Perico Norberto, Codreanu Igor, Schieppati Arrigo, Remuzzi Giuseppe
Department of Medicine and Transplantation, Ospedali Riuniti di Bergamo-Mario Negri Institute for Pharmacological Research, Via Gavazzeni 11, 24125 Bergamo, Italy.
Kidney Int Suppl. 2005 Aug(97):S95-101. doi: 10.1111/j.1523-1755.2005.09716.x.
Chronic kidney diseases are emerging as a global threat to human health. Renal replacement therapy by dialysis or renal transplantation prolongs survival in patients with end-stage renal disease (ESRD) and, in most cases, provides a good quality of life. In all wealthy countries, new patients on dialysis outnumber those who die, and the group of patients on renal replacement therapy is growing. The provision of adequate treatment to all is absorbing a large proportion of the health care budget and is being looked at with concern by policymakers. Because rationing of dialysis or deciding that some patients cannot be treated is out of the question, clinicians should be looking for ways to prevent the need for dialysis in as many patients as possible. Simple and inexpensive treatments are plausible and possibly effective. There is robust experimental evidence that proteinuria is responsible for interstitial inflammation and subsequent fibrosis, which thereby contributes to progressive renal function loss. Clinical studies and clinicopathologic correlations in patients with progressive nephropathies indicate that observations in experimental models are relevant to understanding human disease. Researchers have identified an important correlation between urinary protein excretion and rate of glomerular filtration rate decline in patients with diabetic and nondiabetic chronic nephropathy. Renoprotection is a strategy that aims to interrupt or reverse this process. The current therapeutic approach for proteinuric chronic nephropathies is based on blockade of the renin-angiotensin system with angiotensin converting-enzyme inhibitors and/or angiotensin-receptor blockers that limit proteinuria, and reduce glomerular filtration rate decline and risk of ESRD more effectively than other antihypertensive treatments. Full remission of the disease, however, is seldom obtained, particularly when pharmacologic intervention is started late. For those who do not respond, treatment procedures to achieve remission and/or regression must include a multimodel strategy to implement renoprotection. The role of lifestyle changes, including smoking cessation, should not be overlooked. A more concerted, strategic, and multisectorial approach, underpinned by solid research evidence, is essential to help reverse the increasing incidence of these chronic diseases, not just for a few beneficiaries, but equitably and on a global scale.
慢性肾脏病正成为全球人类健康的一大威胁。透析或肾移植等肾脏替代疗法可延长终末期肾病（ESRD）患者的生存期，且在大多数情况下能提供良好的生活质量。在所有富裕国家，新接受透析的患者数量超过死亡患者，接受肾脏替代疗法的患者群体正在扩大。为所有人提供充分治疗正在消耗大量医疗保健预算，政策制定者对此表示关切。由于透析配给或决定某些患者无法接受治疗是不可能的，临床医生应寻找方法尽可能多地预防患者需要透析。简单且廉价的治疗方法似乎可行且可能有效。有确凿的实验证据表明，蛋白尿会导致间质炎症及随后的纤维化，进而导致肾功能逐渐丧失。对进行性肾病患者的临床研究及临床病理相关性分析表明，实验模型中的观察结果与理解人类疾病相关。研究人员已确定糖尿病和非糖尿病慢性肾病患者尿蛋白排泄与肾小球滤过率下降速率之间存在重要关联。肾脏保护是一种旨在中断或逆转这一过程的策略。目前针对蛋白尿性慢性肾病的治疗方法是基于用血管紧张素转换酶抑制剂和/或血管紧张素受体阻滞剂阻断肾素 - 血管紧张素系统，这些药物比其他抗高血压治疗更有效地限制蛋白尿、降低肾小球滤过率下降及ESRD风险。然而，很少能实现疾病的完全缓解，尤其是在药物干预开始较晚时。对于无反应者，实现缓解和/或病情逆转的治疗程序必须包括实施肾脏保护的多模式策略。包括戒烟在内的生活方式改变的作用不应被忽视。以坚实的研究证据为支撑，采取更协调、更具战略性和多部门的方法对于帮助扭转这些慢性病发病率上升的趋势至关重要，这不仅是为了少数受益者，而是要在全球范围内公平地实现。
