继发性肾小球疾病诊治中的几个重要问题

继发性肾小球疾病指继发于全身疾病而同时累及到肾脏以肾小球病变为主的病变 ,在我国主要是糖尿病肾病、狼疮性肾炎、高血压性肾脏病变、以及乙肝相关性肾炎等等 ,它们发生率渐次升高 ,已成为导致慢性肾功能衰竭仅次于慢性肾小球肾炎的主要病因。本文就它们的发病机制 ,诊治中应注意的主要问题作一评述。1　糖尿病肾病虽然至今我国尚未有糖尿病肾病发生率准确数字 ,但其在慢性肾衰的发病原因中的比例已有明显上升之事实已为所共知。当前除了深入开展有关预防糖尿病发生的健康教育以外 ,早期对糖尿病肾病的诊断并及时加以处理显然是减少本病…     

对2型糖尿病合并肾病患者的临床治疗研究

目的对2型糖尿病合并肾病患者的临床的治疗与研究,分析糖尿病合并肾病的临床治疗与诊断的意义。方法通过对100名2型糖尿病合并肾病患者进行临床观察,得出2型糖尿病合并肾病的临床特点和病理的改变。结果对100名2型糖尿病合并肾病患者的的检查,86名患者被确认为糖尿病合并肾病,占总数的86%;8名患者是糖尿病合并肾病的非糖尿病肾病疾病,占总数的8%;剩下的6名患者则是非糖尿病肾病疾病,占总数的5%。其中2型糖尿病合并肾病的检查结果符合该诊断病率96%,误诊4%。经过两组的检查与临床表现该实验得出的结果在差异上均无统计学的意义。结论 2型糖尿病合并肾病的患者中有很少的一部分是非糖尿病肾病的患者。如果只是根据以往的临床经验与资料则很难做出正确的判断。通过对2型糖尿病合并肾病患者的临床治疗的观察,对以后治疗这类糖尿病合并肾病提供了重要的研究与参考资料。     

糖尿病肾病的诊断与分期

糖尿病肾病早期,患者可无症状;而当发展到中、晚期,其治疗往往十分棘手。因此,糖尿病肾病的早期诊断与分期甚为重要。１糖尿病肾病的诊断１．１临床表现糖尿病肾病的临床表现并不特异,而且出现较晚。肾病早期可全无症状,当患者出现临床症状时,往往已进入糖尿病肾病...     

血清胱抑素C、超敏C反应蛋白联合检测诊断糖尿病肾病的意义

糖尿病肾病(DN)是糖尿病严重的并发症,约15%的2型糖尿病患者在发病后10～20年发生[1].如何准确评估糖尿病肾病患者肾功能,做出正确的治疗对策,对阻止肾病进一步发展有重要的意义.本文旨在通过联合检测血清胱抑素C(CysC)、超敏C反应蛋白(HS-CRP),研究其对糖尿病肾病早期诊断的价值,现将结果报道如下.     

糖尿病肾病研究及防治进展

糖尿病肾病(DN)是糖尿病主要的微血管并发症之一,也是患者致死、致残的重要原因。1型糖尿病和2型糖尿病均可发生糖尿病肾病,而且其发生率呈逐年增多趋势。因此,对其发病机制的研究和治疗措施的探索就显得十分重要。由于DN早期症状不明显,当发现高血压、浮肿等临床症状时已不可逆转,故必须早期诊断,在纠正高血糖、高血压、控制饮食的基础上予以适当的药物进行治疗,防止DN进一步进展。     

心钠素基因多态性与2型糖尿病肾病易感性的关联研究

糖尿病肾病是 2型糖尿病的主要晚期并发症之一 ,其确切发病机制及遗传学基础尚未完全阐明。在遗传学水平早期发现糖尿病肾病高危人群 ,并对其进行积极合理的治疗可预防或延缓糖尿病肾病的发生和发展。本研究通过对 2型糖尿病正常白蛋白尿组、临床肾病组 (包括微量白蛋白尿及大量白蛋白尿 )及正常对照组之间心钠素 (ＡＮＦ)基因Ｃ/Ｔ多态性频率差异的研究 ,旨在观察ＡＮＰ基因多态性与 2型糖尿病肾病之间的关联 ,进而评估该基因多态性在 2型糖尿病肾病中的作用。一、对象和方法1.对象 :据 1985年ＷＨＯ诊断标准确诊的 2型糖尿病患者 (ＤＭ组 …     

