糖尿病性腎症の診断と治療(シリーズ「糖尿病の治療」(6))

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  • シリーズ トウニョウビョウ ノ チリョウ 6 トウニョウビョウセイジンショウ ノ シンダン ト チリョウ
  • Diagnosis and Treatments of Diabetic Nephropathy(Series "Treatment of Diabetes Mellitus" (6))

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Diabetic nephropathy has been the leading cause of end-stage renal disease in Japan since 1998. Mortality rates after commencing dialysis are higher in diabetic patients than in non-diabetic patients; therefore, early diagnosis and treatment of this serious complication are issues of prime importance. Diabetic nephropathy is classified into the following 5 stages; stage 1: normoalbuminuria, stage 2: microalbuminuria, stage 3: clinical albuminuria, stage 4: renal failure, and stage 5: dialysis stage. For quantitative evaluation of albuminuria in diabetic patients, measurement of albumin excretion in a 24-h urine collection has been the gold standard; however, collection errors due to improper timing and missed samples may lead to significant over- and under-estimation of albuminuria. For convenience and consistency, recent guidelines recommended measurement of albumin-to-creatinine ratio (ACR) in a random spot urine collection. Normoalbuminuria is diagnosed if ACR < 30 mg/g creatinine, microalbuminuria if ACR was 30-299 mg/g creatinine, and clinical albuminuria if ACR ⪰ 300 mg/g creatinine. Evidence indicates strict glycemic control and tightly lowering blood pressure are both effective to prevent the onset and progression of nephropathy. Hemoglobin Aic, as a measure of glycemic control, is recommended to maintain<6.5%. Recent guidelines proposed lower values of blood pressure (130/80 mmHg) for diabetic patients than for non-diabetic patients (140/90 mmHg). Regarding the selection of antihypertensive drugs, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are recommended as the first line therapy for hypertension in diabetes. Most of diabetic patients, especially those with advanced nephropathy, require more than two antihypertensive drugs to establish target levels of blood pressure; therefore, adding calcium-channel blockers, beta-adrenergic blockers, and small dose of diuretics should be considered as appropriate according to each patient's condition.

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