Adecuación y necesidad de las terapias basadas en incretinas en la enfermedad renal crónica: consenso de expertos RAND/UCLA para América Latina
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Fecha
2026
Autores
Rico-Fontalvo, Jorge
Rodrigo Daza-Arnedo
Eduardo Lorca-Herrera
Dina-Batlle, Eliana
Proenca de Moraes, Thyago
Elbert, Alicia
Builes-Montaño, Carlos E.
Correa-Rotter, Ricardo
Sánchez-Polo, Vicente
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Sociedad Latinoamericana de Nefrología e Hipertensión
Resumen
Antecedentes: La evidencia que respalda a las terapias basadas en incretinas como modificadoras del riesgo renal continúa
ampliándose; sin embargo, su aplicación clínica sigue siendo heterogénea entre distintos fármacos, fenotipos de enfermedad
renal crónica (ERC) y sistemas de salud. En América Latina, la variabilidad en el acceso y la implementación acentúa la
necesidad de una priorización guiada por fenotipos y de distinguir entre intervenciones que pueden considerarse razonables
y aquellas que deben considerarse necesarias. Método: Se llevó a cabo un estudio formal de consenso de expertos utilizando
el método RAND/UCLA de adecuación, reportado de acuerdo con los estándares RAND/UCLA y la guía ACCORD.
Un panel multidisciplinario de expertos latinoamericanos (n = 9) evaluó la adecuación de cuatro terapias basadas en incretinas
(dulaglutida, liraglutida, semaglutida y tirzepatida) en 18 escenarios clínicamente relevantes de ERC, utilizando una
escala de 9 puntos en dos rondas independientes de calificación. Tras la primera ronda, se realizó una reunión presencial
moderada para revisar las medianas y las distribuciones de las puntuaciones, así como para refinar la redacción de los
escenarios. Las combinaciones escenario-terapia clasificadas como adecuadas tras la segunda ronda se evaluaron posteriormente
en cuanto a necesidad en una tercera ronda independiente. El desacuerdo se evaluó mediante el rango interpercentílico
y el rango interpercentílico ajustado por simetría, y las clasificaciones finales se establecieron según los criterios
estándar RAND/UCLA. Resultados: En los 18 escenarios y las cuatro terapias evaluadas, las calificaciones de adecuación
fueron más consistentemente favorables para la semaglutida y más selectivas para la tirzepatida, mientras que la dulaglutida
y la liraglutida se clasificaron predominantemente como inciertas. Tras la discusión y la refinación de los escenarios, las calificaciones de la segunda ronda fueron más conservadoras y se resolvió todo el desacuerdo observado en la primera
ronda. Dos escenarios orientados a la seguridad, antecedente de pancreatitis aguda y adultos mayores con fragilidad y
pérdida de peso involuntaria, se clasificaron de manera uniforme como inapropiados para todas las terapias. La necesidad
se estableció principalmente para la semaglutida en fenotipos cardiorrenales albuminúricos de mayor riesgo y para la tirzepatida,
en escenarios seleccionados, particularmente cuando la obesidad coexistía con albuminuria persistente. En conjunto,
la albuminuria, el riesgo residual a pesar de una terapia basal optimizada (bloqueo del sistema renina-angiotensina e
inhibición del cotransportador sodio-glucosa tipo 2), el fenotipo metabólico y la comorbilidad cardiovascular emergieron
como los principales determinantes del juicio experto. Conclusiones: En este consenso RAND/UCLA, la necesidad de
terapias basadas en incretinas se concentró en fenotipos de ERC albuminúricos de alto riesgo, de forma más consistente
para la semaglutida y de manera más limitada para la tirzepatida, mientras que la dulaglutida y la liraglutida se calificaron
generalmente como inciertas. Estos hallazgos proporcionan un marco pragmático para apoyar la priorización terapéutica y
la toma de decisiones compartida en América Latina, y ponen de relieve vacíos críticos de evidencia en la ERC avanzada,
la enfermedad dependiente de diálisis y la ERC no diabética.
