糖尿病肾病

糖尿病肾病(DN)是糖尿病(DM)最常见的并发症之一，在西方国家其已成为导致慢性肾衰竭的最主要原因。本文就近来DN发病机制、诊断、治疗的主要进展、特别是与临床实践有关的内容进行阐述。     

早期糖尿病肾病的治疗进展

近年来,随着糖尿病（DM）发病率的迅速增加,糖尿病肾病（DN）的发生率亦明显提高.DN是DM的微血管并发症,也是导致慢性肾衰的主要原因之一,30%～50%的DM患者可发生DN[1].DN治疗的关键在于早期诊断及治疗,患者一旦进入临床蛋白尿期,其肾损害难以逆转.     

糖尿病肾病的治疗

糖尿病肾病（DN）是糖尿病最常见、最严重的慢性微血管并发症之一,也是引起终末期肾病的主要原因之一。DN病程迁延,发病隐匿,早期多无症状,易延误诊断。DN一旦出现,肾功能迅速恶化进入终末期肾病。为及时发现DN,糖尿病患者应每年常规行尿微量白蛋白的筛查。T1DM于确诊5a后进行初筛,T2DM确诊后应立即开始筛查。尿微量白蛋白增高者于3-6个月内收集2次尿标本重复检测,3次标本检测结果有2次达到标准则可确诊。确诊后应采用综合治疗措施。     

糖尿病肾病炎性反应发生机制及抗炎治疗的研究进展

糖尿病肾病（DN）是糖尿病最常见和最严重的慢性并发症之一。既往研究主要集中在血糖、血脂代谢紊乱和血流动力学异常等方面,近来越来越多的研究表明DN是一种慢性低水平炎性反应性疾病,本文阐述DN炎性反应发生机制及抗炎治疗的研究进展,为进一步延缓或逆转DN的进程提供新的方法。     

依帕司他治疗早期糖尿病肾病36例疗效观察

糖尿病肾病（DN）是糖尿病慢性并发症重要的微血管病变之一,也是造成肾功能衰竭的最常见原因之一。依帕司他能有效治疗糖尿病神经病变,如肢端感觉异常、糖尿病神经源性膀胱、自主神经功能受损所致的胃食管病变等。2010年2—9月,我们观察了依帕司他对早期DN患者的治疗效果。现报告如下。     

糖尿病肾病治疗进展

糖尿病肾病(DN)是糖尿病的慢性并发症,已逐渐成为终末期肾病(ESRD)的主要原因。临床上通过饮食治疗、强化血糖控制、加强血压控制、降低蛋白质、抗氧化应激等综合治疗,能够有效地延缓肾病的进展、减少ESRD的发生、改善DN患者的预后。     

硫氧还蛋白和硫氧还蛋白相互作用蛋白与糖尿病肾病关系的研究进展

糖尿病肾病(DN)是糖尿病最常见的微血管并发症之一,临床上一旦发生,肾脏损害常呈不可逆进展,透析病人中DN患者占20%~40%[1],故DN的早期诊断及治疗对于改善患者生活质量及预后具有重要的临床意义.     

老年糖尿病肾病低血糖的护理体会

糖尿病肾病（DN）是糖尿病危害性较大的慢性并发症,糖尿病肾病患者在降糖治疗过程中常出现急性并发症低血糖反应,如得不到及时治疗,会导致休克、诱发心绞痛、心肌梗死或脑梗死等严重并发症。持久严重的低血糖不能及时纠正,将会导致患者神经系统损害,甚至危及生命。早期诊断和应对低血糖,对老年糖尿病肾病患者非常重要。现将2006年1月～2008年2月我科收治的老年糖尿病肾病患者中发生低血糖的76例患者抢救和护理经验报道如下。     

"DN一号"治疗糖尿病肾病疗效观察

糖尿病肾病 ( DN)是糖尿病最常见的慢性并发症 ,也是糖尿病的主要死亡原因。我们在多年临床经验的基础上 ,采用辨病与辨证相结合的方法 ,将中药方剂“DN一号”用于 62例 DN患者 ,观察治疗前后患者的尿蛋白、肾功能和多种细胞因子变化 ,现将结果报告如下。1　资料与方法1 .1　临床资料　本文 62例 DN患者 ,病程 2～ 1 8年。其中早期糖尿病肾病 ( Incipent DN)组 2 8例 ,平均年龄 5 3( 2 6～ 70 )岁 ;尿蛋白排泄率 ( UAE) 2 0～ 2 0 0 μg/min。将其随机分为糖尿病西药组 ( IDN- C组 )、中药DN一号组 ( IDN- D组 )。临床期糖尿病肾…     

