Hypertension, high blood sugar of diabetic nephropathy

Diabetic nephropathy is one of the microvascular complications of diabetes the most important type 2 diabetes patients with nephropathy prevalence of
34.7%. With the rapid economic development, people's living standards continue to improve, the incidence of diabetes is increasing year by year, diabetes
Patients with nephropathy have increased. In developed countries diabetic nephropathy has become the first cause of ESRD, but also has become following the second cause of primary glomerular diseases, diabetes caused by one of the main reasons for death, disability, so the effective prevention and treatment of diabetic nephropathy has become one of the major issue.
Development and staging of diabetic nephropathy
Diabetic nephropathy is one of the diabetic microangiopathy often associated with diabetic retinopathy. Egg
White urine is a sign of diabetic nephropathy progress. The sustained microalbuminuria in early diabetic nephropathy,, the prosecution
Measured urinary conventional urine protein may be negative or only trace detection of urinary albumin excretion rate (UAER)
Of 20 to 200 μg / min or of 30 ~~ 300 mg/24 h; once the development to the period of clinical diabetic nephropathy, ie, urinary protein
(+) Or more, UAER,> 200 μg / min or> 500 mg/24 h in patients with glomerular filtration rate (GFR)
Was a progressive decline in, and tend to increase in blood pressure, renal pathological damage to the irreversible stage, the most
Final development of renal failure.
Diabetic nephropathy is divided into five, one, two clinical difficult to diagnose, often sustained microalbumin
Clinical can only be diagnosed when the urine of diabetic nephropathy 3. This time after a positive and effective antihypertensive, hypoglycemic therapy,
Part of the urinary albumin excretion in patients with reduced or negative, kidney disease reversal or development delay. But if we can not
Do on a regular basis to check the urine in patients with urinary albumin excretion rate, until the patients had edema, high
Blood pressure, proteinuria, renal function abnormalities before considering the possibility of diabetic nephropathy, and more have been developed to sugar
4 of diabetes nephropathy, the lesion is irreversible. Thus, clinical guidelines suggest that diabetic patients should be regularly
(1/3 ~ 6 months) monitoring of urine and the detection of urinary albumin in order to achieve early diagnosis,
Early treatment. The occurrence and development of diabetic nephropathy follow the laws of the two intersecting curves, one for proteinuria
Curve from the negative, trace a large number of urinary protein gradually increased, and the other a curve for the glomerular filtration rate from
Higher than normal, normal to decreased, the two curves cross more than four diabetic nephropathy.
In addition, we should also pay attention to the identification,
Patients with diabetes and proteinuria, should not be diagnosed as diabetic nephropathy, history of diabetes less than five years, the sudden appearance of a large number of patients with proteinuria and normal renal function, not associated with diabetic retinopathy, basic can exclude diabetic nephropathy possible, to referral to superiors Hospital Nephrology Renal biopsy pathological diagnosis in order to give the correct treatment. If we blindly follow the treatment of diabetic nephropathy will be adversely affected by illness. The etiology of diabetic nephropathy is very complex, it is not very clear, but mainly the following risk factors: genetic, hypertension, high blood sugar and obesity, dyslipidemia, high uric acid. Including hypertension and high blood sugar is an important risk factor for the occurrence and development of diabetic nephropathy. Previous studies recognized cardiovascular and cerebrovascular diseases is diabetes the most common complications and death in the direct cause of hypertension and high blood sugar can significantly increased the incidence of cardiovascular and cerebrovascular diseases.
The relationship between hypertension and diabetic nephropathy
Hypertension to the glomerular capillary bed is passed through the systemic blood pressure, increased pressure within the ball, filtration pressure increase
High, resulting in increased glomerular sclerosis. Hypertension and diabetic nephropathy can promote each other. Hypertension can
The progressive increase in type 2 diabetic patients with normal urine albumin levels of urinary albumin and clinical diabetes
Nephropathy in patients with renal function deterioration. Antihypertensive treatment to prevent or delay a of the two is too
The occurrence and development of process. Studies have shown that the level of blood pressure control affect the prognosis of diabetes were independent risk
Factors.
Decline in glomerular filtration rate (GFR) and blood pressure levels. According to the 2007 edition of diabetes anti
Governance guidelines, patients with proteinuria <1 g/24 h the control of blood pressure should be below 130/80 mm Hg [including the 2007
American Diabetes Association (ADA) guidelines and the European Society for Cardiovascular Diseases / European Society of Hypertension (ESC /
ESH) guidelines to blood pressure control below 130/80 mm Hg given as proteinuria <1 g / d in patients with buck head
Value]; marked proteinuria> 1 g/24 h in patients, blood pressure control should be below 125/75 mm Hg, based primarily on
MDRD (The Modification of Diet in Renal Disease Study) clinical evidence-based medical research.
The study was supported by the leadership of the U.S. National Institutes of Health (NIH), 15 kidney disease center, compared different antihypertensive goals
Value of delay in patients with chronic kidney disease, kidney damage to progress. MDRD study finds that: egg
White urine> 1 g / patients of d, mean arterial pressure (MAP) should be strictly controlled to 92 mm Hg in order to effectively delay the
Kidney damage to progress. Moreover, in the same MAP level, lower systolic blood pressure and pulse pressure is heavier than lower diastolic blood pressure
Needs. The study recommended that the control of blood pressure below 125/75 mm Hg as proteinuria> 1 g / d in patients with the
Step-down target. The proteinuria <1 g / d of CKD patients blood pressure should be controlled and to what level, the MDRD study
Study is not a conclusion.
