1、會計學(xué)1acei和和arb類藥物在糖尿病腎病中的應(yīng)用類藥物在糖尿病腎病中的應(yīng)用第1頁/共77頁第2頁/共77頁第3頁/共77頁第4頁/共77頁第5頁/共77頁 其他其他 促進(jìn)細(xì)胞凋亡，影響胰島素促進(jìn)細(xì)胞凋亡，影響胰島素和脂質(zhì)代謝和脂質(zhì)代謝第6頁/共77頁第7頁/共77頁RAS在腎臟疾病中的作用在腎臟疾病中的作用第8頁/共77頁第9頁/共77頁第10頁/共77頁K/DOQI第11頁/共77頁葉平、程慶礫Clinical Cardiorenal Intersection Disease第12頁/共77頁缺血性心臟病缺血性心臟病（臨床）（臨床）左室肥厚左室肥厚（超聲）（超聲）心力衰竭心力衰竭（臨床）

2、（臨床）普通人群普通人群8%-13%20 %3%-6%CKD3-4期期(糖尿病和非糖尿病腎病糖尿病和非糖尿病腎病)NA25 % -50 %NACKD1-4期期(腎移植術(shù)后腎移植術(shù)后)15%50%-70%NACKD5期期(血液透析血液透析)40%75%40%CKD5期期(腹膜透析腹膜透析)40%75%40%葉平、程慶礫Clinical Cardiorenal Intersection Disease第13頁/共77頁第14頁/共77頁葉平、程慶礫Clinical Cardiorenal Intersection Disease第15頁/共77頁傳統(tǒng)危險因素傳統(tǒng)危險因素非傳統(tǒng)危險因素非傳統(tǒng)危險因素

3、老年人老年人蛋白尿蛋白尿男性男性高半胱氨酸高半胱氨酸高血壓高血壓脂蛋白脂蛋白A和載脂蛋白和載脂蛋白A亞型亞型高高LDL-C脂蛋白碎片脂蛋白碎片低低HDL-C貧血貧血糖尿病糖尿病鈣鈣/磷代謝異常磷代謝異常吸煙吸煙細(xì)胞外容量負(fù)荷增加細(xì)胞外容量負(fù)荷增加缺乏體力活動缺乏體力活動電解質(zhì)失衡電解質(zhì)失衡更年期更年期氧化應(yīng)激氧化應(yīng)激心血管病家族史心血管病家族史炎癥（炎癥（CRP）左室肥厚左室肥厚營養(yǎng)不良營養(yǎng)不良血栓形成因素血栓形成因素睡眠障礙睡眠障礙NO/內(nèi)皮素的平衡破壞內(nèi)皮素的平衡破壞第16頁/共77頁K/DOQI第17頁/共77頁分分 期期描描 述述GFR(ml/min/1.73m2)1腎損害；腎損害；G

4、FR正?；蛘；?02腎損害伴腎損害伴GFR輕度輕度60893中度中度GFR30594重度重度GFR15295腎衰竭腎衰竭15簡化的簡化的MDRD方程方程 GFR=186(Scr)-1.154年齡 -0.203(0.742女性)(1.210非裔)K/DOQI第18頁/共77頁分期描述分期描述GFR（ml/min/1.73m2）代償期代償期5080失代償期失代償期2550腎衰竭期腎衰竭期1025尿毒癥期尿毒癥期10第19頁/共77頁第20頁/共77頁 分期分期 臨床表現(xiàn)臨床表現(xiàn)病理學(xué)表現(xiàn)病理學(xué)表現(xiàn)腎小球高濾過腎小球高濾過和腎臟肥大期和腎臟肥大期無無無病理學(xué)損傷無病理學(xué)損傷正常白蛋白尿期正常白蛋白