糖尿病肾病护肾四部曲

糖尿病肾病是糖尿病微血管并发症之一，在临床上能诊断出的糖尿病肾病一般至少已经是到了糖尿病肾病川期。已患糖尿病肾病的患者如何保护肾脏并延缓疾病的进程呢？本刊为此采访了北京中医药大学东直门医院肾病内分泌科副主任医师柳红芳大夫。     

血管紧张素转换酶基因多态性与糖尿病肾病

糖尿病肾病的发病受多因素影响，并与遗传有关。肾素－血管紧张素系统在糖尿病肾病发病中起重要作用，该系统的关键酶——血管紧张素转换酶（ＡＣＥ）水平主要受ＡＣＥ基因调控。多数研究表明ＡＣＥ基因多态性与糖尿病肾病密切相关，糖尿病肾病患者Ｄ等位基因明显高于非糖尿病肾病患者，但也有不同的观察结果，其差异可能与种族或观察的样本数有关     

关注糖尿病肾病

糖尿病肾病是糖尿病最为常见的慢性并发症之一,在2型糖尿病患者中其患病率高达34．7％,常在糖尿病发病5～10g后出现。在大部分西方国家,糖尿病已成为终末期肾病的第一位致病因素,在我国因糖尿病肾病而需要透析的患者所占的比例也在逐渐增加。     

超声在诊断糖尿病并发肾病患者中的应用

目的对临床糖尿病肾病患者采用超声检查技术的诊断效果进行比较分析,探讨超声结果对患者临床诊断效果的影响。方法分析采用各项超声检查对糖尿病肾病患者诊断效果的差异。结果糖尿病肾病患者早期血、尿检查结果正常时,可根据超声检查结果确定肾脏体积及血流变化。结论超声在动态监测糖尿病肾病患者早期诊断及病程进展等方面的准确度明显高于其它方法,特别是三维超声技术和超声弹性成像准确度更高。     

糖尿病肾病发生发展的相关危险因素

糖尿病的并发症之一糖尿病肾病在糖尿病及终末期肾病患者中出现的比例在逐年增加。糖尿病肾病的高发病率给社会带来了沉重的经济负担,也是导致糖尿病患者残疾和死亡的首要原因。因此,本文主要对与糖尿病肾病发生发展有关危险因素做一综述,为临床医生诊治及干预糖尿病肾病提供参考。     

Absolute level and rate of change of albuminuria over 1 year independently predict mortality and cardiovascular events in patients with diabetic nephropathy.

AIMS: To determine the nature of the association between baseline albuminuria and risk of all-cause mortality and cardiovascular disease, and to determine if the rate of change of albuminuria from baseline over 1 year predicts these endpoints in patients with diabetic nephropathy. METHODS: Cohort study of 427 patients (161 Type 1 and 266 Type 2) with diabetic nephropathy defined as urinary albumin excretion (UAE) > or = 30 mg/24 h at baseline (mean age 53.4 years). Patients were recruited at the time of referral to a diabetic nephropathy clinic and followed up annually for an average of 5 years. UAE rate was re-measured at 1 year and the rate of change from baseline calculated. RESULTS: All-cause mortality and cardiovascular disease increased significantly and continuously across quintiles of baseline UAE (P for linear trend < 0.001 in both outcomes). The rate of change of albuminuria over 1 year (log10) independently predicted all-cause mortality (hazard ratio (95% confidence interval) 1.76 (1.39, 3.11)) and cardiovascular mortality (1.57 (1.13, 5.22)). Taken as a categorical variable, a rate of change of albuminuria > or = 30% independently predicted mortality and cardiovascular events (2.07 (1.5, 4.30) and 1.89 (1.33, 4.06), respectively). CONCLUSIONS: The rate of change of albuminuria over 1 year independently predicts mortality and cardiovascular disease in diabetic nephropathy and may have clinical utility as a risk marker in identifying a subgroup of patients at particular risk. The risk of these outcomes is continuous across the range of baseline albuminuria in patients with diabetic nephropathy.     