真武汤治疗糖尿病肾病68例

糖尿病肾病(DN)是糖尿病最常见的微血管并发症,主要病理改变为肾小球动脉硬化导致的慢性肾脏疾病[1],是慢性肾衰竭和糖尿病患者死亡的主要原因之一.糖尿病肾病起病隐匿,早期无明显症状,仅出现尿微量白蛋白异常升高,难以引起足够重视,然而一旦进展到晚期,肾小球病变无法逆转,很快发展成为终末期肾病[2].西医治疗以饮食调理、控制血糖、调控血压等为主,治疗效果一般.笔者在西医常规常规基础上,配以中药真武汤调理取得较好的疗效.     

Epidemiology of diabetic nephropathy

The epidemiology of diabetic nephropathy (DN) should be approached from two angles: a) incidence of diabetic nephropathy in patients with diabetes, and b) epidemiology of chronic renal failure (CHRF) in diabetic patients. According to data from different sources, DN affects, in all its stages, about one third of patients irrespective of the type of diabetes they suffer from, with the peak rate of incidence after 15 years of duration of the illness. It is estimated that the rate of DN prevalence is 4-8% of patients monitored in diabetes centres. In addition, a significant portion of diabetics, especially the type 2 diabetic patients, are affected by the non-diabetic type nephropathy of primarily atherosclerotic etiology. Currently, DN is the principal cause of CHRF in advanced industrial countries (Western Europe, USA,Japan). A similar trend has been recorded in the Czech Republic which has one of the highest incidences of DN among the former Eastern Block countries. Most affected patients are type 2 diabetes patients. The cause of the above increase is the growing prevalence and incidence of type 2 diabetes, and, primarily, better care for type 2 diabetes patients who live long enough to develop severe macro and microvascular complications including DN. The principal factors influencing the risk of a diabetic patient developing DN are long-term monitoring ofglycaemia, control of hypertension, genetic (ethnic) factors, age and sex. Metabolic control has an effect on the risk of diabetic nephropathy developing in type 1 and 2 diabetes, yet it is blood pressure control which is critical for the progression of chronic renal insufficiency in DN patients. In view of the high number of diabetic patients with CHRF which, in addition, associates with their high polymorbidity and extensive demands put on medical and nursing care which is not directly associated with CHRF therapy, we have to do with a serious medical and economic problem.     

Analysis of the clinical course of 130 Japanese non-insulin-dependent diabetic patients undergoing dialysis

To clarify the characteristics of diabetic nephropathy (DN) in Japanese patients with non-insulin-dependent diabetes (NIDDM), we analyzed the clinical course of 130 such patients who began dialysis treatment due to DN between 1978 and 1988 at the Diabetes Center of Tokyo Women's Medical College. Analysis of the clinical course prior to attending the Diabetes Center revealed that 64 (49.2%) of the patients neglected or discontinued their initial treatment for diabetes until the development of diabetic complications because of the lack of symptoms. The average duration of untreated diabetes in these patients was 10.7 ± 4.6 years. The biggest problem for NIDDM patients was the absence of symptoms until the development of diabetic complications.     

�ٴ�ָ���ж��������������Ԥ���ֵ�������

糖尿病肾病是糖尿病主要的并发症,已成为终末期肾脏病的主要病因之一。糖尿病合并肾脏损害有很大比例是非糖尿病性肾脏疾病,两者的治疗和预后明显不同,因此早期诊断对改善预后尤为重要。综合应用年龄、糖尿病病程、糖尿病视网膜病变、血压、血糖等临床指标有助于两者的鉴别诊断及判断预后,但单纯应用临床指标仍存在一定局限性,对怀有疑问的病例仍需依靠肾活检进行确诊。新型生物标志物的临床应用价值还须进一步验证。     

Beta 2-microglobulin in the diagnosis of kidney lesions in diabetes mellitus patients

The beta2-microglobulin (beta2-MCG) test was done in 115 patients with an insulin dependent type of diabetes mellitus: 30 of them were without renal pathology, 58 had diabetes mellitus with diabetic nephropathy (DN), and 27 had concomitant chronic pyelonephritis. The effect of glucosuria and proteinuria on the beta2-MCG level was revealed. DN development and progress resulted in an increase in the beta2-MCG concentration in the blood that correlated with a decrease in the glomerular filtration. beta2-MCG urinary excretion grew in a clinically manifested DN stage only. Concomitant pyelonephritis in diabetes mellitus patients resulted mostly in a rise of the beta2-MCG level in the urine. Its concentration in the urine during the exacerbation of pyelonephritis exceeded the indices of the control group, on an average, by 467.9%. The beta2-MCG test is a valuable additional criterion in the differential diagnosis of DN in diabetes mellitus patients.     

