Chantrel F, Moulin B, Hannedouche T
Department of Nephrology, Hôpital Universitaire de Strasbourg, Strasbourg, France.
Diabetes Metab. 2000 Jul;26 Suppl 4:37-44.
Despite multiple evidence-based data that diabetic nephropathy is largely preventable and its progression slowed by currently available interventions diabetic patients are often undertreated, especially for the lowering of blood pressure. Recent studies, (HOT Syst-Eur, SHEP, UKPDS, CAPPP, ABCD, HOPE) have confirmed the efficiency of intensively treated blood pressure in reducing morbidity-mortality in this group of patients at high risk. Low blood pressure targets are mandatory, but may not be that easy to achieve, especially in the presence of renal failure. Early prescription of a combination of antihypertensive drugs is often neccessary. Thus, the clinical question relates to the best combination of drugs. Most studies in hypertensive diabetic patients have dealt with 3 classes of antihypertensives drugs: diuretics, beta-blockers and ACE-inhibitors. Diuretics are one of the most efficient hypotensive drugs available for treatment of hypertension in diabetic patients. Their use must be encouraged early in the stepped approach since diabetes is usually associated with mid-volume expansion due to hyperinsulinism and hyperadrenergic state. In spite of the proven benefit of beta-blockers in diabetic patients, these drugs are largely underused. The indications for selective beta-blockers should probably be broadened for most diabetic patients in primary prevention. Beta-blockers are essential in secondary prevention for patients with coronary artery disease and hypertension. ACE-inhibitors are now more and more widely prescribed in diabetic patients at all stages of hypertension and nephropathy, but paradoxally their use has not been validated in Type 2 diabetic nephropathy. When the desired blood pressure target is obtained, cardiovascular outcome and probably also progression of diabetic nephropathy are significantly improved independently of a specific drug. Early combination therapy, including ACE-inhibitors, diuretics and beta-blockers, should be promptly proposed to all hypertensive diabetic patients to achieve low blood pressure and prevent high cardiovascular burden and progression of nephropathy.
尽管有多项基于证据的数据表明，糖尿病肾病在很大程度上是可以预防的，并且目前可用的干预措施能够减缓其进展，但糖尿病患者往往治疗不足，尤其是在血压控制方面。最近的研究（HOT Syst-Eur、SHEP、UKPDS、CAPPP、ABCD、HOPE）证实，强化血压治疗对于降低这类高危患者的发病率和死亡率是有效的。设定较低的血压目标是必要的，但可能并不容易实现，尤其是在存在肾衰竭的情况下。早期联合使用抗高血压药物通常是必要的。因此，临床问题涉及到最佳的药物组合。大多数针对高血压糖尿病患者的研究涉及三类抗高血压药物：利尿剂、β受体阻滞剂和血管紧张素转换酶抑制剂（ACEI）。利尿剂是治疗糖尿病患者高血压最有效的降压药物之一。由于糖尿病通常与高胰岛素血症和高肾上腺素能状态导致的血容量中度增加有关，因此在阶梯式治疗方法中应尽早鼓励使用利尿剂。尽管β受体阻滞剂在糖尿病患者中已被证明有益，但这些药物的使用仍普遍不足。对于大多数处于一级预防的糖尿病患者，选择性β受体阻滞剂的适应证可能需要扩大。β受体阻滞剂对于患有冠状动脉疾病和高血压的患者的二级预防至关重要。ACEI现在在高血压和肾病各阶段的糖尿病患者中越来越广泛地被处方，但矛盾的是，其在2型糖尿病肾病中的使用尚未得到证实。当达到理想的血压目标时，心血管结局以及糖尿病肾病的进展可能会独立于特定药物而得到显著改善。应立即向所有高血压糖尿病患者建议早期联合治疗，包括使用ACEI、利尿剂和β受体阻滞剂，以实现低血压并预防高心血管负担和肾病进展。