常用糖尿病肾病动物模型研究概述

糖尿病肾病是糖尿病进展到晚期阶段的一种微血管并发症,大约有20%~40%的糖尿病患者晚期会进展为糖尿病肾病。在全世界范围内,糖尿病肾病已经成为终末期肾脏病的主要原因。动物模型是研究糖尿病肾病发病机制和治疗方法的良好工具。目前常用的糖尿病肾病模型,都在病理生理上不同程度地模拟了人类糖尿病肾病的部分特征。但糖尿病肾病的研究并未取得可观的进展,其阻碍主要是目前尚无能够完全模拟人类糖尿病肾病所有特征的有效动物模型。本文主要从造模机制、病理生理、优缺点等方面出发,对目前常用的糖尿病肾病动物模型作一综述。     

Diabetes und Nieren

The year 2012 was a key year for diabetic nephropathy. First data from the German chronic kidney disease-study (GCKD) as a register of the course of nephropathy with CKD stages 2–5 were published. According to this study hypertensive nephropathy has replaced diabetic nephropathy as the main reason for initiating chronic hemodialysis treatment. Genetic studies for unraveling the genetic background became rarer and the focus was on hypothesis-free genome-wide association studies. The study results indicated how critical the definition of the phenotype including the controls is to be seen in the face of the disillusioning results. Just as always no biological effects were demonstrated. Urinary podocalyxin could become a marker for the early impairment of podocytes in diabetic patients. Furthermore, the premature termination of the “aliskirin trial in type 2 diabetes using cardiovascular and renal disease endpoints” (ALTITUDE) trial which tested the dual blockade of the renin-angiotensin-aldosterone (RAAS) system and aliskirin plus angiotensin conversion enzyme (ACE) inhibitor or sartan, has been relined by published data. The initial increase of strokes could not be confirmed; however, there were significantly more episodes of hyperkalemia, which can be attributed to serious flaws in the study design.     

Hematuria and red cell casts in typical diabetic nephropathy

Hematuria and red cell casts are unusual urinary findings in patients with diabetic nephropathy. This glomerular disease is more typically characterized by the presence of moderate to severe proteinuria. Hematuria with red blood cell casts in patients with suspected diabetic nephropathy suggests the presence of a second, unrelated form of glomerulonephritis. The full clinical and renal pathologic findings in eight patients with otherwise typical diabetic nephropathy who also had significant hematuria and red cell casts in the urinary sediment are reported. Three of the patients had an immune-mediated form of glomerulonephritis identified. Careful histologic, electron microscopic, and immunofluorescent examination of the renal tissue from the remaining five patients demonstrated only diabetic nephropathy, without evidence of immune-mediated glomerulonephritis in any. Screening urinalysis in a population of 30 patients with diabetic nephropathy revealed hematuria in 30 percent and red cell casts in 13 percent. It is concluded that significant hematuria with red cell casts may be a clinical feature of diabetic nephropathy.     

Renal disease in relatives of Indo-Asian Type 2 diabetic patients with end-stage diabetic nephropathy

AIMS/HYPOTHESIS: Indo-Asian immigrants in The Hague, The Netherlands, have a nearly 40-fold higher risk of end-stage diabetic nephropathy compared to the Caucasian population. To detect a genetic susceptibility for nephropathy within the Indo-Asian population, we assessed whether familial clustering of nephropathy occurs in families of Indo-Asian Type 2 diabetic patients. METHODS: We compared nephropathy prevalence between two groups of first-degree relatives of Indo-Asian patients with Type 2 diabetes; the first group (case relatives) consisted of 169 relatives of patients with end-stage diabetic nephropathy; the second group (control relatives) consisted of 161 relatives of diabetic patients who had no nephropathy. The case and control relatives were examined for diabetes, blood pressure, renal function, microalbuminuria and urine dipstick measurements. RESULTS: The mean age was 41 years and similar in the case and control relatives. Diabetes was distributed equally in both family groups. We did not find more nephropathy in first-degree relatives of Indo-Asian Type 2 diabetic patients with end-stage diabetic nephropathy in comparison with the control-relatives. CONCLUSION/INTERPRETATION: We could not detect a genetic susceptibility for diabetic nephropathy within the Indo-Asian population. The lack of familial clustering of renal disease in Indo-Asian diabetic patients points to a general genetic or environmental susceptibility for diabetic nephropathy in this population.     

