Re: [討論] 關於蛋白尿首選藥物
: : → hahawow:聽說降低蛋白尿不一定能減緩腎功能惡化..... 11/28 17:08
: 對糖尿病的尿蛋白,目前認為降低蛋白尿,可減緩腎功能惡化;
: 其它種類的,證據則較弱
Kidney Int. 2012 Mar;81(6):586-94.
Combined intensive blood pressure and glycemic control does not produce
an additive benefit on microvascular outcomes in type 2 diabetic patients.
ACCORD Study Group.
Abstract
A reduction of either blood pressure or glycemia decreases some microvascular
complications of type 2 diabetes, and we studied here their combined effects.
In total, 4733 older adults with established type 2 diabetes and hypertension
were randomly assigned to intensive (systolic blood pressure less than 120
mm Hg) or standard (systolic blood pressure less than 140 mm Hg) blood
pressure control, and separately to intensive (HbA1c less than 0.060) or
standard (HbA1c 0.070-0.079) glycemic control.
Prespecified microvascular outcomes were a composite of renal failure and
retinopathy and nine single outcomes. Proportional hazard regression models
were used without correction for type I error due to multiple tests. During
a mean follow-up of 4.7 years, the primary outcome occurred in 11.4% of
intensive and 10.9% of standard blood pressure patients (hazard ratio 1.08),
and in 11.1% of intensive and 11.2% of standard glycemia control patients.
Intensive blood pressure control only reduced the incidence of
microalbuminuria (hazard ratio 0.84), and intensive glycemic control
reduced the incidence of macroalbuminuria and a few other microvascular
outcomes. There was no interaction between blood pressure and glycemic
control, and neither treatment prevented renal failure. Thus, in older
patients with established type 2 diabetes and hypertension, intensive
blood pressure control improved only 1 of 10 prespecified microvascular
outcomes. None of the outcomes were significantly reduced by simultaneous
intensive treatment of glycemia and blood pressure, signifying the lack of
an additional beneficial effect from combined treatment.
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※ 編輯: hahawow 來自: 123.192.237.38 (11/28 18:38)
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最有證據力的研究方法是找出一群有DM with proteinuria的病人,分為兩組
然後實驗組採取降蛋白尿的措施,然後再分析renal outcome
不過目前好像沒這種大規模prospective study
那就只能從現有大規模study中去找尋具有類似作用的study,
但當我們面對病人時,我們面對的是是否該採取某種intervention,
所以精神仍舊應該是在比較intervention與否對outcome影響,
DM proteinuria目前建議的處理不外乎ACEI/ARB(/DRI?), 降血壓, 降血糖
要比較intervetion與否的差異,當然去找以DM為population,
而且intervention組有ACEI/ARB(/DRI?), 降血壓, 降血糖的study
從中找出一entry時有proteinuria的病人,然後比較這群病人後來的renal outcome,
ACCORD算是非常大型的RCT,而且不是個別廠商主導,
按理講randomization應該不會有太大問題,
兩組之間的proteinuria比率差異應該是來自intervention無誤,
而這樣的差異卻沒有反應在renal outcome上面,
會讓個人懷疑降蛋白尿這件事與renal outcome之間的因果關聯
至於裡面是否有retrospective prospective挑出proteinuria的病人來分析,
abstract中沒寫,那篇也非免費文章......
我沒看到level A evidence證明,特別如此大規模study都還做不出結果,
所以只能說降低蛋白尿*[31;1m不一定*[37;0m能減緩腎功能惡化.....
上面是 Type 2 DM,那Type 1 DM呢?
那來看看DCCT/EDIC的分析
Long-term renal outcomes of patients with type 1 diabetes and
microalbuminuria: an analysis of the DCCT/EDIC cohort
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3085024/
Intensive diabetes therapy, glycemia, and long-term renal outcomes
Adjusting for age, gender, and duration of diabetes, hazard ratios associated
with intensive diabetes therapy were 0.64 for progression to macroalbuminuria
(95% confidence interval 0.40, 1.02), 0.65 for impaired GFR (0.36, 1.16), and
1.92 for regression to normoalbuminuria (1.28, 2.86), p<0.05 for regression
only (Table 3). Further adjusting for BMI and use of RAAS inhibitors and
lipid-lowering medications, hazard ratios associated with intensive diabetes
therapy were 0.61 for progression to macroalbuminuria (0.38, 0.98), 0.64 for
impaired GFR (0.35, 1.17), and 2.16 for regression to normoalbuminuria (1.43,
3.26).
做了那麼多年CI都還跨1.00,而他這個PMA(Persistent microalbuminuria) cohort
也並非以entry即有MA來抓人,
This study focuses on 325 DCCT/EDIC participants who developed incident
persistent microalbuminuria (PMA) during the course of DCCT/EDIC Study
observation.
意即裡面混有非intervention因素產生的microalbuminuria病人
※ 編輯: hahawow 來自: 123.192.237.38 (11/29 12:57)
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