McLaughlin K, Jardine A G
Glasgow Royal Infirmary and Department of Medicine and Therapeutics, Western Infirmary, UK.
Diabetes Obes Metab. 1999 Nov;1(6):307-15. doi: 10.1046/j.1463-1326.1999.00041.x.
From the viewpoint of nephrologists dealing with diabetic patients with ESRD and the associated complications and devastating prognosis, the need to reduce the incidence, and delay the rate of progression of diabetic nephropathy is obvious. Studies published within the last year have provided support for views that seem intuitively obvious; that improved glycaemic control and reduced blood pressure are associated with delayed onset and delayed progression of diabetic nephropathy. These reports have also demonstrated the difficulty of achieving ideal blood pressure targets and glycaemic control in diabetic patients. Thus, even with available therapy it is likely that improved compliance and achieving targets will have a major impact on disease outcome. There is evidence in several subgroups that ACEi are beneficial over other agents and the favourable side-effect and efficacy profile of these agents makes it reasonable to suggest that they should be used 'first line' in all patients with diabetes unless specifically contra-indicated. However, the failure to readily achieve blood pressure targets and the need for polypharmacy suggest that novel agents are required. We believe that statin therapy will have a major impact on CVD in diabetic patients and is also likely to delay progression; studies assessing the combined affect of anti-hypertensive and statin therapy specifically on the development and progression of diabetic nephropathy will be necessary before evidence-based recommendations can be made. The role for newer agents and targeting high risk groups using genetic markers remains uncertain but we await there development with interest. The future can only get better for patients with DN.
从肾病科医生治疗患有终末期肾病及相关并发症和严重预后的糖尿病患者的角度来看，降低糖尿病肾病的发病率并延缓其进展速度的必要性是显而易见的。去年发表的研究为一些看似直观明显的观点提供了支持，即改善血糖控制和降低血压与糖尿病肾病的发病延迟和进展延缓相关。这些报告也证明了在糖尿病患者中实现理想血压目标和血糖控制的困难。因此，即使采用现有的治疗方法，提高依从性并实现目标可能对疾病结局产生重大影响。在几个亚组中有证据表明，血管紧张素转换酶抑制剂（ACEi）比其他药物更有益，并且这些药物良好的副作用和疗效特征使得有理由建议，在所有糖尿病患者中，除非有明确禁忌，否则都应将其作为“一线”用药。然而，难以轻易实现血压目标以及需要联合用药表明需要新型药物。我们认为他汀类药物治疗将对糖尿病患者的心血管疾病产生重大影响，也可能延缓疾病进展；在能够提出基于证据的建议之前，有必要进行研究评估抗高血压药物和他汀类药物联合治疗对糖尿病肾病发生和进展的综合影响。新型药物的作用以及使用基因标记针对高危人群的作用仍不确定，但我们饶有兴趣地期待它们的发展。对于糖尿病肾病患者来说，未来只会变得更好。