Anemia in Diabetic Patients Reflects Severe Tubulointerstitial Injury and Aids in Clinically Predicting a Diagnosis of Diabetic Nephropathy

Objective A kidney biopsy is generally performed in diabetic patients to discriminate between diabetic nephropathy (DN) and non-diabetic kidney disease (NDKD) and to provide more specific treatments. This study investigated the impact of anemia on the renal pathology and the clinical course in patients who underwent a kidney biopsy. Methods We reviewed 81 patients with type 2 diabetes who underwent a percutaneous kidney biopsy. Patients were classified into two groups: isolated DN (DN group, n=30) and NDKD alone or concurrent DN (NDKD group, n=51) groups. The laboratory and pathological findings and clinical courses were investigated. Results In the NDKD group, membranous nephropathy was the most common finding (23.5%), followed by IgA nephropathy (17.6%) and crescentic glomerulonephritis (13.7%). In the logistic regression analysis, the absence of severe hematuria and presence of anemia were significantly associated with a diagnosis of DN. Akaike''s information criterion (AIC) and net reclassification improvement (NRI) analyses revealed improved predictive performance by adding anemia to the conventional factors (AIC 100.152 to 91.844; NRI 27.0%). The tissues of patients in the DN group demonstrated more severe interstitial fibrosis and tubular atrophy (IF/TA) than those in the NDKD group (p<0.05) regardless of the rate of global glomerulosclerosis, and IF/TA was related to the prevalence of anemia (odds ratio: 7.31, 95% confidence interval: 2.33-23.00, p<0.01) according to a multivariable regression analysis. Furthermore, the isolated DN group demonstrated a poorer prognosis than the NDKD group. Conclusion DN is associated with anemia because of severe IF/TA regardless of the renal function, and anemia helps clinician discriminate clinically between isolated DN and NDKD.     

Role of aromatic amino acids in pathogeneses of diabetic nephropathy in Chinese patients with type 2 diabetes

BackgroundWe aimed to estimate the associations between aromatic amino acids (AAAs) and diabetic nephropathy (DN) in patients with type 2 diabetes (T2D).MethodsWe collected clinical and metabolomic data from 132 healthy subjects (HS group), 132 type 2 diabetes patients without diabetic nephropathy (T2D group) and 132 diabetic nephropathy patients (DN group) in tertiary hospital from May 2015 to August 2016. The odds ratio (OR) and 95% confidence interval (CI) were obtained by logistic regression.ResultsThe odds ratio of tyrosine for DN increased gradually. High tyrosine was associated with an increased OR of DN (model 3, OR:0.329, 95%CI, 0.144–0.750) when comparing extreme quantiles.ConclusionIn Chinese patients with T2D, elevated tyrosine was associated with increased risk of DN.     

糖代谢终产物与糖尿病肾病尿毒症的相关研究

目的　研究糖代谢终产物 (AGE)水平与糖尿病肾病 (DN)尿毒症的关系 ,探讨 AGE对 DN的影响及其作用机制。方法　将 6 2例糖尿病 (DM)患者分为 DM无肾病组、DN组 (尿毒症透析组和非透析组 ) ,并设 30例体检正常者做对照组 ,采用 EL ISA法进行血清 AGE检测。结果　 DM无肾病组与对照组比较 AGE明显增高(P<0 .0 5 ) ,与血糖呈正相关 ;DN组 AGE明显增高 (P<0 .0 5 ) ,与血糖及血肌酐呈正相关。尿素症透析组与非透析组 AGE无显著性差异 (P>0 .0 5 )。结论　高血糖状态是引起 DM慢性并发症的主要原因 ;且血糖增高程度与并发症发生率直接相关 ;肾功能衰竭时 AGE明显升高 ,对全身器官造成损害。     

Maternal history of type 2 diabetes is associated with diabetic nephropathy in type 1 diabetic patients

