Cooper M E
Department of Medicine, University of Melbourne, Austin, Australia.
J Hypertens Suppl. 1996 Dec;14(6):S11-4.
Many studies have emphasized the role of antihypertensive drugs and in particular angiotension converting enzyme (ACE) inhibitors in the retardation of diabetic nephropathy. Although these studies have focused predominantly on patients with overt proteinuria, more recently a number of investigators have explored the role of ACE inhibitors in both type I and type II diabetic patients with an earlier phase of diabetic renal disease known as microalbuminuria. These agents are now being considered as renoprotective agents not only in hypertensive patients but also in those with 'normal' blood pressure. Initially, studies in type I diabetic patients showed that ACE inhibition was effective in retarding the increase in albuminuria which was observed in placebo treated groups. More recently, several multi-centre placebo controlled studies have been performed suggesting that prolonged treatment not only reduced albuminuria but also preserved renal function. The role of ACE inhibition in microalbuminuric type II diabetic patients is less well characterised although several studies have recently described beneficial effects of ACE inhibition on albuminuria and possibly on renal function.
Although ACE inhibitors have been clearly shown to reduce urinary albumin excretion in diabetic patients, the issue as to whether they confer a specific benefit over other classes of antihypertensive agents remains controversial. Several meta-analyses have suggested that ACE inhibitors are more potent at decreasing albuminuria or proteinuria than other antihypertensive agents, for a given reduction in blood pressure. The Melbourne Diabetic Nephropathy Study Group has instituted a study which is placebo-controlled and is confined to normotensive type I and type II diabetic patients. The ACE inhibitor perindopril has been compared not only with placebo but also with the dihydropyridine calcium channel blocker, nifedipine. Preliminary analysis reveals that after 12 and 24 months of treatment, perindopril is more effective in reducing albuminuria than placebo or nifedipine.
ACE inhibitors are a promising class of antihypertensive agents in diabetic patients with microalbuminuria. These drugs should be considered as first line agents in such patients, even in the absence of systemic hypertension.
许多研究强调了抗高血压药物，尤其是血管紧张素转换酶（ACE）抑制剂在延缓糖尿病肾病方面的作用。尽管这些研究主要集中在显性蛋白尿患者，但最近一些研究人员探讨了ACE抑制剂在I型和II型糖尿病患者早期糖尿病肾病（即微量白蛋白尿）中的作用。现在，这些药物不仅被视为高血压患者的肾脏保护剂，也被视为血压“正常”患者的肾脏保护剂。最初，对I型糖尿病患者的研究表明，ACE抑制可有效延缓安慰剂治疗组中观察到的蛋白尿增加。最近，进行了几项多中心安慰剂对照研究，结果表明长期治疗不仅可减少蛋白尿，还可保护肾功能。ACE抑制在微量白蛋白尿II型糖尿病患者中的作用尚不明确，尽管最近有几项研究描述了ACE抑制对蛋白尿以及可能对肾功能的有益影响。
尽管ACE抑制剂已被明确证明可减少糖尿病患者的尿白蛋白排泄，但它们是否比其他类别的抗高血压药物具有特定优势仍存在争议。几项荟萃分析表明，对于给定的血压降低，ACE抑制剂在降低蛋白尿或蛋白尿方面比其他抗高血压药物更有效。墨尔本糖尿病肾病研究小组开展了一项安慰剂对照研究，该研究仅限于血压正常的I型和II型糖尿病患者。ACE抑制剂培哚普利不仅与安慰剂进行了比较，还与二氢吡啶钙通道阻滞剂硝苯地平进行了比较。初步分析显示，治疗12个月和24个月后，培哚普利在减少蛋白尿方面比安慰剂或硝苯地平更有效。
ACE抑制剂是治疗微量白蛋白尿糖尿病患者的一类有前景的抗高血压药物。即使在没有全身性高血压的情况下，这些药物也应被视为这类患者的一线用药。
