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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,
