(USRDS) 2004Kimmelstiel-Wilson (Annual Data Report presents data on end-stage renal disease) [1] 2002 (1548 ) 1. (glomerular basement mem- thickening) (1726.4 brane ) 2002 (365 ) 1.5 2.5 2. (mesangial expansion) (38.7%) (ECM, extracellular matrix) periodic acid-schiff(pas) 5 7 ( d i f f u s e glomerulosclerosis) 3. (glomerular basement membrane) 25 35% (tubular basement membrane) [2,3] 8 10% (Bowan's capsule) [4] (linear pattern) IgG albumin 80% [5] 1. Kimmelstiel-Wilson nodules 92 (microaneurysm) (mesangial expansion) (nodular nephrosclerosis) 2. (afferent ) and efferent glomerular arteriolar hyalinosis) (immunoglobulin, complement, fibrinogen and albumin) (hypertrophy) ( ) 3. (tubular basement membrane [8,9,10,11] ( thickening) (interstitial expansion) 94 17 2 117
(global sclerosis) 1. (hyaline caps hyaline exudative lesions in the glomerular subendothelial space) (silent) 2. (capsular drop) (e.g. basement membrane thickening, mesangial expansion) 20 µg/min ( 30 mg/day) [11] ( ) (microalbuminuria) 7 (basement membrane thickening, mesangial expansion) 20 200 µg/min ( 30 300 mg/day) [12] [16,17] ( (e.g. membranous nephropathy, 400% 500% ) minimal lesion nephropathy, mesangial proliferative (30%) [18] glomerulonephritis, and chronic GN) [13,14] (overt diabetic nephropathy with clinical proteinuria) 77% 23% [14] 40% [15] (hyperfiltration) 15 18 75% 25 (albumin excretion rate) ( 1) ( 5 10 ) (Pima Indians) (hypertrophy-hyperfunction) 30% [19] 118 94 17 2
1. Timed collection 24-hr collection Spot collection (overnight) (µg/min) (mg/24 hr) (µg/mg Cr) Normoalbuminuria 20 30 30 Microalbuminuria 20 200 30 300 30 300 Proteinuria 200 300 300 [20] ( ) [21] 1.5 2.5 (Diabetes Complications (glomerular basement membrane and Control Trial) thickening) (progression) [22] ( UK Prospective Diabetes Study UKPDS 25% (microvascular complication)) [23] 20 (hemodynamic) 200 µg/min ( 30 300 mg/day) (glomerular hyperfiltration) [24] 77% 23% (genetic) [14] 83% [25] (1) [26] (2) 24 0.5 TGF- angitension-ii protein kinase (3) (4) C (PKC) glycosylation products aldose-reductase (5) endothelin prostaglandin 94 17 2 119
95% (microalbuminuria) [6] ( [16,17] ) DCCT UKPDS [27] 130/80 mmhg (angiotensin converting enzyme inhibitors ACEI) ( II (Angiotensin Receptor blocker 25% 60% ARB) [7]) [28,29] ACEI ( (ADA) RBC cast) (progression) 25% (microvascular complication) (CDA) ACEI (normoalbuminuria) ( ) (130/80 mmhg) GFR (National Kidney Foundation) ACEI (Cr) 1.5 mg/ (American Diabetes Association; ADA) dl 5 ( ) (nephropathy) [30,31] (retinopathy) (neuropathy) [32] DCCT UKPDS (DCCT) (UKPDS) (NSAID) (aminoglycoside) 120 94 17 2
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