Parving H H
Steno Diabetes Center, Gentofte, Denmark.
J Hypertens Suppl. 1998 Jan;16(1):S99-101.
The prevalence of abnormally elevated urinary albumin excretion rate (> 30 mg/24 h) is approximately 40% in insulin-dependent and in non-insulin-dependent diabetic patients. Diabetes has become the leading cause of end-stage renal failure in Europe, USA and Japan. Approximately 90% of the direct and indirect costs of caring for diabetic patients are spent on the complications of diabetes.
Identification of patients at high risk of developing diabetic nephropathy is possible by screening for microalbuminuria (30-300 mg/24 h). Additional risk factors/ markers for development of nephropathy are male sex, genetic predisposition, ethnic conditions, early onset of diabetes, poor metabolic control, hyperfiltration, elevated prorenin and smoking. Elevated urinary albumin excretion rate indicates a substantially increased cardiovascular morbidity and mortality risk in diabetic patients.
Randomized controlled trials in normotensive insulin-dependent and in non-insulin-dependent diabetic patients with persistent microalbuminuria indicate that angiotensin converting enzyme (ACE) inhibitors diminish urinary albumin excretion rate, and postpone and may even prevent progression to clinical overt nephropathy. These findings indicate that screening and intervention programs could probably save lives and lead to considerable economic savings.
Systemic blood pressure elevation to a hypertensive level is an early and frequent phenomenon in diabetic nephropathy. Furthermore, nocturnal blood pressure elevation (non-dippers) occurs more frequently in patients with nephropathy. Systemic blood pressure elevation, hyperglycaemia, albuminuria and the D polymorphism in the ACE gene accelerate the progression of diabetic nephropathy. Studies of the impact of other potential progression promoters (i.e. smoking, hyperlipidaemia and protein intake) have yielded conflicting results. Effective blood pressure reduction using ACE inhibitors or drugs of other classes, or both, frequently in combination with diuretics reduces albuminuria, delays the progression of nephropathy, postpones renal failure and improves survival in patients with diabetic nephropathy. Antihypertensive treatment for diabetic nephropathy extends life and saves money.
在胰岛素依赖型和非胰岛素依赖型糖尿病患者中，尿白蛋白排泄率异常升高（>30毫克/24小时）的患病率约为40%。在欧洲、美国和日本，糖尿病已成为终末期肾衰竭的主要病因。护理糖尿病患者的直接和间接费用中，约90%用于糖尿病并发症。
通过筛查微量白蛋白尿（30 - 300毫克/24小时）可识别出有发生糖尿病肾病高风险的患者。肾病发生的其他风险因素/标志物包括男性、遗传易感性、种族情况、糖尿病早发、代谢控制不佳、超滤、肾素原升高和吸烟。尿白蛋白排泄率升高表明糖尿病患者心血管发病和死亡风险大幅增加。
对血压正常的胰岛素依赖型和非胰岛素依赖型持续性微量白蛋白尿糖尿病患者进行的随机对照试验表明，血管紧张素转换酶（ACE）抑制剂可降低尿白蛋白排泄率，延缓甚至可能预防进展为临床显性肾病。这些发现表明，筛查和干预项目可能挽救生命并带来可观的经济节省。
系统性血压升高至高血压水平是糖尿病肾病早期常见现象。此外，肾病患者夜间血压升高（非勺型血压）更为常见。系统性血压升高、高血糖、蛋白尿和ACE基因的D多态性会加速糖尿病肾病进展。关于其他潜在进展促进因素（即吸烟、高脂血症和蛋白质摄入）影响的研究结果相互矛盾。使用ACE抑制剂或其他类药物或两者联合有效降低血压，且常与利尿剂联合使用，可减少蛋白尿，延缓肾病进展，推迟肾衰竭并改善糖尿病肾病患者的生存率。糖尿病肾病的降压治疗可延长寿命并节省费用。
