Markell M S, Friedman E A
Department of Medicine, SUNY Health Science Center, Brooklyn 11203.
Diabetes Care. 1992 Sep;15(9):1226-38. doi: 10.2337/diacare.15.9.1226.
Diabetic nephropathy is currently the leading cause of new patients requiring dialysis in the United States. Management of the diabetic patient with ESRD is complicated by the frequent coexistence of complications affecting other organ systems, including retinopathy, cardiovascular disease, peripheral neuropathy, or autonomic neuropathy, manifested as gastroparesis, diarrhea or obstipation, cystopathy, or orthostatic hypotension. Associated clinical syndromes must be followed and treated, if possible, while preparing the patient to receive renal replacement therapy. Both the clinical condition and the psychosocial environment are key factors in choice of ESRD therapy for an individual patient. Rehabilitation data are best for patients who undergo kidney transplantation, but these data are confounded by the fact that the healthiest patients are referred for this treatment modality. Living, related kidney transplant is the preferred initial choice for the diabetic patient with kidney disease. At most centers, both in the United States and abroad, the cadaveric transplant is the second choice for uremia therapy. At the appropriate institution, the patient with type I diabetes may also be considered for a simultaneous cadaveric pancreas transplant. While awaiting cadaveric transplantation, or if contraindication to transplantation is present (chronic infection, recent malignancy, or severe cardiac disease), diabetic patients with severe impairment of the glomerular filtration rate (less than 10-15 ml/min) are referred for vascular access placement and/or insertion of a peritoneal catheter. The decision regarding the choice of CAPD vs. hemodialysis must be made on an individual basis. Rehabilitation and survival data for these therapies are similar, although technique survival rates for CAPD decline dramatically as time progresses because of infectious complications. In-center hemodialysis has the worst survival and rehabilitation profile, but the sickest, most debilitated patients with the highest number of comorbid conditions tend to be referred for that therapeutic modality. Most studies of rehabilitation were performed before use of recombinant human erythropoietin, and comparison between ESRD treatment modalities will have to be reevaluated now that the drug is routinely used.
糖尿病肾病目前是美国新增透析患者的主要病因。患有终末期肾病（ESRD）的糖尿病患者的管理较为复杂，因为常并存影响其他器官系统的并发症，包括视网膜病变、心血管疾病、周围神经病变或自主神经病变，表现为胃轻瘫、腹泻或便秘、膀胱病变或体位性低血压。在准备让患者接受肾脏替代治疗时，必须跟踪并尽可能治疗相关临床综合征。临床状况和社会心理环境都是为个体患者选择ESRD治疗方法的关键因素。康复数据对于接受肾移植的患者最为有利，但这些数据因最健康的患者被转诊至这种治疗方式这一事实而变得复杂。亲属活体肾移植是患有肾病的糖尿病患者的首选初始治疗方式。在美国和国外的大多数中心，尸体肾移植是尿毒症治疗的第二选择。在合适的机构，I型糖尿病患者也可考虑同时进行尸体胰腺移植。在等待尸体肾移植期间，或者如果存在移植禁忌证（慢性感染、近期恶性肿瘤或严重心脏病），肾小球滤过率严重受损（低于10 - 15毫升/分钟）的糖尿病患者会被转诊进行血管通路置入和/或腹膜导管插入。关于选择持续性非卧床腹膜透析（CAPD）还是血液透析的决定必须因人而异。这些治疗方法的康复和生存数据相似，尽管由于感染并发症，随着时间推移，CAPD的技术生存率会大幅下降。中心血液透析的生存和康复情况最差，但合并症最多、病情最重、最虚弱的患者往往会被转诊至这种治疗方式。大多数康复研究是在使用重组人促红细胞生成素之前进行的，鉴于该药物已常规使用，现在必须重新评估ESRD治疗方式之间的比较。
