1] Department of Endocrinology and Diabetes, St Vincent's Hospital, Melbourne and Professorial Fellow, University of Melbourne, Fitzroy, Victoria, Australia [2] University of Melbourne, Parkville, Victoria, Australia.
1] University of Melbourne, Parkville, Victoria, Australia [2] Endocrine Centre and Department of Medicine, Austin Health, Melbourne, Victoria, Australia [3] Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia.
Kidney Int. 2014 Jul;86(1):50-7. doi: 10.1038/ki.2014.98. Epub 2014 Apr 9.
The concept of microalbuminuria has been central to the development of clinical practice and research in the area of diabetic kidney disease (DKD). However, in recent times, the value of a paradigm of DKD based solely on microalbuminuria has been questioned. Although both the absolute level and rate of change of microalbuminuria are linked to the development and progression of DKD, microalbuminuria on its own lacks the necessary sensitivity or specificity to accurately predict kidney outcomes for people with diabetes. The development of microalbumiuria can no longer be viewed as a committed and irreversible stage of DKD, as spontaneous remission is now reported as a common occurrence. In addition, the absence of microalbuminuria or its progression to proteinuria does not signify that an individual patient is safe from a progressive decline in glomerular filtration rate (GFR). Furthermore, although reductions in albuminuria within the microalbuminuric range can be linked to a slower GFR decline in observational studies, this relationship has not been robustly demonstrated in intervention studies. Conclusions regarding the kidney health of individuals with diabetes will continue to be flawed if an inappropriate emphasis is placed on the presence or absence of albuminuria or changes in albuminuria within the microalbuminuric range. This has important implications in terms of undermining the value of microalbuminuria as a surrogate renal end point for intervention trials. There is a need to develop broader models of progressive DKD that include novel pathways and risk markers apart from those related to the traditional 'albuminuric pathway' to renal impairment.
微量白蛋白尿的概念一直是糖尿病肾病 (DKD) 临床实践和研究领域的核心。然而，最近，仅基于微量白蛋白尿的 DKD 范式的价值受到了质疑。尽管微量白蛋白尿的绝对水平和变化率与 DKD 的发生和进展有关，但微量白蛋白尿本身缺乏足够的敏感性或特异性来准确预测糖尿病患者的肾脏结局。微量白蛋白尿的发展不能再被视为 DKD 的一个确定和不可逆转的阶段，因为现在有报道称其自发缓解是常见的。此外，即使微量白蛋白尿缺失或进展为蛋白尿，也不能表明个体患者的肾小球滤过率 (GFR) 不会逐渐下降。此外，尽管在观察性研究中，微量白蛋白尿范围内的白蛋白尿减少与 GFR 下降速度较慢有关，但在干预性研究中并未得到稳健的证明。如果过分强调白蛋白尿的存在或缺失，或者过分强调微量白蛋白尿范围内的白蛋白尿变化，那么对糖尿病患者肾脏健康的结论将继续存在缺陷。这对于削弱微量白蛋白尿作为干预试验替代肾脏终点的价值具有重要意义。需要开发更广泛的 DKD 进展模型，除了与传统的“白蛋白尿途径”有关的途径和风险标志物外，还包括新的途径和风险标志物。