Background: Evidence supporting incretin-based therapies as modifiers of kidney risk is expanding; however, their clinical application remains heterogeneous across agents, chronic kidney disease (CKD) phenotypes, and health care systems. In Latin America, variability in access and implementation heightens the need for phenotype-driven prioritization and for distinguishing interventions that may be considered reasonable from those that should be regarded as necessary. Method: We conducted a formal expert consensus study using the RAND/UCLA Appropriateness Method, reported in accordance with RAND/UCLA standards and the ACCORD guideline. A multidisciplinary panel of Latin American experts (n = 9) rated the appropriateness of four incretin-based therapies (dulaglutide, liraglutide, semaglutide, and tirzepatide) across 18 clinically relevant CKD scenarios using a 9-point scale in two independent rating rounds. Following Round 1, an in-person moderated meeting was held to review medians and rating distributions and to refine scenario wording. Scenario-therapy combinations classified as appropriate after Round 2 were subsequently evaluated for necessity in a third independent round. Disagreement was assessed using the interpercentile range and the interpercentile range adjusted for symmetry, with final classifications based on standard RAND/UCLA criteria. Results: Across 18 scenarios and four therapies, appropriateness ratings were most consistently favorable for semaglutide and more selective for tirzepatide, whereas dulaglutide and liraglutide were predominantly classified as uncertain. After discussion and scenario refinement, second-round ratings were more conservative, and all disagreement observed in Round 1 was resolved. Two safety-oriented scenarios: prior acute pancreatitis and older adults with frailty and unintentional weight loss, were uniformly classified as inappropriate for all therapies. Necessity was established primarily for semaglutide in albuminuric, higher-risk cardiorenal phenotypes and, for tirzepatide, in selected scenarios, particularly when obesity coexisted with persistent albuminuria. Across scenarios, albuminuria, residual risk despite optimized foundational therapy (renin-angiotensin system blockade and inhibition of sodium-glucose cotransporter type 2), metabolic phenotype, and cardiovascular comorbidity emerged as the dominant drivers of expert judgment. Conclusions: In this RAND/UCLA consensus, the necessity for incretin-based therapy was concentrated in higher-risk, albuminuric CKD phenotypes, most consistently for semaglutide and scarcer for tirzepatide, whereas dulaglutide and liraglutide were generally rated as uncertain. These findings provide a pragmatic framework to support prioritization and shared decision-making in Latin America and underscore essential evidence gaps in advanced CKD, dialysis-dependent disease, and non-diabetic CKD.
Background: Evidence supporting incretin-based therapies as modifiers of kidney risk is expanding; however, their clinical application remains heterogeneous across agents, chronic kidney disease (CKD) phenotypes, and health care systems. In Latin America, variability in access and implementation heightens the need for phenotype-driven prioritization and for distinguishing interventions that may be considered reasonable from those that should be regarded as necessary. Method: We conducted a formal expert consensus study using the RAND/UCLA Appropriateness Method, reported in accordance with RAND/UCLA standards and the ACCORD guideline. A multidisciplinary panel of Latin American experts (n = 9) rated the appropriateness of four incretin-based therapies (dulaglutide, liraglutide, semaglutide, and tirzepatide) across 18 clinically relevant CKD scenarios using a 9-point scale in two independent rating rounds. Following Round 1, an in-person moderated meeting was held to review medians and rating distributions and to refine scenario wording. Scenario-therapy combinations classified as appropriate after Round 2 were subsequently evaluated for necessity in a third independent round. Disagreement was assessed using the interpercentile range and the interpercentile range adjusted for symmetry, with final classifications based on standard RAND/UCLA criteria. Results: Across 18 scenarios and four therapies, appropriateness ratings were most consistently favorable for semaglutide and more selective for tirzepatide, whereas dulaglutide and liraglutide were predominantly classified as uncertain. After discussion and scenario refinement, second-round ratings were more conservative, and all disagreement observed in Round 1 was resolved. Two safety-oriented scenarios: prior acute pancreatitis and older adults with frailty and unintentional weight loss, were uniformly classified as inappropriate for all therapies. Necessity was established primarily for semaglutide in albuminuric, higher-risk cardiorenal phenotypes and, for tirzepatide, in selected scenarios, particularly when obesity coexisted with persistent albuminuria. Across scenarios, albuminuria, residual risk despite optimized foundational therapy (renin-angiotensin system blockade and inhibition of sodium-glucose cotransporter type 2), metabolic phenotype, and cardiovascular comorbidity emerged as the dominant drivers of expert judgment. Conclusions: In this RAND/UCLA consensus, the necessity for incretin-based therapy was concentrated in higher-risk, albuminuric CKD phenotypes, most consistently for semaglutide and scarcer for tirzepatide, whereas dulaglutide and liraglutide were generally rated as uncertain. These findings provide a pragmatic framework to support prioritization and shared decision-making in Latin America and underscore essential evidence gaps in advanced CKD, dialysis-dependent disease, and non-diabetic CKD.
Descripción
Palabras clave
Enfermedad renal crónica, Enfermedad renal diabética, Terapias basadas en incretinas, Agonistas del receptor GLP-1., Tirzepatida, Semaglutida, Método de adecuación RAND/UCLA, América Latina
Citación
Rico-Fontalvo J, et al. Adecuación y necesidad de las terapias basadas en incretinas en la enfermedad renal crónica: consenso de expertos RAND/UCLA para América Latina. Nefro Latinoam. 2026;23:1-14. doi: 10.24875/NEFRO.M26000075
