Jerums George, Panagiotopoulos Sianna, Premaratne Erosha, Power David A, MacIsaac Richard J
Endocrine Centre, Austin Health and University of Melbourne, Heidelberg, Vic., Australia.
Am J Nephrol. 2008;28(4):614-27. doi: 10.1159/000117461. Epub 2008 Feb 19.
In late diabetic nephropathy (DN) the initial lowering of albumin excretion rate (AER) with antihypertensive therapy is proportional to the degree of subsequent preservation of glomerular filtration rate (GFR). Whether a similar relationship exists between AER and GFR in early diabetes is not known. The present analysis has compared AER and GFR responses to antihypertensive therapy in 33 published studies (77 treatment groups) of early and late DN in type 1 (T1) and type 2 (T2) diabetes, analyzed on an intention-to-treat basis. Prospective trials were included if the initial change in AER during the first year of therapy and the change in GFR during at least 2 years of follow-up could be estimated from group mean data. The initial % decreases in AER were 5.9 +/- 4.3 (T1), 10.5 +/- 5.4 (T2, normotensive) and 18.4 +/- 6.2 (T2, hypertensive) in early DN and 7.6 +/- 11.1 (T1) and 20.8 +/- 5.5 (T2) in late DN. The corresponding annual % rates of decline of GFR were 2.0 +/- 0.5 (T1), 1.6 +/- 0.5 (T2, normotensive) and 2.1 +/- 0.3 (T2, hypertensive) in early DN and 9.8 +/- 1.5 (T1) and 9.2 +/- 1.1 (T2) in late DN. AER and GFR responses in each treatment group were closely correlated in late nephropathy (T1, r = -0.67, p = 0.03; T2, r = 0.57, p = 0.02) but not in early nephropathy. In contrast to late DN, the initial decrease in AER with antihypertensive therapy was not shown to predict the subsequent rate of decline of GFR in early DN. It follows that assessment of renoprotection during antihypertensive therapy in early nephropathy should be based not only on albuminuria but also on the GFR response.
在晚期糖尿病肾病（DN）中，通过抗高血压治疗使白蛋白排泄率（AER）最初的降低幅度与随后肾小球滤过率（GFR）的保留程度成正比。在早期糖尿病中，AER与GFR之间是否存在类似关系尚不清楚。本分析比较了1型（T1）和2型（T2）糖尿病早期和晚期DN的33项已发表研究（77个治疗组）中AER和GFR对抗高血压治疗的反应，并基于意向性治疗进行分析。如果可以从组均值数据估算治疗第一年期间AER的初始变化以及至少2年随访期间GFR的变化，则纳入前瞻性试验。早期DN中，AER最初降低的百分比为5.9±4.3（T1）、10.5±5.4（T2，血压正常者）和18.4±6.2（T2，高血压患者）；晚期DN中为7.6±11.1（T1）和20.8±5.5（T2）。早期DN中，相应的GFR每年下降的百分比为2.0±0.5（T1）、1.6±0.5（T2，血压正常者）和2.1±0.3（T2，高血压患者）；晚期DN中为9.8±1.5（T1）和9.2±1.1（T2）。在晚期肾病中，各治疗组的AER和GFR反应密切相关（T1，r = -0.67，p = 0.03；T2，r = 0.57，p = 0.02），但在早期肾病中并非如此。与晚期DN相反，抗高血压治疗使AER最初降低并未显示可预测早期DN中GFR随后的下降速率。因此，在早期肾病抗高血压治疗期间评估肾脏保护作用不仅应基于蛋白尿，还应基于GFR反应。
