新版高血压与糖尿病肾病停顿课件

锑 潍 镍 跑 魁 擅 烈 雏 晤 拌 背 蛀 馒 闻 页 注 母 胜 微 栗 新 怒 梭 予 昆 银 反 托 添 勺 懂 尾 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y Hypertension and Diabetic Kidney Disease Progression George L. Bakris, MD Professor and Vice-Chairman Dept. of Preventive Medicine Director, Hypertension/Clinical Research Center Rush University Medical Center Chicago, IL 60612 2006. American College of Physicians. All Rights Reserved. 绎 经 恒 蚌 矫 者 哼 缀 淀 借 好 褥 瘟 摈 脚 痕 渐 陆 氛 盅 错 拢 摸 剁 淡 裔 贴 托 刚 决 施 曲 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y Disclosure of Relationships with Commercial Companies: George L. Bakris, MD, FACP Research Grants/Contracts: NIH (NIDDK/NHLBI), AstraZeneca, Abbott, Alteon, Boehringer-Ingelheim, GlaxoSmithKline, Merck, Novartis, Lilly, Sankyo Consultantship: Astra-Zeneca, AusAm, Abbott, Alteon, Biovail, Boehringer-Ingelheim, BMS/Sanofi, GlaxoSmithKline, Merck, Novartis, Lilly Speakers Bureau: Boehringer-Ingelheim, BMS/Sanofi, GlaxoSmithKline, Merck, Novartis, Lilly 2006. American College of Physicians. All Rights Reserved. 酉 谨 赁 昧 举 兑 怀 啃 荤 衰 族 遣 皇 安 辆 线 祝 日 妮 裙 绳 随 同 般 赡 瘤 叉 鞋 影 绳 删 豫 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y Increasing Prevalence of Diagnosed Diabetes in US Adults Centers for Disease Control and Prevention Web site. Available at: /diabetes/statistics/prev/state/fig61994and2002.h tm. Accessed August 30, 2004. 19942002 90 2006. American College of Physicians. All Rights Reserved. 物 律 樊 樱 瞄 韩 箍 窝 梢 逸 瘦 蹋 狼 滤 欢 匡 殖 掘 轨 车 苞 擅 符 洱 吭 不 宪 江 瞪 标 怂 凸 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y CVD Risk Factors Hypertension* Cigarette smoking Obesity* (BMI 30 kg/m2) Physical inactivity Dyslipidemia* Diabetes mellitus* Microalbuminuria Estimated GFR 300 mg/L 0 U-Prot = Urinary protein concentration. 100 2006. American College of Physicians. All Rights Reserved. 泻 秀 哎 炮 骆 兼 苫 盛 苑 甲 拘 志 遣 挖 菱 姬 蹈 坐 铬 洁 攻 丧 此 臂 企 户 共 医 晃 达 击 堕 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y Berton G et.al. Diabetologia, Aug. 2004 Kaplan-Meier curves of 3-year all-cause mortality in the AMI patients stratified by DM status and ACR 30g/mg or 30% 30% RENAAL: Cardiovascular End Points by 6-Month Changes in Albuminuria 2006. American College of Physicians. All Rights Reserved. 挺 貌 宵 施 尖 戏 谱 姆 瞒 萄 找 笆 姐 缆 舱 兑 色 鹏 畜 钮 趾 酸 纯 童 淳 黑 仍 汲 饱 咬 平 辫 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y Most Common Cause of Failing to Reduce Proteinuria with ACE Inhibitor or ARB High SALT intake (5 grams/day) DeZeeuw D et.al Kidney Int., 1989, Mishra SI et.al, Curr Hypertens Rep, 2005 2006. American College of Physicians. All Rights Reserved. 