOMENDADO que todo teste anormal da relação albumina/creatinina (acima de 30 mg/g) ou concentração de albumina (acima de 30 mg/L) seja confirmado em duas de três amostras, coletadas com intervalo de três meses a seis meses por causa da variabilidade diária.
I B
R4 – O tratamento intensivo da hiperglicemia em indivíduos com
DM1 ou DM2 É RECOMENDADO para prevenção de DRD. I A
R5 – O controle intensivo da glicemia É RECOMENDADO em
indivíduos com DM para reduzir a albuminúria. . I B
R6 – No tratamento de pessoas com DM2 e DRD com TFG 30-60 mL/min/1,73 m2 ou com albuminúria > 200 mg/g, É
RECOMENDADO o uso de inibidores do SGLT2 para reduzir a progressão para doença renal terminal e morte.
I A
R7 – No paciente DM2 e DRD com TFG >30 mL/min/1,73 m2 DEVE SER CONSIDERADA a combinação de inibidores do SGLT2 com outro antidiabético, preferentemente a metformina, para otimização do controle glicêmico e potencial redução do risco cardiovascular, considerando as limitações determinadas pela filtração glomerular.
IIa B
R8 – Em pacientes DM2 com DRD e TFG >30 mL/min/1,73 m2, o uso de agonistas do receptor do GLP-1 (GLP1-RA) DEVE SER
CONSIDERADO para redução da albuminúria. IIa B
R9 – Em indivíduos com DM2 e DRD com TFGe <30 mL/min/1,73m2, com HbA1c acima da meta, DEVE SER
CONSIDERADO prioritariamente o tratamento com insulina para melhorar o controle glicêmico.
IIa B
R10 – Em pacientes com DM2 e DRD com TFG 15-30
mL/min/1,73m2, e HbA1c acima da meta, os inibidores da DPP-4, algumas sulfonilureias (glipizida e gliclazida) e os GLP-1 RA PODEM SER CONSIDERADOS para melhora do controle glicêmico.
IIb B
R11 – Em indivíduos com DM2 em diálise e HbA1c acima da meta
É RECOMENDADO prioritariamente o uso de insulina. I B
R12 – Em pacientes DM em diálise, É RECOMENDADA a utilização de esquemas de insulina baseados no horário da hemodiálise e nos níveis de glicemia pré e pós-diálise, sendo necessária a redução de pelo menos 25% da dose de insulina rápida ou ultrarrápida aplicada logo antes da refeição anterior à diálise
I B
R13 – É RECOMENDADO tratamento intensivo da hipertensão arterial sistêmica, em razão dos benefícios cardiovasculares e da
evolução da DRD. I A
R14 – A meta de pressão arterial <130 mmHg x 80 mmHg É RECOMENDADA para pacientes com DRD que possam atingir essa meta sem efeitos colaterais.
I A
R15 – Meta de pressão arterial <130 mmHg x 80 mmHg É RECOMENDADA para pacientes adultos com DM e risco aumentado de acidente vascular encefálico.
I B
R16 – É RECOMENDADO o uso de inibidores da enzima conversora (IECA) ou bloqueadores do receptor da angiotensina (BRA) para pacientes que apresentem albuminúria elevada, com o objetivo de reduzir a progressão da doença renal, independentemente dos níveis da pressão arterial.
I A
R17 – O uso combinado de iECA e BRA NÃO É RECOMENDADO, pelo maior risco de hipercalemia, piora da função renal,
hipotensão postural e síncope.
III A
R18 – O uso de antagonistas do receptor mineralocorticoide DEVE SER CONSIDERADO para proteção renal, em associação com os
IECAs ou BRAs. IIa B
R19 – Em pacientes com DRD e TFG <60 mL/min/1,73 m2 (não dialítica) e pacientes pós-transplante renal, É RECOMENDADO o uso de estatinas de alta potência com o objetivo de reduzir eventos cardiovasculares.
I A
R20 – Em pacientes com DRD em diálise, sem doença arterial clínica, NÃO ESTÁ RECOMENDADO INICIAR o uso de estatinas. No entanto, nos pacientes que já usavam estatina antes do início da diálise, esta deve ser mantida.
III A
R21 – Em pacientes em hemodiálise e LDL-c acima de 145 mg/dL e/ou com doença coronariana estabelecida, o início de estatina
PODE SER CONSIDERADO. IIb B
R22 – Em pacientes com DRD grave, em fase pré-diálise, É RECOMENDADA a restrição de proteínas da dieta em 0,8 g/kg de
peso ideal/dia. I A
R23 – DEVE SER CONSIDERADO o limite de ingestão de sódio em até 1,5 g/dia (ou de sal em até 3,75 g/dia), quando houver
hipertensão arterial.
IIa B
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