伴尿微量白蛋白增高的2型糖尿病肾病患者的循证治疗（附2例报告）_《中国循证医学杂志》

作者：

陈小兰 , 蒙张敏 , 郑玉霞 , 王双

四川大学华西医院老年科（成都 610041）;

关键词：

糖尿病肾病白蛋白尿血管紧张素受体拮抗剂循证治疗

DOI：

10.7507/1672-2531.20080046

视频：

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摘要 全文 图表 视频 参考文献 施引文献 补充材料

目的　为两例尿微量白蛋白增高的2型糖尿病肾病患者制定治疗方案。
方法　根据循证临床实践的方法，提出问题，检索证据，对所获证据进行评价，并结合患者意愿为患者制定治疗方案。
结果　共纳入14个随机对照试验，2个系统评价，2个Meta分析和41个临床指南。证据结果表明：① 尿白蛋白增高是糖尿病患者心血管事件的独立危险因素；② 血管紧张素受体拮抗剂能降低2型糖尿病肾病患者尿白蛋白水平。③ 降糖降压治疗能使此类患者获益。结合患者情况，应用证据治疗1月后，2例患者血肌酐恢复正常，尿白蛋白转阴性。
结论　以高质量证据，结合患者情况制定治疗方案，能明显保护肾脏及心脏，降低尿白蛋白，但远期预后尚需要更长时间的随访观察。

引用本文： 陈小兰,蒙张敏,郑玉霞,王双. 伴尿微量白蛋白增高的2型糖尿病肾病患者的循证治疗（附2例报告）. 中国循证医学杂志, 2008, 08(3): 210-213. doi: 10.7507/1672-2531.20080046 复制

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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.
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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.
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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.
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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.

《中国循证医学杂志》

伴尿微量白蛋白增高的2型糖尿病肾病患者的循证治疗（附2例报告）

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《中国循证医学杂志》

伴尿微量白蛋白增高的2型糖尿病肾病患者的循证治疗（附2例报告）

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