5、尿期GFRGFR高出正常水平，運動后高出正常水平，運動后UAEUAE升高升高20g/min20g/min，休息后恢復(fù)正常，休息后恢復(fù)正常5g/min5g/minGBMGBM增厚，系增厚，系膜區(qū)基質(zhì)增多膜區(qū)基質(zhì)增多早期糖尿病腎病期早期糖尿病腎病期（持續(xù)微量白蛋白期）（持續(xù)微量白蛋白期）GFR開始下降到正常，開始下降到正常， UAEUAE持續(xù)升高持續(xù)升高, ,血壓升高，血壓升高，ACR30-300g/mgACR30-300g/mg腎小球結(jié)節(jié)樣腎小球結(jié)節(jié)樣改變和小動脈改變和小動脈玻璃樣變玻璃樣變臨床糖尿病腎病期臨床糖尿病腎病期持續(xù)大量蛋白尿，持續(xù)大量蛋白尿，UAEUAE200g/min200g/mi

6、n，30%30%患者出現(xiàn)腎病綜合征，患者出現(xiàn)腎病綜合征，GFRGFR持續(xù)明持續(xù)明顯下降顯下降出現(xiàn)典型的出現(xiàn)典型的K-W結(jié)節(jié)結(jié)節(jié)終末期腎衰竭終末期腎衰竭GFR 15ml/min.1.73m15ml/min.1.73m2 2，蛋白尿減，蛋白尿減少少腎臟縮小腎臟縮小第21頁/共77頁第22頁/共77頁第23頁/共77頁第24頁/共77頁第25頁/共77頁第26頁/共77頁第27頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2,

7、FEBRUARY 2007第28頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第29頁/共77頁第30頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第31頁/共77頁2007 KDOQI

8、CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第32頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第33頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom Ameri

9、can Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第34頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第35頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO

10、2, SUPPL 2, FEBRUARY 2007第36頁/共77頁第37頁/共77頁第38頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第39頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 200

11、7第40頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第41頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第42頁/共77頁2007 KDOQI CPG and CPR for Diabe

12、tes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第43頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第44頁/共77頁2007 KDOQI CPG and CPR for Diabetes and CKDfrom American Journal of Kidney

13、 Diseases VOL 49, NO 2, SUPPL 2, FEBRUARY 2007第45頁/共77頁第46頁/共77頁第47頁/共77頁終發(fā)生腎功能衰竭，需要透析終發(fā)生腎功能衰竭，需要透析或腎移植。或腎移植。第48頁/共77頁第49頁/共77頁第50頁/共77頁第51頁/共77頁第52頁/共77頁第53頁/共77頁第54頁/共77頁第55頁/共77頁第56頁/共77頁第57頁/共77頁第58頁/共77頁第59頁/共77頁第60頁/共77頁第61頁/共77頁第62頁/共77頁第63頁/共77頁第64頁/共77頁第65頁/共77頁第66頁/共77頁第67頁/共77頁第68頁/共77頁厄貝

14、沙坦對厄貝沙坦對AT1的阻斷作用比纈沙的阻斷作用比纈沙坦和氯沙坦強，時間也更持久坦和氯沙坦強，時間也更持久Burnier M. Circulation. 2001;103;904-912Kassler-Taub K, et al. Am J Hypertens. 1998 ;11(4 Pt 1):445-453 Mancia G, et al. Blood Pressure Monitoring. 2002;7:135-142第69頁/共77頁第70頁/共77頁謝謝謝謝第71頁/共77頁第72頁/共77頁I. Inclusion criteriaA. Age 3070; (1 year; or

15、b. elevated fasting or stimulated C-peptide levelC. Diabetic nephropathy1. 24-h urine protein excretion 900 mg2. Serum creatinine between 90 and 265 mol/l (1.03.0 mg/dl) in women and between 110 and 265 mol/l (1.23.0 mg/dl) in menD. Hypertension1. Seated SBP 135 mmHg and/or seated DBP 85 mmHg untreated; or2. Receiving antihypertensive medicationII. Exclusion criteriaA. Age of onset of type II diabetes 20 yearsB. Type I diabetesC. Absolute requirement for an ACEI, AIIRA or CCBD. Cardiovascular disease1. Unst