AIMS: Insulin resistance is a key feature of type 2 diabetes. It is also involved in the development and progression of microvascular complications. We analysed the relationship between parental history of diabetes, insulin resistance and diabetic nephropathy (DN) and assessed the specific maternal and paternal influences of history of type 2 diabetes on DN in type 1 diabetic offspring. METHODS: We recorded information regarding family history of type 2 diabetes and of cardiovascular disease in 160 consecutive, unrelated type 1 diabetic patients. Insulin resistance was assessed using a validated estimation of the glucose disposal rate (eGDR). RESULTS: Type 1 diabetic patients with a maternal history of type 2 diabetes were more likely to be insulin-resistant (P=0.043) and to have renal complications (P=0.0041) than those from the reference group (without parental history of diabetes), while patients with a paternal history were not different from those from the reference group, regarding eGDR and DN. Time to development of abnormal albuminuria was significantly affected by maternal history of type 2 diabetes (log-rank=12.66; P=0.0004) and by familial history of premature cardiovascular disease (log-rank=5.48; P=0.0234). In multivariate analysis, a maternal history of type 2 diabetes was independently associated with nephropathy after adjustment for sex, diabetes duration and familial history of premature cardiovascular disease. CONCLUSION: Maternal history of type 2 diabetes is independently associated with DN in type 1 diabetic patients. This might suggest the transmission of a maternal trait related to microvascular complications, raising the hypothesis of imprinted genes predisposing to diabetic renal disease.     

Diabetic nephropathy in the elderly

Renal impairment is frequent in aged diabetic patients, notably with type 2 diabetes. It results from a multifactorial pathogeny, particularly the combined actions of hyperglycaemia, arterial hypertension and ageing. Diabetic nephropathy (DN) is associated with an increased cardiovascular mortality. DN often leads to end stage renal failure (ESRF) which causes specific problems of decision and practical organization of extra-renal epuration in diabetic and aged patients. In the absence of renal biopsy, clinical signs are often insufficient to assess the diabetic origin of a nephropathy in an elderly diabetic patient. Prevention of DN is principally based on tight glycaemic and blood pressure control. The progression of renal lesions can be retarded by strict blood pressure control, notably by blocking of the renin-angiotensin system, if well tolerated in aged patients. It is absolutely necessary to avoid the worsening of renal lesions by potentially nephrotoxic products, notably non steroidal anti-inflammatory drugs (NSAIDs) and iodinated contrast media. At the stage of renal failure, it is important to adapt the antidiabetic treatment, and in the majority of the cases, to switch to insulin when glomerular filtration rate (GFR) is below 30 ml/mn/1.73 m2.     

PAI-1基因启动子区4G/5G基因多态和Enos第4内含子a/b基因多态与糖尿病肾病的相关性研究

为探讨 PAI- 1基因启动子区 4 G/ 5 G基因多态性、一氧化氮合酶 (e NOS)第 4内含子 2 7bp插入 /缺失 (a/b)多态性与糖尿病肾病 (DN)的相关性 ,采用发色底物法测定 PAI- 1活性 ;等位基因特异性引物 PCR扩增技术测定 PAI- 1基因 4 G/ 5 G多态性 ;聚合酶链反应测定 e NOS基因第 4内含子 2 7bp的 a/ b多态性。结果显示 ,Hb A1c、SBP、TC、e NOS基因第 4内含子 a/ b多态均属 DN的独立危险因素。早期糖尿病肾病组 (DN+组 ) a等位基因及 ab基因型频率显著高于糖尿病非肾病组 (DN-组 ) (P<0 .0 5 )。DN+组血浆 PAI- 1活性明显高于 DN-组 (P<0 .0 5 ) ;4 G纯合子组 PAI- 1活性明显高于 4 G/ 5 G杂合子及 5 G纯合子组 (P<0 .0 0 5 )。2型糖尿病患者中 ,4 G纯合子和a/ b杂合子携带者 DN的相对风险明显增加 (P<0 .0 5 ) ,4 G杂合子携带者 DN的相对风险增加不明显 (P>0 .0 5 )。当 a/ b杂合子和 4 G纯合子基因多态并存时 DN的发病风险明显增加。认为 PAI- 1基因启动子区 4 G/ 5 G基因多态、e NOS基因第 4内含子 a/ b多态与 DN的发生、发展有关。两种基因多态同时存在时 ,DN的发病风险明显增加