The selection and application of antihypertensive drugs
Delay in the occurrence and development of diabetic nephropathy, we choose antihypertensive drugs benefit more? First
The antihypertensive drugs selected for the angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor antagonist
(ARB) and the new listing of a renin inhibitor, has a lot of evidence in the basic and clinical research
Implementation can improve the prognosis of early diabetic nephropathy. Of ACEI and ARB class of antihypertensive drugs because it can reduce the renal
Ball filtration pressure and improve renal blood flow dynamics, inhibit the production and secretion of inflammatory factors and cytokines, suppression
System of mesangial cells, fibroblasts and macrophage activation and proliferation, to improve the permeability of the filtration membrane, reduce urinary
Protein excretion and so on to become the first choice for diabetic nephropathy. Therefore, in clinical practice, when patients with micro egg
White urine, with or without hypertension, should be given ACEI or ARB treatment. The recommended start small dose,
One dose every 1 to 2 weeks, patients able to tolerate the maximum dose is appropriate, that is not symptomatic low
Elevated blood pressure, drug-free serum creatinine, and hyperkalemia is appropriate. For trace, or a small amount of proteinuria the risk of
Usually the application of drugs, a dose of 1 to 2 times, the exclusion of other interfering factors,
A few months later the majority of patients with urinary protein standards. For patients with massive proteinuria, should first check 24
Urinary protein, and then gradually increase to a single drug dose can ACEI the ARB, based on each
Months urinary protein quantification check, and patients on drug tolerance of plus or minus dose (not yet
More and better evidence-based medicine evidence that combination therapy is better than single drug treatment). If the application of ACEI
Or ARB blood pressure can not be achieved and can be combined calcium antagonists. If accompanied by edema, can be combined diuretic
Agent.
beta blockers as first choice, but for the young, and rapid heart rate, history of ischemic heart disease
Patients can be applied. In addition, in the step-down at the same time, also need to limit sodium intake, increasing exercise, quitting smoking
Adjusting lifestyles treatment.
The relationship between hyperglycemia and diabetic nephropathy
High blood sugar can cause kidney a series of pathophysiological changes, including: non-enzymatic glycation end products increase, sorbitol increased production, enhanced oxidative stress, protein kinase C and transforming growth factor (TGF) beta activity increased, resulting in glomerular increased extracellular matrix, cell injury and proteinuria increased. Another long-term high blood sugar so that the glomerulus in a hyperfiltration state, resulting in glomerular hyperperfusion and ball pressure, so that the glomerular hypertrophy, basement membrane thickening, increased capillary permeability, proteinuria formation , eventually leading to glomerulosclerosis.
DCCT study conducted in 1441 patients with type 1 diabetes patients from 29 medical centers in the United States and Canada in 1993, with its strict design, large-scale observation for a long time been recognized as the most convincing studies that strict control high blood sugar can effectively delay the onset and development of diabetic nephropathy. Studies have shown that strict control of blood sugar can make of microalbuminuria in type 1 diabetes incidence decreased by 39%, the incidence of clinical proteinuria decreased by 54%. The United Kingdom Prospective Diabetes Study (UKPDS) is so far the longest Prospective Diabetes Study, intensive therapy group intervention on selected newly diagnosed patients with type 2 diabetes for more than 10 years, mean HbA1c was 7.0%, the conventional therapy group was 7.9%. Intensive treatment of the relative risk of any diabetes-related endpoint by 12%, mainly due to reduced risk of microvascular complications. Intensive glucose control can make the occurrence of microalbuminuria in patients with type 2 diabetes by 30 percent. Analysis found that intensive treatment HbA1c decreasing by 1%, 21% lower relative risk of any diabetes-related endpoint, the risk of microvascular complications can be reduced by 37%. For blood sugar control, with HbA1c as a blood glucose target value method. According to Chinese Medical Association in August 2010 Ninth National Endocrine Conference released the "China Adult 2
Diabetes, HbA1c control goal of the expert consensus, it is recommended that the HbA 1c monitoring the condition of patients every 3 to 6 months
OK time, blood glucose control targets must be individualized, individualized. For elderly patients with diabetes,
Existing cardiovascular disease or risk, the blood glucose target should be relaxed, to avoid the occurrence of hypoglycemia and
Increased risk of death.
The choice of antidiabetic drugs sulfonylureas mouth medication, insulin is the preferred biguanide drugs in renal function is
Often can be applied to the α-glucosidase inhibitors have fewer side effects, regardless of renal function can take. To
Insulin sensitizers current debate, the United States has been under the city, it is not recommended.
Expert tips
Diabetes is a disease of serious harm to human health. Closely related to the occurrence of diabetic nephropathy, development and high blood pressure, high blood sugar. Control of blood pressure and blood sugar levels were independent risk factors affecting the prognosis of diabetic nephropathy. Strict blood pressure, blood glucose control is of great significance to reduce proteinuria and protect renal function and prevention of cardiovascular and cerebrovascular complications, In addition, we should also pay attention to the regulation of lipid levels to statin cholesterol lowering agents, should be to control high uric acid hyperlipidemia, appropriate restrictions on the amount of protein intake, avoiding use of nephrotoxic drugs. Regular monitoring of urine, urinary protein excretion, renal function and blood sugar levels, in order to adjust the treatment plan, and strive to make the indicators achieved and delay the development of diabetic nephropathy, while reducing the occurrence of cardiovascular complications and fatal complications, improve quality of life of patients with diabetes.