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[ADA2007]George Bakris教授现场专访:糖尿病肾病防治

作者:idiabetes 2007/6/27 15:22:00    加入收藏

  George Bakris  教授( scientific sessions meeting committee)
《国际糖尿病》:Okay, my first question is about: this year ADA issued a statement on primary prevention of cardiovascular disease for patients with diabetes, what’s the background and purpose of the statement publication?
Dr George Bakris:Well, the background for this statement, pretty much was designed to, like the JNC 7, and like other guidelines, be proactive and try to incorporate life style changes and other pharmacological changes like low dose aspirin to try to reduce the risk of the cardiovascular disease and stroke, heart attack, which is the most permanent events, to really reduce the risk of these events concurrent as the first place with diabetes itself, raise the risks of the problems, so that was the background, it was really to make a statement specifically for people with diabetes, as primary prevention, rather than general statement to everybody, so it was more tailored to the patients with the diabetes.
《国际糖尿病》:In order to slow down the progression of kidney disease for hypertensive patients, what kind of antihypertensive drugs should be used and what level of blood pressure should be needed?
Dr George Bakris:Well, the current international guidelines, which is what you are talking about the JNC 7, the European guidelines, it really doesn’t matter international guidelines, every body calls for less than 130 over 80 as the blood pressure goal. This is based almost exclusively on retrospective analysis of large clinical trials, there is a large prospective clinical study going on right now, called ACCORD, which is actually randomized to two different level of blood pressure, one is on 120, and then the other blood pressure is around 140 or little less than 140. This study will be finished in 2010 and 10,000 patients, and it will feasibly answer whether the lower blood pressure goal is in fact related to lower cardiovascular events. That is the goal right now. As far as the treatment approach, in the presence of diabetes with no kidney disease, no albuminuria, normal kidney function, it really doesn’t matter what agents are use, you want to get the blood pressure down and patient have to take the medications, so obviously very low side effects profile. So drugs like angiotensin receptor blockers are preferred, because they have neutral side effects profiles, compared to other antihypertensive drug, ACE inhibitors are also very good and even calcium antagonists in the very early stages, without kidney disease, are very good. Once you have kidney disease, once you have proteinurea that is graded as 300mg a day you must use high doses of angiotensin receptor blockers or ACE inhibitors, while I say high doses, obviously in Asian countries, high tolerate does will be different from that high doses in Western world. Drugs like diuretics, low doses will be needed, calcium antagonists, especially non-hydropyridines agent like Diltiazem, an agent certainly available in Japan, I don’t know whether it will be available in Europe. Amlodipine, is very good as adjunctive therapy in some circumstance, and the most important thing, and probably very difficult in Asian countries, low salt diet, low salt diet. So soy sauce is gone. And you need to change cooking style, which is very difficult, but high salt diet the worst thing possibly, because it actually reduces the benefits of the agent.
现行的国际指南,如你所谈到的JNC 7、欧洲指南等均认为将血压降至130/80以下是理想的血压目标。这是几乎是基于所有大型临床试验的回顾性分析得到的。目前正在准备进行一项大型前瞻性临床分析,称为ACCORD,它将患者再次随机化分组至两组血压目标组中,一组为120mmHg,另外一组为140mmHg或稍低于140mmHg.该研究将于2010年完成,预计纳入10,000名患者,该试验能够解释较低的血压是否与较低的心血管风险相关。这是目前的目标。至于治疗手段,在肾脏疾病、蛋白尿且肾功能正常的糖尿病患者中,你用何种药物并不重要,你想把血压降下来,患者也会服用药物,且副作用非常少。ARB类药物比较好,因为与其他抗高血压药物相比,它具有较中性的副作用。ACEI类药物也很不错,即使钙离子拮抗剂,在早期时,如无肾脏疾病,也非常好。一旦你有肾脏疾病,一旦有蛋白尿,如300mg/天,则应应用高剂量的ARB类或ACEI类药物,我所说的较高耐受剂量,在亚洲国家当然不同于西方国家。诸如利尿剂类的药物,需要小剂量。钙离子拮抗剂,特别是非羟基吡啶类药物,如地尔硫卓,在日本已经可应用,我不知道在欧洲是否也可以。氨氯地平在有些情况下也是非常好的辅助用药。最重要的问题,在亚洲国家可能很难解决的问题,就是推广低盐饮食。需要改变烹饪习惯,但这样做很难。高盐饮食或许会带来很多负面影响,因为它可以降低很多药物的功效。
《国际糖尿病》:You said ACCORD is the first study to examine the blood pressure goal for the hypertensive patients?
Dr George Bakris:Well, it will be the first large, randomized trial to look at that. The other more important study, which is already done in diabetes, it is UKPDS, but in the UKPDS low goal was 144, so you really don’t know about it, but the ACCORD 130 will be first.
《国际糖尿病》:DM is the most common cause of end stage renal disease (ESRD), and microalbuminurea(MA) incidence increases in DM patients, compared with nondiabetic patients. How to screen and manage MA in diabetic patients? Could you give us any suggestions based on evidence or related guideline? 
Dr George Bakris:So, microalbuminurea is defined as 30-300 mg per day, is a cardiovascular risk marker if the kidney sending you the message about the state of the vessels. So how should you screen? The currently acceptable screening test is the spart albumin/creatinine ratio, to be done in the morning preferablely, and if you are using radioactive agents to measure that, you can’t just do one time; you should do twice and ideally three times, over the following a couple of weeks. Now if it is positive, and the blood pressure is normal, the first thing you need to do is reduce the salt intake. And if the patient is obses, you need to put a lot of exercise program for them. And if they smoke, they need to stop smoking, because all those things can cause microalbuminurea. If the person is hypert
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