Skip to main content
SpringerLink
Log in

Protektion der Nierenfunktion bei Diabetikern

Protection of renal function in diabetics

  • Schwerpunkt: Diabetes mellitus
  • Published:
Der Internist Aims and scope Submit manuscript

Zusammenfassung

Der Nephropathieverlauf wird durch zahlreiche beeinflussbare Faktoren moduliert. In der Primärprävention vermindert eine normnahe Stoffwechselführung von Diabetesbeginn an das Risiko der Mikroalbuminurieentwicklung in Abhängigkeit vom erreichten HbA1c-Wert. Hypertensive Diabetiker sollten mit RAS-blockierenden Substanzen konsequent behandelt werden. Bei bereits bestehender Nephropathie kann eine multifaktorielle Therapie die weitere Progression verhindern oder zumindest verzögern. Dazu gehören eine konsequente Blutdrucksenkung in den normotensiven Bereich unter Verwendung von RAS-blockierenden Substanzen (auch bei noch normotensiven Patienten) sowie eine möglichst normnahe Stoffwechselführung unter Beachtung der bei Niereninsuffizienz veränderten Pharmakokinetik und -dynamik der blutzuckersenkenden Substanzen. Die Beeinflussung weiterer Faktoren (Rauchen, Eiweißaufnahme, Anämie) und die Beachtung allgemein nephroprotektiver Maßnahmen ergänzen das Behandlungsspektrum. Wegen der hohen kardiovaskulären Morbidität haben Lipidsenkung oder ASS-Gabe wesentliche Bedeutung. Ein engmaschiges Monitoring der Nierenfunktion und der Therapiefaktoren ist unerlässlich.

Abstract

The course of diabetic nephropathy is affected by several factors that can be manipulated. In primary prevention, near normal metabolic control beginning at the time of the diagnosis of diabetes diminishes the risk of microalbuminuria to an extent depending on the HbA1c level attained. Hypertensive diabetics should be consistently treated with renin-angiotensin system (RAS)-blocking agents. In secondary prevention, a multifactorial therapy is able to stop or retard further progression. Its components are a sustained decrease of blood pressure in the normotensive range using RAS-blocking agents (normotensive patients should also be treated) as well as near normal metabolic control that takes into account the changing pharmacokinetic and pharmacodynamic properties of blood glucose-lowering drugs in renal insufficiency. Consideration of further factors (smoking, protein intake, anemia) and several general nephroprotective measures complete the treatment spectrum. Therapy for dyslipidemia and the administration of aspirin are important in view of the high cardiovascular morbidity. It is essential to monitor kidney function and the therapeutic components at short intervals.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4

Literatur

  1. Hasslacher C, Kempe P, Ritz E et al. (2007) Praxisleitlinie Diabetische Nephropathie. Diabetologie 2 (Suppl 2): S159–S162

    Article  Google Scholar 

  2. The Diabetes Control and Complications Trial Research Group (1995) Effect of intensive therapy on the development and progression of diabetic nephropathy in the diabetes control and complications trial. Kidney Int 47: 1703–1720

    Article  Google Scholar 

  3. The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group (2000) Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive therapy. N Engl J Med 342: 381–389

    Article  Google Scholar 

  4. Ohkubo Y, Kishikawa H, Araki E et al. (1995) Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus; a randomized prospective 6-year study. Diabetes Res Clin Pract 28: 103–117

    Article  PubMed  CAS  Google Scholar 

  5. UK Prospective Diabetes Study Group (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2-diabetes(UKPDS 33). Lancet 352: 837–853

    Article  Google Scholar 

  6. Lindholm L, Ibsen H, Dahlöf B et al. (2002) Cardiovascular morbidity and mortality in patients with diabetes in the Losartan intervention für endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 359: 1004

    Article  PubMed  CAS  Google Scholar 

  7. Ruggenenti P, Ilieva A, Bruno S (2004) Preventing microalbuminuria in type 2 diabetes. N Engl J Med 351: 1941–1951

    Article  PubMed  CAS  Google Scholar 

  8. Stratton IM, Cull CA, Adler AI (2006) Additive effects of glycaemia and blood pressure exposure on risk of complications in type 2 diabetes: a prospective observational study (UKPDS 75). Diabetologia 49: 1761–1769

    Article  PubMed  CAS  Google Scholar 

  9. The EUCLID Study Group (1997) Randomised placebo-controlled trial of lisinopril in normotensive patients with insulin-dependent diabetes and normoalbuminuria or microalbuminuria. Lancet 349: 1787–1792

    Article  Google Scholar 

  10. Ravid M, Brosh D, Levi Z et al. (1998) Use of Enalapril to attenuate decline in renal function in normotensive, normoalbuminuric patients with type 2 diabetes mellitus. Ann Intern Med 128: 982–988

