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1、糖尿病肾脏病病人的血糖控制,唐雯 北京大学第三医院,大纲,目前已经存在的在糖尿病肾脏病病人中的血糖控制效果的证据 肾功能基本正常的1和2型糖尿病病人 透析前的病人 HD和PD的病人 目前已经建议的糖尿病肾脏病病人血糖控制的方法 降糖药物的治疗 胰岛素治疗 可能的研究领域,Intensive treatment of hyperglycemia prevents DKD and may slow the progression of established kidney disease,Lowering HbA1c levels to approximately 7.0% reduces the
2、 development of microalbuminuria. (Strong) Lowering HbA1c levels to approximately 7.0% reduces the development of macroalbuminuria. (Moderate) Lowering HbA1c levels to approximately 7.0% reduces the rate of decrease in GFR. (Weak),KDOQI Clinical Practice Guidelines and Clinical Practice Recommendati
3、ons for Diabetes and Chronic Kidney Disease: Am J Kidney Dis 49:S1-S180, 2007 (suppl 2),Effect of Glycemic Control on Kidney Function and Albuminuria in Type 1 Diabetes,The Diabetes Control and Complications Trial : DCCT,Study design: a multicenter,randomized clinical trial Participants: 1441 patien
4、ts with type 1 diabetes Group: primary-prevention cohort: 726 with no retinopathy secondary-intervention cohort: 715 with mild retinopathy Intervention: intensive therapy :administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood gluc
5、ose monitoring conventional therapy : one or two daily insulin injections Followed for a mean of 6.5 years Main Outcome Measures: appearance and progression of retinopathy and other complications,DCCT-Measurements of Glycosylated Hemoglobin and Blood Glucose in Patients with IDDM Receiving Intensive
6、 or Conventional Therapy,The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977-986, 1993,DCCT,56%,43%,34%,The Diabetes Contr
7、ol and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977-986, 1993,primary-prevention cohort,secondary-intervention cohort,The Epidemiology of Di
8、abetes Interventions and Complications: EDIC study,Study design: Observational study begun in 1993 (following DCCT closeout) in 28 medical centers in the United States and Canada. During the EDIC study: glycemic levels no longer differed substantially Participants:1349 (of 1375) EDIC volunteers who
9、had kidney evaluation at years 7 or 8 Main Outcome Measures: Development of microalbuminuria, clinical-grade albuminuria, hypertension, or increase in serum creatinine level.,EDIC,Sustained effect of intensive treatment of type 1 diabetes mellitus on development and progression of diabetic nephropat
10、hy: The Epidemiology of Diabetes Interventions and Complications (EDIC) Study. JAMA 290:2159-2167, 2003,EDIC,EDIC,Develop hypertension: intensive treatment group 29.9% conventional-treatment: 40.3%; P001. A serum creatinine level of 2 mg/dL or greater intensive-treatment vs the conventional-treatmen
11、t group (5 vs 19, P=.004) Required dialysis and/or transplantation fewer patients experienced either of these outcomes in the intensive group (4 vs 7, P=0.36).,Effect of Glycemic Control on Kidney Function and Albuminuria in Type 2 Diabetes,The Kumamoto Study,Study design: a randomized clinical tria
12、l Participants 110 Japanese patients with type 2 diabetes Group: the primary prevention cohort: 55 with no retinopathy the secondary intervention cohort: 55 with simple retinopathy Intervention: multiple insulin injection therapy (MIT) groups (administered three or more daily insulin injections) con
13、ventional insulin injection therapy (CIT) groups (administered one or two daily intermediate-acting insulin injections) Follow up : 8 years Main Outcome Measures: Worsening of microvascular complications,43.5%,11.5%,Shichiri M, Kishikawa H, Ohkubo Y, Wake N: Long-term results of the Kumamoto Study o
14、n optimal diabetes control in type 2 diabetic patients. Diabetes Care 23:B21-B29, 2000 (suppl 2),The Kumamoto Study,40%,16%,Secondary intervention cohort,Primary prevention cohort,The Kumamoto Study,glycemic threshold to prevent the onset and progression of diabetic microvascular complications was a
15、s follows: HbA1c 6.5%, fasting blood glucose concentration 110 mg/dl, 2-h postprandial blood glucose concentration 180 mg/dl,UKPDS,Study design: randomized clinical trial Participants: 3867 newly diagnosed patients with type 2 diabetes Intervention: intensive management using a sulfonylurea or insul
16、in conventional management with diet alone Endpoints: Three aggregate endpoints any diabetes-related endpoint (sudden death, death from hyperglycaemia or hypoglycaemia, fatal or non-fatal myocardial infarction, angina, heart failure, stroke, renal failure, amputation,vitreous haemorrhage, retinopathy requiring photocoagulation, blindness in one eye, or cataract extraction); diabetes-related death (death from myocardial infarction, stroke, peripheral vascular disease, renal disease, hyperglycaemia or hypoglycaemia, and sudden death); all-cause mortality,