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糖尿病肾病的透析治疗

Author
Lionel U Mailloux, MD, FACP
Section Editors
Jeffrey S Berns, MD
David M Nathan, MD
Deputy Editor
Alice M Sheridan, MD
Translators
刘迅, 主任医师

引言

虽然将血压恢复到正常水平(优选血管紧张素转换酶抑制剂)及严格控制血浆葡萄糖浓度可以延缓糖尿病肾病的发生及进展，但许多患者依然会进展到终末期肾病(end-stage renal disease, ESRD)[1-3]。糖尿病肾病进展的重要决定因素包括：组织学病变的严重程度和蛋白尿的绝对量[4]。美国肾脏数据系统(United States Renal Data System, USRDS)2013年年度数据报告的数据显示，新的ESRD发病率自2000年稳定后，于2011年首次有所下降[5]。

糖尿病是需要肾脏替代治疗的新患者ESRD的最常见病因，在美国大约占新发病例的45%[6,7]。虽然糖尿病的比例(157例/100万人口)在ESRD基础病因诊断中仍然是最高的，但新患者中这一比例已经在2011年下降了4.2%[5]。尽管在其他国家不太常见，但在德国和澳大利亚，分别有34%及30%的新透析患者有糖尿病[8]。如来自欧洲10项注册研究数据所报道的，也发现在德国之外的欧洲国家新透析患者中糖尿病的比例渐增[9]。但该比例在丹麦似乎保持稳定，这或许是由于广泛采取了加强肾脏保护措施[10]。

在美国和波多黎各，虽然糖尿病所致ESRD的患者总数持续增加，但对于有糖尿病的患者来说，其发生ESRD的风险似乎在减小[7]。这一风险下降的原因仍然不明确，但是改善血糖和血压控制及使用血管紧张素转化酶抑制剂或血管紧张素受体阻滞剂可能起到了一定作用[2,7,11]。

患者生存率

进行维持性透析的糖尿病患者的生存率比慢性肾小球疾病或高血压导致终末期肾衰竭的非糖尿病患者低[6,12,13]。如2013年USRDS数据库所示，仅有大约34%的糖尿病患者在开始血液透析后5年仍存活[5]；这表明与以前的5年结局相比，生存率已经略有改善[14]。生存率还与年龄呈负相关，在血压控制良好并且没有临床明显心脏疾病的年轻患者中生存率最高[6,15]。

但是，较早的生存数据可能过于乐观，因为它是基于USRDS的信息。USRDS排除了开始透析后90日内死亡的患者[14]。2013年的数据基于从透析启动后第1日开始计算的生存率。当将这类个体也纳入死亡率研究时，即使是在患者有相对较高生存率的国家的透析中心，需要透析的糖尿病患者的生存率仍然很低。例如，法国一个透析中心的84例需要透析的连续2型糖尿病患者中，有27例(32%)在平均随访211日时死亡[16]。

      

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Literature review current through: 2017-06 . | This topic last updated: 2016-03-07.
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