伴尿微量白蛋白增高的2型糖尿病腎病患者的循證治療（附2例報告）_《中國循證醫學雜志》

作者：

陳小蘭 , 蒙張敏 , 鄭玉霞 , 王雙

四川大學華西醫院老年科（成都 610041）;

關鍵詞：

糖尿病腎病白蛋白尿血管緊張素受體拮抗劑循證治療

DOI：

10.7507/1672-2531.20080046

視頻：

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目的　為兩例尿微量白蛋白增高的2型糖尿病腎病患者制定治療方案。
方法　根據循證臨床實踐的方法，提出問題，檢索證據，對所獲證據進行評價，并結合患者意愿為患者制定治療方案。
結果　共納入14個隨機對照試驗，2個系統評價，2個Meta分析和41個臨床指南。證據結果表明：① 尿白蛋白增高是糖尿病患者心血管事件的獨立危險因素；② 血管緊張素受體拮抗劑能降低2型糖尿病腎病患者尿白蛋白水平。③ 降糖降壓治療能使此類患者獲益。結合患者情況，應用證據治療1月后，2例患者血肌酐恢復正常，尿白蛋白轉陰性。
結論　以高質量證據，結合患者情況制定治療方案，能明顯保護腎臟及心臟，降低尿白蛋白，但遠期預后尚需要更長時間的隨訪觀察。

引用本文： 陳小蘭,蒙張敏,鄭玉霞,王雙. 伴尿微量白蛋白增高的2型糖尿病腎病患者的循證治療（附2例報告）. 中國循證醫學雜志, 2008, 08(3): 210-213. doi: 10.7507/1672-2531.20080046 復制

1.	Hillege HL, Fidler V, Diercks GF, et al. Urinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population. Prevention of Renal and Vascular End Stage Disease (PREVEND) Study Group. Circulation, 2002, 106(14): e9037- e9038.
2.	Pitt B, Segal R, Martinez FA, et al. Randomized trial of losartan versus captopril in patients over 65 with heart failure (Evaluation of Losartan in The Elderly Study, ELITE). Lancet, 1997, 349(9054): 747-752.
3.	de Zeeuw D, Remuzzi G, Parving HH, et al. Albuminuria, a therapeutic target for cardiovascular protection in type 2 diabetic patients with nephropathy. Circulation, 2004, 110(8): 921-927.
4.	Parving HH, Lehnert H, Jens BM, et al. for the Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria Study Group: The Effect of Irbesartan on the Development of Diabetic Nephropathy in Patients with Type 2 Diabetes. N Engl J Med, 2001, 345: 851.
5.	Viberti G, Nigel M. Wheeldon for the MicroAlbuminuria Reduction With VALsartan (MARVAL) Study Investigators Microalbuminuria Reduction With Valsartan in Patients With Type 2 Diabetes Mellitus: A Blood Pressure–Independent Effect. Circulation, 2002,106: 672-678.
6.	Weber MA, Julius S, Kjeldsen SE, et al. Blood pressure dependent and independent effects of antihypertensive treatment on clinical events in the VALUE Trial. Lancet, 2004, 363(9426): 2049-2051.
7.	Mogensen CE, Neldan S, Tikkanen I, et al. Randomised controlled trial of dual blockade of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study. BMJ, 2000, 321: 1440-1444.
8.	Hollenberg NK, Parving HH, Viberti G, et al. Albuminuria response to very high-dose valsartan in type 2 diabetes mellitus. J Hypertens, 2007, 25(9): 1921-1926.
9.	UK Prospective Diabetes Study (UKPDS) Group. Tight blood pressure control and risk of macrovascular and microvascylar complications in type 2 diabetes: UKPDS 38. BMJ, 1998, 317(7160): 703-713.
10.	Strippoli GFM, Craig M, Craig JC. Antihypertensive agents for preventing diabetic kidney disease. In: Cochrone Library. 2006, Issue 2.
11.	Lovell HG. Angiotension converting enzyme inhibitors in normotensive diabetic patients with microalbuminuria. In: Cochrone library. 2005, Issue 3.
12.	Parving HH, Lehnert H, Jens BM, et al. for the Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria Study Group The Effect of Irbesartan on the Development of Diabetic Nephropathy in Patients with Type 2 Diabetes. N Engl J Med, 2001, 345: 870.
13.	Eijkelkamp WB, Zhang Z, Remuzzi G, et al. Albuminuria is a target for renoprotective therapy independent from blood pressure in patients with type 2 diabetic nephropathy: post hoc analysis from the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) trial. J Am Soc Nephrol, 2007, 18(5): 1540-1546.
14.	Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet, 2000, 355: 253-259.
15.	Sasso FC, Carbonara O, Persico M, et al. Irbesartan reduces the albumin excretion rate in microalbuminuric type 2 diabetic patients independently of hypertension: a randomized double-blind placebo-controlled crossover study. Diabetes Care, 2002, 25(11): 1909-1913.
16.	Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascularoutcomes in patients with type 2 diabetes and nephropathy. N Engl J Med, 2001, 345: 861-869.
17.	Kasiske BL, Kalil RS, Ma JZ, et al. Effect of antihypertensive therapy on the kidney in patients with diabetes: a meta-regression analysis.Ann Intern Med, 1993, 118(2): 129-138.
18.	Strippoli GF, Craig MC, Schena FP, et al. Role of blood pressure targets and specific antihypertensive agents used to prevent diabetic nephropathy and delay its progression. J Am Soc Nephrol, 2006, 17(4 Suppl 2): S153-155.
19.	American Diabetes Association (ADA). Standards of medical care in diabetes. Diabetes Care, 2007, 30: S4-41S.