    PubMed  CAS  Google Scholar 

  11. Heart Outcomes Prevention Evaluation Study Investigators (2000) Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. Lancet 355: 253–259

    Article  Google Scholar 

  12. Scott U, Warram JH, Hanna LS (2001) A nonlinear effect of hyperglycemia and current cigarette smoking are major determinants of the onset of microalbuminuria in type 1 diabetes. Diabetes 50: 2842–2849

    Article  PubMed  CAS  Google Scholar 

  13. Klein R, Klein BEK, Moss SE (1993) Incidence of gross proteinuria in older-onset diabetes. A population-based perspective. Diabetes 42: 381–389

    Article  PubMed  CAS  Google Scholar 

  14. Thomas MC, Rosengard-Bärlund M, Forsblom C (2006) Serum lipids and the progression of nephropathy in type 1 diabetes. Diabetes Care 29: 317–322

    Article  PubMed  CAS  Google Scholar 

  15. Wang PH (1997) When should ACE inhibitors be given to normotensive patients with IDDM. Lancet 349: 1782

    Article  PubMed  CAS  Google Scholar 

  16. Ravid M, Savin H, Jutrin I et al. (1993) Long-term stabilizing effect of Angiotensin-converting enzyme inhibition on plasma creatinine and on proteinuria in normotensive type 2 diabetic patients: Ann Intern Med 118: 577–581

    Google Scholar 

  17. Ahmad J, Siddiqui M, Ahmad H (1997) Effective postponement of diabetic nephropathy with enalapril in normotensive type 2 diabetic patients with microalbuminuria. Diabetes Care 20: 1576–1581

    Article  PubMed  CAS  Google Scholar 

  18. Hasslacher C (2006) Metabolische Kontrolle bei diabetischer Nephropathie. Diabetologe 2: 410–418

    Article  Google Scholar 

  19. Peterson JC, Adler S, Burkart JM (1995) Blood pressure control, proteinuria, and the progression of renal disease: the modification of diet in renal disease study. Ann Intern Med 123: 754–762

    PubMed  CAS  Google Scholar 

  20. Strippoli G, Craig M, Deeks J (2004) Effects of angiotensin converting enzyme inhibitors and angiosin II receptor antagonists on mortality and renal outcomes in diabetic nephropathy: systematic review. BMJ 329: 828

    Article  PubMed  CAS  Google Scholar 

  21. Barnett AH, Bain SC, Bouter P (2004) Angiotensin-receptor blockade versus converting-enzyme inhibition in type 2 diabetes and nephropathy. N Engl J Med 351: 1952–1961

    Article  PubMed  CAS  Google Scholar 

  22. Mogensen C, Neldam St, Tikkanen I et al. (2000) Randomised controlled trial of dual blockade of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study: BMJ 321: 1440–1444

  23. Rossing K, Jacobsen P, Pietraszek L (2003) Renoprotective effects of adding angiotensin II receptor blocker to maximal recommended doses of ACE inhibitor in diabetic nephropathy. Diabetes Care 26: 2268–2274

    Article  PubMed  CAS  Google Scholar 

  24. Nakao N, Yoshimura A, Morita H et al. (2003) Combination treatment of angiotensin II receptor blocker and angiotensin converting enzyme inhibitor in non-diabetic renal disease (COOPERATE). Lancet 361: 117–124

    Article  PubMed  CAS  Google Scholar 

  25. Nyberg G, Blohme G, Nordern G (1987) Impact of metabolic control in progression of clinical diabetic nephropathy. Diabetologia 30: 82–86

    PubMed  CAS  Google Scholar 

  26. Hasslacher C, Bostedt-Kiesel A, Kempe H et al. (1993) Effect of metabolic factors and blood pressure on kidney function in proteinuric Type 2 (non-insulin dependent) diabetic patients. Diabetologia 36: 1051–1056

    Article  PubMed  CAS  Google Scholar 

  27. Manto A, Cortroneo P, Marra G et al. (1995) Effect of intensive treatment in diabetic nephropathy in patients with type 1 Diabetes. Kidney Int 47: 231–235

    Article  PubMed  CAS  Google Scholar 

  28. Mai-Szu Wu, Chun-Chen Yu, Chih-Wei Yang et al. (1997) Poor pre-dialysis glycaemic control is a predictor of mortality in type 2 diabetic patients on manintenance haemodialysis. Nephrol Dial Transplant 12: 2105–2110

    Article  Google Scholar 

  29. Warram JH, Scott LJ, Hanna LS et al. (2000) Progression of microalbuminuria to proteinuria in type 1 diabetes; Nonlinear relationship with hyperglycemia. Diabetes 49: 94–98

    Article  PubMed  CAS  Google Scholar 

  30. Sarafidis PA, Bakris GL (2006) Protection of the kidney by thiazolidinediones: an assessment from bench to bedside. Kidney Int 70: 1223–1233

