( Diabetic nephropathy) ( Microalbuminuria ) ( Macroalbuminuria )

Transcription

1 % ( ESRD ) mg ( ) ( 300 mgday ) DCCBs ) dihydropyridine calcium channel blockers ( non- DCCBs ( -blockers ( diuretics ) 10%) 0.8 ( 60 mlmin per 1.73 m 2 30 mlmin per 1.73 m 2 ( Diabetic nephropathy) ( Microalbuminuria ) ( Macroalbuminuria ) 427

2 100 ACEIs ) ( Angiotensin-converting enzyme inhibitors, ( Angiotension receptor blockers, ARBs ( Glomerular filtration rate, GFR ) ) 13 ( RD ) ( ) ( angiotension receptor blockers ARBs ) ( ESRD ) % ( ES- dihydropyridine calcium channel blockers ( DCCBs ) ( 300 mgday ) non- DCCBs ( -blockers ) ( diuretics ) 17, United Kingdom Prospective Diabetes Study ( UKPDS ) ( angiotensin-converting enzyme inhibitors ACEIs ) ( 140 mmhg ) ( glomerular filtration rate GFR ) (1) ( ) (2) 24 (3) ( 4

3 ) ( 24 ) 60 mlmin per 1.73 m 2 ) ( 26 ( microalbuminuria ) gmg ( ) ( macroalbuminuria ) 300 gmg Cockroft-Gault Levy ( ( MDRD ) ) orgprofessionalskdoqigfr_calculator.cfm albumin excretion rate UAER ) ( urinary ( ) mlmin per 1.73 m 2 GFR (mlmin1.73 m 2 ) * * < mlmin per 1.73 m 2 24 * 33

4 ADA (1) A-Level evidence B- Level evidence C-Level evidence Expert consensus ( Recommended Dietary Allowances, RDA ) (2) (3) ( 1.5 mgdl ) (4) ( 10% ) ( ) (B ) non- DCCBs ( - blockers ) ( diuretics ) non- DCCBs 6.

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7 ADA Standard Recommendations for Treatment of Diabetic Nephropathy Lyh-Jyh Hao, Chwen-Yi Yang 1, Ming-Jei Wu 2, Kuo-Liang Chai 3, Jin-Shiung Cheng 4, and Tain-Cheng Wu 4 Division of Endocrinology and Metabolism, Yung Kang Veterans Hospital. 1 Division of Endocrinology and Metabolism, Department of Internal Medicine, Chi-Mei Medical Center, Tainan, Taiwan. 2 Division of Nephrology, Yung Kang Veterans Hospital. 3 Department of Internal Medicine, Yung Kang Veterans Hospital. 4 Department of Administration, Yung Kang Veterans Hospital. Diabetic nephropathy occurs in 20 40% of patients with diabetes and is the single leading cause of endstage renal disease (ESRD). Persistent albuminuria in the range of mgday (microalbuminuria) has been shown to be the earliest stage of diabetic nephropathy in type 1 diabetes and a marker for development of nephropathy in type 2 diabetes. Microalbuminuria is also a well-established marker of increased cardiovascular disease (CVD) risk. Intensive diabetes management with the goal of achieving near normoglycemia has been shown in large prospective randomized studies to delay the onset of microalbuminuria and the progression of micro- to macroalbuminuria( 300 mgday) in patients with type 1 and type 2 diabetes. In the treatment of both micro- and macroalbuminuria, either ACE inhibitors or ARBs should be used except during pregnancy. With regards to slowing the progression of nephropathy, the use of DCCBs as initial therapy is not more effective than placebo. Their use in nephropathy should be restricted to additional therapy to further lower blood pressure in patients already treated with ACE inhibitors or ARBs. In patients unable to tolerate ACE inhibitors andor ARBs, consider the use of non-dccbs, -blockers, or diuretics for the management of blood pressure. Protein restriction is of benefit in slowing the progression of albuminuria, GFR decline, and occurrence of ESRD. With presence of nephropathy, initiate protein restriction to 0.8 g kg body wt -1 day -1 ( 10% of daily calories). Serum creatinine should be measured at least annually for the estimation of GFR in all adults with diabetes regardless of the degree of urine albumin excretion. Serum creatinine alone should not be used as a measure of kidney function, but used to estimate GFR and stage the level of CKD. Consider referral to a physician experienced in the care of diabetic renal disease either when the GFR has fallen to <60 mlmin per 1.73 m 2 or if difficulties occur in the management of hypertension or hyperkalemia. It is suggested that consultation with a nephrologist be obtained when the GFR is <30 mlmin per 1.73 m 2. Early referral of such patients has been found to reduce cost and improve quality of care and keep people off dialysis longer. ( J Intern Med Taiwan 2006; 17: )