Diabetes medication in CKD
AACE 第Diabetic Kidney Disease二型糖尿病患 T2D 蛋白尿治療
1. pentoxiphylline 療效不佳
2. ARB適合T2D
3. ACEI適合T1D
AACE Diabetic Kidney Disease
糖尿病腎病變是腎臟衰竭主因, 美國約 37% 的DM病患有DKD
同時罹患DM與CKD的病患, 相較於DM無CKD的病患, 心血管併發症及死亡增加 2-3 倍機率.
Diabetic kidney disease (DKD; or diabetic nephropathy) is the leading cause of kidney failure in the United States and affects approximately 37% of patients with diabetes.18 In addition, patients with both diabetes and kidney disease have a 2- to 3-fold higher risk of cardiovascular complications and death relative to patients who have diabetes but normal kidney function.19,20
糖尿病腎病變是以下幾種情況交互作用引起的, 高血糖, 血管收縮素II濃度上升, 遺傳性高血壓, 這些因素造成氧化壓力上升, 發炎前驅細胞激素濃度上升, 血流動力壓力上升引起的機械性傷害,
DKD results from an interplay between hyperglycemia, increased levels of angiotensin II, and increased blood pressure in genetically susceptible individuals (family history of nephropathy is critical). These factors collectively increase oxidative stress, proinflammatory cytokines, and mechanical injury from hemodynamic stress.21-23 Key features of the resulting damage include:
這些因素導致的腎臟損傷包括
腎小球區域微血管表面積減少, 過濾面積下降
腎小管間質纖維化導致腎元減少
腎絲球上皮細胞功能異常
腎絲球基底膜增厚
足細胞損傷
Accumulation of matrix in the mesangial area, which reduces the capillary surface area available for filtration
Nephron dropout due to tubulointerstitial fibrosis
Dysfunction of the glomerular endothelium
Thickening of the glomerular basement membrane (GBM)
Podocyte injury
上述原因彼此影響, 最後導致 GFR 下降, 增加腎臟的蛋白質通透性上升,
These changes occur more or less in concert with each other. Collectively, they lead to a progressive breakdown in the glomerular filtration barrier, which increases the permeability of renal tissues to proteins. Increasing proteinuria further exacerbates the damage caused by hyperglycemia, angiotensin II, and hypertension, progressively worsening renal function.22
type 2 DM 病患確診之後, 每年需檢測血中肌酸酐, 估計 GFR, 檢查尿蛋白/血清肌酸酐比值, 監測慢性腎病的進展
From a clinical perspective, DKD is characterized by an initial period of hyperfiltration, which in a subgroup of genetically susceptible individuals is followed by a declining glomerular filtration rate (GFR) and proteinuria that increases to a varying degree.24,25 Starting at diagnosis of T2D, annual assessment of serum creatinine to estimate GFR and a spot urine albumin:creatinine ratio should be performed to identify, stage, and monitor disease progression.2,25-27
第三期慢性腎病 CKD 又依照GFR分成3a 3b, 很多慢CKD 的患者, 在DM發生前就有慢性腎病, 糖尿病前期患者有 18% 罹患CKD.
Recently, the National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) endorsed the effort by Kidney Disease: Improving Global Outcomes (KDIGO) to update the classification system for kidney disease severity (Table 4). While the thresholds for both estimated GFR and albuminuria remain unchanged in the new classification, 3 albuminuria stages have been added to enhance the GFR stages. Stage 3 CKD has also been subdivided at an estimated GFR of 45 mL/min per 1.73 m2, and there is a new emphasis on clinical diagnosis in addition to GFR and albuminuria stages.27 It is also important to remember that patients may have developed chronic kidney disease (CKD) prior to onset of T2D—nearly 18% of patients with prediabetes have CKD.
Serum creatinine alone is an inaccurate measure of kidney function and should only be used with a GFR-estimating equation such as the Modification of Diet in Renal Disease (MDRD) equation. Many laboratories now routinely report the estimated GFR, and the National Institutes of Health also has GFR calculators.2
預防糖尿病腎病變的策略包括控制A1C
懷疑Ig A 腎炎的病患可轉介到腎臟科
Ig A 腎炎: 快速惡化的腎病變, 尿液檢查發現異常
Prevention of the development or progression of diabetic nephropathy includes optimal control of plasma glucose A1C. Prompt referral to a nephrologist is indicated when the diagnosis of diabetic nephropathy is in doubt (eg, patients with nonclassic presentation, suspected IgA nephropathy, rapidly worsening nephropathy, or active urinary sediment). Patients with advanced or severe kidney disease (estimated GFR 2) also should be cared for in consultation with a nephrologist to delay the progression of nephropathy for as long as possible, unless the T2D caregiver is adept at delivering optimal management of risk factors for worsening nephropathy, such as hyperglycemia, hypertension, and dyslipidemia.
第五期腎病變需要腎臟替代治療(換腎或透析), 需腎臟替代治療的病患, 合併DM的, 相較於沒有DM患者, 死亡率會增加. 多半是因為心血管併發症造成. T2D病患如果進展成末期腎病, 腎臟移植的長期結果優於透析患者.
Patients with stage 5 CKD require renal replacement therapy. Mortality while receiving such therapy is higher in patients with diabetes than in patients without diabetes, largely because of CVD complications.29 Renal transplantation is the preferred replacement therapy for T2D patients who have end-stage kidney disease because long-term outcomes are superior to those achieved with dialysis.
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