The need for early predictors of diabetic nephropathy risk - Is albumin excretion rate sufficient?
The need for early predictors of diabetic nephropathy risk - Is albumin excretion rate sufficient?
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DOI：
10.2337/diabetes.49.9.1399
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发表时间：
2000-09-01
期刊：
影响因子：
7.7
通讯作者：
Mauer, M
中科院分区：
文献类型：
--
作者：
Caramori, ML;Fioretto, P;Mauer, M
最初的研究显示，1型糖尿病患者从微量白蛋白尿（MA）进展为蛋白尿的比率接近80%，这导致MA被广泛接受为糖尿病肾病（DN）风险增加的有用临床预测因子。然而，一些MA患者有相当晚期的肾脏结构改变，在这些情况下，IMA可能是DN的标志物而不是预测因子。最近的;研究已经观察到，在10年内，MA进展为蛋白尿的风险仅为约30-45%，而约30%的患有MA的1型糖尿病患者变为非白蛋白尿，其余的保持微量白蛋白尿。一些MA患者仅出现轻度糖尿病肾脏病变的发现与MA进展为蛋白尿的风险低于最初估计的风险以及一些MA患者恢复正常白蛋白尿的观点一致。为了增加情况的复杂性，一些正常白蛋白尿的长期1型糖尿病患者具有明确的DN病变，并且尽管患有多年糖尿病，但在所有注定进展为蛋白尿的患者中，约40%在初始筛选时是正常白蛋白尿的。2型糖尿病患者也出现了类似的情况，尽管进行的研究较少。因此，MA在随后的十年左右发展为明显肾病的预测精度远低于最初的描述。目前尚不清楚这是否是由于糖尿病肾病自然史的变化，改善的血糖和血压控制，或是否有高估的风险，在原来的研究中，由于样本量小，事后分析，和可变的MA定义。白蛋白排泄率（AER）仍然是DN风险的最佳无创预测因子，应根据既定指南定期测量。然而，AER可能无法定义安全的DN患者或存在DN风险的患者，其准确性足以用于最佳临床决策或某些临床试验的设计。需要对新的风险标志物或几个当前可用的预测参数的组合使用进行调查。
Initial studies showing an similar to 80% rate of progression from microalbuminuria (MA) to proteinuria in type 1 diabetic patients led to the broad acceptance of MA as a useful clinical predictor of increased diabetic nephropathy (DN) risk. Some MA patients, however, have quite advanced renal structural changes, and IMA may, in these cases, be a marker rather than a predictor of DN. More recent; studies have observed only about a 30-45% risk of progression of MA to proteinuria over 10 years, while about 30% of type 1 diabetic patients with MA became nonnoalbuminuric and the rest remained microalbuminuric. The finding that some MA patients have only mild diabetic renal lesions is consistent with the lower than originally estimated risk of progression from MA to proteinuria and with the notion that some MA patients revert to normoalbuminuria. To increase the complexity of the scenario, some normoalbuminuric long-standing type 1 diabetic patients have well-established DN lesions and similar to 40% of all patients destined to progress to proteinuria are normoalbuminuric at initial screening, despite many years of diabetes. A similar picture is emerging In type 2 diabetic patients, although fewer studies have been conducted. Thus, the predictive precision for MA to progress to overt nephropathy over the subsequent decade or so is considerably less than originally described. It is unclear whether this is due to changes In the natural history of DN resulting from improved glycemia and blood pressure control, or whether there were overestimates of risk in the original studies due to the small sample sizes, post hoc analyses, and variable MA definitions. Albumin excretion rate (AER) remains the best available noninvasive predictor of DN risk and should be regularly measured according to established guidelines, However, AER may be unable to define patients who are safe from or at risk of DN with an accuracy that is adequate for optimal clinical decision making or for the design of certain clinical trials. Investigations into new risk markers or into the combined use of several currently available predictive parameters are needed.