Jerums G, Allen T J, Gilbert R E, Hammond J, Cooper M E, Campbell D J, Raffaele J
Endocrine Unit, Austin Hospital, Heidelberg, Australia.
J Diabetes Complications. 1995 Oct-Dec;9(4):308-14. doi: 10.1016/1056-8727(95)80029-e.
Several studies have shown that lowering of blood pressure slows the rate of progression of diabetic renal disease. Some placebo-controlled studies have also shown that angiotensin-converting enzyme (ACE) inhibitors decrease or stabilize albuminuria in incipient nephropathy and slow the rate of progression of advanced nephropathy. However, it is not yet clear if prolonged treatment with ACE inhibitors or with other agents exerts a specific renoprotective effect in incipient diabetic nephropathy. It is proposed that such an effect should be independent from changes in systemic blood pressure and should be characterized by amelioration of the rate of rise of albumin excretion rate (AER) and the rate of fall of glomerular filtration rate (GFR) and independence from changes in other parameters known to influence AER (glycemic control, protein intake, sodium intake). In addition, there should be evidence that the potentially reversible effects of therapeutic intervention on AER and GFR are translated to long-term changes in renal function and structure. This paper reviews the evidence on which the concept of renoprotection is based, with particular reference to choice of end points, heterogeneity of study groups, and complexities of the disease process, and relates this evidence to the natural history of nephropathy in type I and type II diabetes. Based on the above, an assessment is made of the comparative effects of ACE inhibitors and other antihypertensive agents on AER and GFR. It is suggested that longitudinal intra-individual analysis of both variables may be necessary in order to determine whether ACE inhibitors exert greater renoprotection than calcium channel blockers or other antihypertensive agents.
多项研究表明，降低血压可减缓糖尿病肾病的进展速度。一些安慰剂对照研究还表明，血管紧张素转换酶（ACE）抑制剂可减少或稳定早期肾病患者的蛋白尿，并减缓晚期肾病的进展速度。然而，目前尚不清楚长期使用ACE抑制剂或其他药物是否对早期糖尿病肾病具有特定的肾脏保护作用。有人提出，这种作用应独立于全身血压的变化，其特征应为改善白蛋白排泄率（AER）的上升速度和肾小球滤过率（GFR）的下降速度，且不受其他已知影响AER的参数（血糖控制、蛋白质摄入量、钠摄入量）变化的影响。此外，应有证据表明治疗干预对AER和GFR的潜在可逆作用可转化为肾功能和结构的长期变化。本文回顾了肾脏保护概念所基于的证据，特别提及终点的选择、研究组的异质性以及疾病过程的复杂性，并将这些证据与I型和II型糖尿病肾病的自然病程相关联。基于上述内容，对ACE抑制剂和其他抗高血压药物对AER和GFR的比较作用进行了评估。有人认为，为了确定ACE抑制剂是否比钙通道阻滞剂或其他抗高血压药物具有更强的肾脏保护作用，可能需要对这两个变量进行纵向个体内分析。
