Beruflich Dokumente
Kultur Dokumente
Guyton, 1991
ElizabethHughes(19071981)
Treatment
Glycemic control
DCCT
1441 patients with type I DM randomly assigned to
intensive therapy vs. conventional therapy
Intensive therapy reduced microalbuminuria by 39%
Reduced albuminuria by 54%
Treatment
Hypertension control:
Lower the BP, slower the decline in GFR in
patients with diabetic nephropathy
JNC VI recommended BP < 130/85 mmHg in
patients with renal insufficiency
Patients with CKD and > 1g proteinuria, BP
goal should be < 125-130/75-80 mmHg
Treatment
ACE inhibitors:
Type I diabetes with nephropathy:
Lewis et al. NEJM, 1993. captopril vs. placebo
50% RR of combined end points of death, dialysis and
transplantation in ACEI group independent of BP
Treatment
Angiotensin-receptor blockers:
RENAAL study(2001)
1513 pts with type II DM and nephropathy. Losartan vs.
placebo. Losartan reduced the rate of doubling of cr by 16%
but no effect on the rate of death.
IDNT(2001)
1715 type II DM pts with nephropathy. Irbesartan vs.
amlodipine vs. placebo. Irbesartan has 20% lower risk of
reaching endpoints compared to placebo and 23% lower
incidence than that in the amlodipine group
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Treatment
Conclusions:
ACE inhibitors or ARB have a strong
antiproteinuric effect apart from their
antihypertensive actions
Increasing the dose of the ACEI or ARB beyond
the optimum antihypertensive doses further
reduces proteinuria
Antiproteinuric effect is enhanced by a low Na
diet or diuretic
Treatment
Early screening
Tight glycemic control
HTN management
Use ACEI as first line, if not tolerated, use
ARB. Use the maximum dose as tolerated
If still hypertensive or proteinuric, consider
using combination ACEI and ARB, or ACEI
and diuretics