1. Hillege HL, Fidler V, Diercks GF, et al. Urinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population. Prevention of Renal and Vascular End Stage Disease (PREVEND) Study Group. Circulation, 2002, 106(14): e9037- e9038.
2. Pitt B, Segal R, Martinez FA, et al. Randomized trial of losartan versus captopril in patients over 65 with heart failure (Evaluation of Losartan in The Elderly Study, ELITE). Lancet, 1997, 349(9054): 747-752.
3. de Zeeuw D, Remuzzi G, Parving HH, et al. Albuminuria, a therapeutic target for cardiovascular protection in type 2 diabetic patients with nephropathy. Circulation, 2004, 110(8): 921-927.
4. Parving HH, Lehnert H, Jens BM, et al. for the Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria Study Group: The Effect of Irbesartan on the Development of Diabetic Nephropathy in Patients with Type 2 Diabetes. N Engl J Med, 2001, 345: 851.
5. Viberti G, Nigel M. Wheeldon for the MicroAlbuminuria Reduction With VALsartan (MARVAL) Study Investigators Microalbuminuria Reduction With Valsartan in Patients With Type 2 Diabetes Mellitus: A Blood Pressure–Independent Effect. Circulation, 2002,106: 672-678.
6. Weber MA, Julius S, Kjeldsen SE, et al. Blood pressure dependent and independent effects of antihypertensive treatment on clinical events in the VALUE Trial. Lancet, 2004, 363(9426): 2049-2051.
7. Mogensen CE, Neldan S, Tikkanen I, et al. Randomised controlled trial of dual blockade of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study. BMJ, 2000, 321: 1440-1444.
8. Hollenberg NK, Parving HH, Viberti G, et al. Albuminuria response to very high-dose valsartan in type 2 diabetes mellitus. J Hypertens, 2007, 25(9): 1921-1926.
9. UK Prospective Diabetes Study (UKPDS) Group. Tight blood pressure control and risk of macrovascular and microvascylar complications in type 2 diabetes: UKPDS 38. BMJ, 1998, 317(7160): 703-713.
10. Strippoli GFM, Craig M, Craig JC. Antihypertensive agents for preventing diabetic kidney disease. In: Cochrone Library. 2006, Issue 2.
11. Lovell HG. Angiotension converting enzyme inhibitors in normotensive diabetic patients with microalbuminuria. In: Cochrone library. 2005, Issue 3.
12. Parving HH, Lehnert H, Jens BM, et al. for the Irbesartan in Patients with Type 2 Diabetes and Microalbuminuria Study Group The Effect of Irbesartan on the Development of Diabetic Nephropathy in Patients with Type 2 Diabetes. N Engl J Med, 2001, 345: 870.
13. Eijkelkamp WB, Zhang Z, Remuzzi G, et al. Albuminuria is a target for renoprotective therapy independent from blood pressure in patients with type 2 diabetic nephropathy: post hoc analysis from the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) trial. J Am Soc Nephrol, 2007, 18(5): 1540-1546.
14. Heart Outcomes Prevention Evaluation (HOPE) Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet, 2000, 355: 253-259.
15. Sasso FC, Carbonara O, Persico M, et al. Irbesartan reduces the albumin excretion rate in microalbuminuric type 2 diabetic patients independently of hypertension: a randomized double-blind placebo-controlled crossover study. Diabetes Care, 2002, 25(11): 1909-1913.
16. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and cardiovascularoutcomes in patients with type 2 diabetes and nephropathy. N Engl J Med, 2001, 345: 861-869.
17. Kasiske BL, Kalil RS, Ma JZ, et al. Effect of antihypertensive therapy on the kidney in patients with diabetes: a meta-regression analysis.Ann Intern Med, 1993, 118(2): 129-138.
18. Strippoli GF, Craig MC, Schena FP, et al. Role of blood pressure targets and specific antihypertensive agents used to prevent diabetic nephropathy and delay its progression. J Am Soc Nephrol, 2006, 17(4 Suppl 2): S153-155.
19. American Diabetes Association (ADA). Standards of medical care in diabetes. Diabetes Care, 2007, 30: S4-41S.

《中國循證醫學雜志》

伴尿微量白蛋白增高的2型糖尿病腎病患者的循證治療（附2例報告）

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《中國循證醫學雜志》

伴尿微量白蛋白增高的2型糖尿病腎病患者的循證治療（附2例報告）

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