糖尿病肾病(英文)课件

DiabeticNephropathyStatisticalIncreaseinDiabetesInthepast20years,therehasbeenasteadyincreaseintheproportionofallpatientswithESRDwhohavediabetes.Accordingtothe1997reportoftheUSRDS,morethan40%ofallnewlytreatedpatientswithESRDhavediabetes.RenalFailureCumulativeIncidence.Chronicrenalfailurewasaslikelytodevelopatasuperimposablerateinbothdiabeticsubsets.Numbersinparenthesesindicatenumberofpatientsforeachline.糖尿病肾病的发病机理（1）肾内血动力学改变：肾内血流动力学改变是指肾小球高滤过及肾小球高压。动物实验，糖尿病模型建立后，即已存在肾小球的高滤过与肾小球肥大。糖尿病肾病的发病机理（1）高滤过是导致肾功能恶化的主要原因。在非糖尿病性5/6肾切除的动物模型中可见肾小球系膜基质增多，GBM增厚及节段性肾小球硬化。肾小球内高压是导致肾小球硬化的另一重要因素糖尿病肾病的发病机理（2）葡萄糖的毒性效应高血糖可导致内皮细胞，系膜细胞的结构及功能的改变。高血糖促使系膜细胞合成更多的胞外基质。持续的高血糖可使血浆蛋白及组织蛋白糖基化，导致晚期糖基化终末产物的生成。糖尿病肾病的临床表现Ⅰ型及Ⅱ型糖尿病患者都有很大的可能发展为糖尿病肾病，Ⅰ型糖尿病患者其肾病更为显著，进展也更为迅速，当发生了明显糖尿病肾病后，两型的临床表现则无很大差别。临床上按照病理生理特点将Ⅰ型糖尿病肾病分为Ⅰ—Ⅴ期。目前尚无Ⅱ糖尿病肾病的临床分期，但其发生糖尿病肾病时也大体经历高滤过，正常白蛋白尿，微量白蛋白尿，临床糖尿病肾病及慢性肾功能不全等几个阶段。DiabeticNephropathyinTypesI&II.WhereasmicroalbuminuriaandglomerularhyperfiltrationaresubtlepathophysiologicmanifestationsofearlyDN,transformationtoovertclinicalDNtakesplaceovermonthstomanyyears.Whilenotallmicroalbuminuricindividualsprogresstoproteinuriaandazotemia,themajorityareatriskforESRDduetoDN.糖尿病肾病及慢性肾功能不全的预防控制血糖控制血压低蛋白饮食对AGES的治疗Clinicalrecognitionofdiabeticnephropathy.Thetimingofreno-protectivetherapyindiabetesisasubjectofcurrentinquiry.Certainly,hypertension,poormetabolicregulation,andhyperlipidemiashouldbeaddressedineverydiabeticindividualatdiscovery.DiscoveryofmicroalbuminuriaisbyconsensusreasontostarttreatmentwithanACEIineithertypeofdiabetes,regardlessofBPelevation.However,nearlytheentirecourseofrenalinjuryindiabetesisclinicallysilent.Medicalinterventionduringthis“silentphase,”comprisingBPpressureregulation,metaboliccontrol,dietaryproteinrestriction,andadministrationofACEIisrenoprotective,asjudgedbyslowedlossofGFR.PROGRESSIONOFCOMORBIDITY

INTYPEIIDIABETES

COMORBIDITYINDEX

HEARTDISEASEComplicationsInitial%Subsequent%Retinopathy50100Cardiovascular4590Cerebrovascular3070Peripheralvascular1550Creatinineclearancedeclinedfrom81mL/minover74(40—119)mo.Endpoint:dialysisordeath.HEARTDISEASE

HyperlipidemiaHypertensionVolumeoverloadACEinhibitorErythropoietinHeartdiseaseistheleadingcauseofmorbidityanddeathinbothtypeIandtypeIIdiabetes.ThroughoutthecourseofDN,periodicscreeningforcardiacintegrityisappropriate.CLINICALSTRATEGY

MainCollaboratorsConsultantsOpththalmologistNeurologistPodiatristVascularsurgeonCardiologistEndocrinologistNutritionistGastroenterologistNurseeducatorUrologistPLANNINGFORESRD

ExposepatienttotreatmentoptionsEstablishvascularorperitonealaccessEncourageintrafamilialkidneydonationMonitorcreatinine,generalwellbeingEarlydialysisstartManagementwithdialysisOPTIONSINDIABETESWITHESRD

CAPD/CCPDHDTransplantationFirst-yearsurvival75%75%>90%Survival>10y<5%<5%>25%DiabeticcomplicationsProgressProgressSlowprogressionRehabilitationPoorPoorFairtoexcellentPatientacceptanceFairFairGoodtoexcellentSurvivalRatesofDiabeticESRDPatients.Afteradecadeoftreatment,theremarkablesuperiorityofrenaltransplantationoverdialysis(combinedPDandHD,lowercurve)isevidentinthesesurvivalcurvesdrawnfromthe1997reportoftheURDS.Fewerthan1in20dia