    Article  PubMed  CAS  Google Scholar 

  31. Rave K, Heise T, Pfützner A et al. (2001) Impact of diabetic nephropathy on pharmacodynamic and pharmacokinetic properties of insulin in type 1 diabetic patients. Diabetes Care 24: 886–890

    Article  PubMed  CAS  Google Scholar 

  32. Sawicki PT, Didjurgeit U, Mühlhauser I et al. (1994) Smoking is associated with progression of diabetic nephropathy. Diabetes Care 17: 126–131

    Article  PubMed  CAS  Google Scholar 

  33. Biesenbach G, Janko O, Zazgornik J (1994) Similar rate of progression in the predialysis phase in type 1 and type 2 diabetes mellitus. Nephrol Dial Transplant 9: 1097–1102

    PubMed  CAS  Google Scholar 

  34. Zeller K, Whittaker E, Sullivan L et al. (1991) Effect of restricting dietary protein on the progression of renal failure in patients with insulin dependent diabetes mellitus. N Engl J Med 324: 78–84

    Article  PubMed  CAS  Google Scholar 

  35. Hansen HP, Tauber-Lassen E, Jensen BR et al. (2002) Effect of dietary protein restriction on prognosis with diabetic nephropathy. Kidney Int 62: 220–228

    Article  PubMed  Google Scholar 

  36. Hasslacher C (2004) Prävalenz und Schweregrad einer Anämie bei Diabetikern mit eingeschränkter Nierenfunktion. Diab Stoffw 13: 181–185

    Google Scholar 

  37. Thomas MC (2007) Anemia in diabetes: marker or mediator of microvascular disease. Nat Clin Pract Nephrol 3: 20−30

    Article  PubMed  CAS  Google Scholar 

  38. Babazono T, Hanai K, Suzuki K (2006) Lower haemoglobin level and subsequent decline in kidney function in type 2 diabetic adults without clinical albuminuria. Diabetologia 49: 1387–1393

    Article  PubMed  CAS  Google Scholar 

  39. Drüeke TB, Locatelli F, Clyne N (2006) Normalization of hemoglobin level in patients with chronic kidney disease and anemia. N Engl J Med 355: 2071–2084

    Article  PubMed  Google Scholar 

  40. Singh AK, Szczech L, Tang KL (2006) Correction of anemia with epoetin alfa in chronic kidney disease. N Engl J Med 355: 2085–2098

    Article  PubMed  CAS  Google Scholar 

  41. Tonelli M, Keech A, Shepherd J (2005) Effect of pravastatin on people with diabetes and chronic kidney disease. J Am Soc Nephrol 16: 3748–3754

    Article  PubMed  CAS  Google Scholar 

  42. Wanner C, Krane V, März W (2005) Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysios. N Engl J Med 353: 238–248

    Article  PubMed  CAS  Google Scholar 

  43. Douglas K, O‚Malley PG, Jackson J (2006) Meta-analysis: the effect of statins on albuminuria. Ann Intern Med 145: 117–124

    PubMed  CAS  Google Scholar 

  44. Collins R, Armitage J, Parish S (2003) Heart protection study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial. Lancet 361: 2005–2016

    Article  PubMed  Google Scholar 

  45. De Zeeuw D, Remuzzi G, Parving HH et al. (2004) Proteinuria, a target for renoprotection in patients with type2 diabetic nephropathy: lessons from RENAAL. Kidney Int 65: 2309–2320

    Article  Google Scholar 

  46. De Zeeuw D, Remuzzi G, Parving HH et al. (2004) Albuminuria, a therapeutic target for cardiovascular protection in type 2 diabetic patients with nephropathy. Circulation 110: 921–927

    Article  CAS  Google Scholar 

  47. Feld-Rasmussen B, Mathiesen ER, Jensen T et al. (1991) Effect of improved metabolic control on loss of kidney function in type 1 (insulin-dependent) diabetic patients: an update of the Steno studies. Diabetologia 34: 164–170

    Article  Google Scholar 

  48. Gaede P, Vedel P, Parving HH et al. (1999) Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: the Steno type 2 randomised study. Lancet 353: 617–622

    Article  PubMed  CAS  Google Scholar 

Download references

Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehung/en hin: Referententätigkeit für Roche, Novo Nordisk und GlaxoSmithKline.

Author information

Authors and Affiliations

  1. St. Josefskrankenhaus Heidelberg, Akademisches Lehrkrankenhaus der Universität Heidelberg, Landhausstr. 25, 69115, Heidelberg, Deutschland

    C. Hasslacher

Authors
  1. C. Hasslacher
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to C. Hasslacher.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Hasslacher, C. Protektion der Nierenfunktion bei Diabetikern. Internist 48, 686–697 (2007). https://doi.org/10.1007/s00108-007-1894-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00108-007-1894-x

Schlüsselwörter

Keywords

Search

Navigation