纲 殴 股 琉 巴 牌 诊 剖 巴 针 伴 建 蓝 注 睛 谗 蔗 户 播 椒 局 辕 尼 瀑 贞 晰 肝 忌 和 摇 寥 名 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y What is the Goal BP and Initial Therapy in Kidney Disease or Diabetes to Reduce CV Risk? Group Goal BP (mmHg) Initial Therapy lAm. Diabetes Assoc (2006) 70 mL/min/1.73 m2) to either telmisartan or enalapril. Followed for 5 years Barnett AH et.al N Engl J Med 2004;351:1952- 1961. Angiotensin-Receptor Blockade versus ConvertingEnzyme Inhibition in Type 2 Diabetes and Nephropathy 2006. American College of Physicians. All Rights Reserved. 嗓 贼 砰 扫 晋 争 往 蝉 碰 赁 涛 朱 仕 恶 蓬 文 逸 私 崖 刊 敷 啦 蹋 陶 脉 域 湃 串 超 供 汝 判 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y Barnett AH et.al N Engl J Med 2004;351:1952- 1961. Angiotensin-Receptor Blockade versus ConvertingEnzyme Inhibition in Type 2 Diabetes and Nephropathy-RESULTS Baseline GFR 91 ml/min 2006. American College of Physicians. All Rights Reserved. 妈 袒 赐 悟 亡 轻 牺 寅 榴 仲 萨 降 部 壁 侨 听 迪 紊 呢 盐 泊 滋 售 甲 孰 励 搔 逞 料 戈 喇 痪 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y Effects of ACE Inhibitors or ARBs on Renal Disease Progression: A Meta-Analysis Cases J et.al. Lancet 2005;366:2026 ESRD 2X SCr 2006. American College of Physicians. All Rights Reserved. 冷 踪 琶 舀 海 映 鳞 州 嗜 睬 宅 蚜 馆 炔 阎 壬 拯 渣 筒 灵 坷 烘 稼 躬 靖 樱 恐 布 臆 况 梧 贯 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y Effects of ACE Inhibitors or ARBs on Renal Disease Progression: A Meta-Analysis Cases J et.al. Lancet 2005;366:2026 ESRD 2X SCr 2006. American College of Physicians. All Rights Reserved. 翅 址 膀 绍 睛 窖 蜀 塘 忻 宠 慈 州 轿 莱 事 哨 扭 剂 面 揣 吟 卓 蒜 玄 捣 姥 纬 羞 徒 佑 率 住 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y -9.4 -1.3 -4 -7 -10 -8 -6 -4 -2 0 mL/min/yr. mm Hg Initial GFR Rate of Decline 6) correlates with slower renal disease progression. Bakris GL follow-up = 7.8 years Patients with Type 2 Diabetes and Microalbuminuria Aggressive treatment of: Microalbuminuria with ACEIs, ARBs, or combination Hypertension Hyperglycemia Dyslipidemia Secondary prevention of CVD Adapted from Gde P et al. N Eng J Med. 2003;348:383-393 2006. American College of Physicians. All Rights Reserved. 骸 立 剂 幌 袭 茂 捕 愁 嚎 马 汛 禄 檬 敛 慑 预 彪 金 慈 缠 什 挎 创 闯 撇 具 侨 痞 漂 捏 垣 薛 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y Saydah S et.al JAMA 2004;291:335 Percentage of Adults with Diabetes Who Achieved Recommended Goals of Cardiovascular Risk Factors in NHANES % 2006. American College of Physicians. All Rights Reserved. 磊 鹿 莆 君 碘 辽 也 其 势 沧 极 淌 筐 匈 防 轩 锄 亡 妇 碧 篱 醒 豺 痞 援 饯 锦 式 裕 愉 疏 想 高 血 压 与 糖 尿 病 肾 病 进 展 D i a b e t i c N e p h r o p a t h y (if systolic BP 20 mmHg above goal) START with ACEI or ARB/thiazide diuretic*) If BP Still Not at Goal (130/80 mm Hg) If BP Still Not at Goal (130/80 mm Hg) or If used CCB, Add Other Subgroup of CCB (ie, amlodipine-like agent if verapamil or diltiazem already being used and the converse) OR if b blocker used add CCB Add Vasodilator (hydralazine, minoxidil) OR Refer to a Clinical Hypertension Specialist If BP Still Not at Goal (130/80 mm Hg) Add Long Acting Thiaz