Cyclic relationships between diabetic nephropathy and cardiovascular risk factors

The most common cause of death in diabetes is cardiovascular. Diabetic nephropathy has an important role in cardiovascular disease among susceptible diabetic patients. What is not well appreciated is that independent cardiovascular death risk factors (e.g., hypertension, hyperglycemia, dyslipidemias and microalbuminuria) may each have a cyclic relationship with diabetic nephropathy. Thus, as discussed in this review, each risk factor may aggravate diabetic nephropathy, increasing the likelihood of end-stage renal disease. Diabetic nephropathy in turn may aggravate each of the risk factors, increasing the likelihood of a cardiovascular event. These cardiovascular risk factors, amplified by vicious cycles with diabetic nephropathy, may then lead to accelerated cardiovascular morbidity and mortality.     

Hereditary factors in the development of diabetic renal disease

The role of genetics in diabetic renal disease has been suspected on the basis of follow-up and familial studies. Barely half of Type 1 patients who develop a diabetic retinopathy also develop nephropathy, and the relative risk of nephropathy for a diabetic proband is around 3 if a sib is affected. Candidate genes for diabetic nephropathy can be divided into two categories: those affecting glucose metabolism in target organs of diabetic microangiopathy, and those affecting renal changes in response to hyperglycaemia. The role of angiotensin-I-converting enzyme (ACE) insertion/deletion (I/D) polymorphism has been suspected for several years. Evidence of its possible role in the development and progression of diabetic renal disease is presented here.     

Incidence of cardiovascular disease in Type 1 (insulin-dependent) diabetic subjects with and without diabetic nephropathy in Finland

Summary This study evaluates the impact of diabetic nephropathy on the incidence of coronary heart disease, stroke and any cardiovascular disease in the Finnish population, which has a high risk of Type 1 (insulin-dependent) diabetes mellitus and cardiovascular disease. We performed a prospective analysis of the incidence of coronary heart disease, stroke and cardiovascular disease in all Type 1 subjects in the Finnish Type I diabetes mellitus register diagnosed before the age of 18 years between 1 January 1965 and 31 December 1979 nationwide. The effect of age at onset of diabetes, attained age at the end of follow-up, sex, diabetes duration and of the presence of diabetic nephropathy on the risk for cardiovascular disease was evaluated. Cases of nephropathy, coronary heart disease, stroke and all cardiovascular diseases were ascertained from the nationwide Finnish Hospital Discharge Register and National Death Register using computer linkage with the Type I diabetes mellitus register. Of the 5148 Type 1 diabetic patients followed up, 159 had a cardiovascular event of which 58 were coronary heart diseases, 57 stroke events and 44 other heart diseases. There were virtually no cases of cardiovascular disease before 12 years diabetes duration. The cumulative incidence of cardiovascular disease by the age of 40 years was 43 % in Type 1 diabetic patients with diabetic nephropathy, compared with 7 % in patients without diabetic nephropathy, similarly in men and women. The relative risk for Type 1 diabetic patients with diabetic nephropathy compared with patients without diabetic nephropathy was 10.3 for coronary heart disease, 10.9 for stroke and 10.0 for any cardiovascular disease, similarly in men and women. The presence of nephropathy in Type I diabetic subjects increases not only the risk of coronary heart disease, but also of stroke by tenfold. [Diabetologia (1998) 41: 784–790] Received: 14 August 1997 and in final revised form: 2 March 1998     

Clinical diabetic nephropathy: natural history and complications

Diabetic nephropathy develops in about 45% of insulin dependent diabetics of whom two-thirds will develop renal failure, the rest dying from cardiovascular disease. Most of the excess mortality of insulin dependent diabetics occurs in those with proteinuria. Among non-insulin dependent diabetics nephropathy is also an important cause of increased mortality but this is mainly from cardiovascular disease. Once diabetic nephropathy is established it progresses relentlessly to end-stage renal failure over about seven years, but ranging from five to 20 years. The explanation for the different rates of progression in individual patients is not understood. Hypertension accompanies diabetic nephropathy and its treatment may retard the progression of renal failure. Other forms of intervention include glycaemic control which has not been shown to have any effect, and protein restriction for which no conclusions can be drawn at present. The diagnosis of diabetic nephropathy is straightforward in the presence of a typical history and clinical features. Non-diabetic renal disease is sometimes the cause of renal failure and may require specific treatment; prognosis for renal failure treatment may be better than for nephropathy patients with other diabetic complications. Other diabetic complications develop as diabetic nephropathy progresses, most notably cardiac and peripheral vascular disease. Proliferative retinopathy and neuropathy are considerable problems and their management needs attention both before and after renal failure treatment.