糖尿病肾病的防治策略.ppt

* * * * * * * * * * * * 当3个月的饮食及运动干预后，糖化血红蛋白仍大于6.5，开始口服药治疗。 * * Because hypertension and dyslipidaemia tend to be co-morbid with type 2 diabetes, true treatment to target is not a matter of glycaemic control only. A multifactorial intervention is needed. The study from the Steno Diabetes Center in Denmark proves that optimal management in type 2 diabetes includes control of BP to 130/80 mmHg and reduction of LDL cholesterol. Patients were randomised to either conventional (n = 80) or intensive treatment (n = 80). Intensive treatment included insulin to control HbA1C to 6.5%, a diuretic to control BP, and an ACE inhibitor, regardless of BP level. Additional therapies were as follows: Intensive treatment: an angiotensin II receptor blocker to control BP to  130/80 mmHg, dietary management of serum lipids (cholesterol: 190 mg/dl; fasting triglycerides: 150 mg/dl), and aspirin 150 mg/day. Conventional treatment: BP control to 135/85 mm Hg and serum lipid control (cholesterol 250 mg/dl; fasting triglycerides 180 mg/dl), with aspirin therapy reserved for patients with known ischaemia. Gaede P et al. N Engl J Med 2003; 348: 383–93. * * * * * ACEI ACEI: Serum Cr 3mg/dl,血钾5.5mmol/L 治疗中： Cr上升 30%, 　　　　 Cr不上升表示效果不好 停 药：血钾＞６mmol/L，Ｃr上升30% 主要指标：尿总蛋白，尿白蛋白下降 ACEI和ARB联合治疗 Steno-2 研究 试验设计 开放性对照平行试验，有160例有微量白蛋白尿的2型白人糖尿病患者参与 患者随机分组，接受全科医师的常规治疗或Steno糖尿病中心的强化治疗 常规治疗组 强化治疗组 终点事件检查 微血管病变 大血管病变 4 年 8 年 80 80 160 强化治疗组的干预措施 饮食干预：脂肪摄入量小于总热量的30％；饱和脂肪酸小于总热量的10％ 运动干预：30分钟轻中度运动，每周5次 鼓励患者及家属戒烟 所有患者使用相当于50mg bid开博通剂量的ACEI或相当于50mg bid 络沙坦剂量的ARB 所有患者使用阿司匹林（除非有禁忌证） 当HbA1c6.5%, 使用口服药 当口服药使用至极量而HbA1c7.0%，开始使用胰岛素 第8年生化危险因素 糖化血红蛋白(%) 9.0 7.9 收缩压(mmHg) 146 131 舒张压(mmHg) 78 73 总胆固醇(mmol/l) 5.6 4.1 LDL-Ch(mmol/l) 3.3 2.1 甘油三酯(mmol/l) 3.0 1.7 尿白蛋白(mg/24h) 126 26 常规组 强化组 STENO-2 * Composite endpoint = CV death and amputation (with either therapy), a