McKenna K, Thompson C
Department of Diabetes, Victoria Infirmary, Glasgow.
Scott Med J. 1997 Aug;42(4):99-104. doi: 10.1177/003693309704200401.
The presence of persistent microalbuminuria in IDDM is strongly predictive of the future development of end stage renal failure and of cardiovascular disease to a lesser extent. Screening for microalbuminuria is an essential component of modern diabetes practice, as effective antihypertensive therapy, and particularly, the use of angiotensin converting enzyme inhibitors is of proven benefit in retarding progression of renal disease. Cost benefit analysis justifies the expense of microalbuminuria screening programmes and early intervention. It has been estimated that the use of angiotensin converting enzyme inhibitors in microalbuminuric IDDM will save 5200 Pounds-11,000 Pounds per year of life saved. Angiotensin converting enzyme inhibitors are not free of side-effects, and it is therefore essential, given the intrinsic variability of the albumin excretion rate, and the regression to normoalbuminuria of a significant proportion of patients, to confirm the diagnosis of microalbuminuria by repeated measurements prior to the commencement of treatment. The value of intensive glycaemic control is unproven, and further prospective studies are required. There are no proven therapies for the prevention of macrovascular disease in IDDM, although the value of cessation of smoking and aggressive blood pressure control are undoubted in the non-diabetic population. Controversy persists about the value of lipid lowering therapy, especially in young patients, although even in this group there is an increased risk of cardiovascular disease. Microalbuminuria is the strongest known predictor of cardiovascular disease in NIDDM; in contrast to the situation in the non-diabetic population, active lipid lowering therapy is not of proven cardiac benefit, but intervention seems justifiable when taken in the context of the very high prevalence of cardiovascular disease. Microalbuminuria is also predictive of end stage renal disease in NIDDM. Although intervention with angiotensin converting enzyme inhibitors has not been proven to prevent end stage renal disease, stabilisation of albumin excretion rate and creatinine clearance have been demonstrated in normotensive NIDDM, and it seems likely that longer term follow-up studies will confirm the benefit of angiotensin converting enzyme inhibitors in the prevention of end-stage renal disease. The observed predictive power of microalbuminuria as regards both cardiac and renal risk in NIDDM when considered in conjunction with the preliminary results of the benefits of angiotensin converting enzyme inhibition lend further support to the employment of microalbuminuria screening in NIDDM.
胰岛素依赖型糖尿病（IDDM）患者持续存在微量白蛋白尿强烈预示着终末期肾衰竭的未来发展，在较小程度上也预示着心血管疾病的发生。筛查微量白蛋白尿是现代糖尿病治疗的重要组成部分，因为有效的抗高血压治疗，尤其是使用血管紧张素转换酶抑制剂，已被证明对延缓肾病进展有益。成本效益分析证明了微量白蛋白尿筛查项目和早期干预的费用是合理的。据估计，在微量白蛋白尿的IDDM患者中使用血管紧张素转换酶抑制剂，每挽救一年生命可节省￡5200 - ￡11,000。血管紧张素转换酶抑制剂并非没有副作用，因此，鉴于白蛋白排泄率的内在变异性以及相当一部分患者会恢复至正常白蛋白尿状态，在开始治疗前通过重复测量来确诊微量白蛋白尿至关重要。强化血糖控制的价值尚未得到证实，需要进一步的前瞻性研究。对于IDDM患者预防大血管疾病，尚无经证实的治疗方法，尽管戒烟和积极控制血压在非糖尿病人群中的价值是毋庸置疑的。关于降脂治疗的价值仍存在争议，尤其是在年轻患者中，尽管即使在这一群体中，心血管疾病的风险也有所增加。微量白蛋白尿是已知的非胰岛素依赖型糖尿病（NIDDM）患者心血管疾病最强的预测指标；与非糖尿病人群的情况不同，积极的降脂治疗尚未被证明对心脏有益，但鉴于心血管疾病的高患病率，进行干预似乎是合理的。微量白蛋白尿在NIDDM中也可预测终末期肾病。尽管使用血管紧张素转换酶抑制剂进行干预尚未被证明可预防终末期肾病，但在血压正常的NIDDM患者中已证明白蛋白排泄率和肌酐清除率可稳定，长期随访研究似乎有可能证实血管紧张素转换酶抑制剂在预防终末期肾病方面的益处。当结合血管紧张素转换酶抑制益处的初步结果来考虑时，微量白蛋白尿在NIDDM中对心脏和肾脏风险的预测能力进一步支持了在NIDDM中进行微量白蛋白尿筛查。
