DIAGNOSTICO Y TRATAMIENTO DE LA NEFROPATIA DIABETICA

(especial para SIIC © Derechos reservados)
El incremento de la excreción de albúmina urinaria es predictivo de insuficiencia renal terminal y de eventos vasculares. Por ello es prioritaria su detección para realizar una actuación agresiva y simultánea sobre todos los factores de riesgo vascular.
Autor:
José Antonio Gimeno Orna
Columnista Experto de SIIC

Institución:
Hospital Comarcal de Alcañiz, Servicio de Endocrinología


Artículos publicados por José Antonio Gimeno Orna
Recepción del artículo
17 de Julio, 2006
Aprobación
2 de Agosto, 2006
Primera edición
29 de Enero, 2007
Segunda edición, ampliada y corregida
7 de Junio, 2021

Resumen
La nefropatía diabética es la afección renal secundaria a la hiperglucemia crónica. Aunque la excreción de albúmina urinaria es la clave del diagnóstico de la nefropatía diabética, hasta 30% de pacientes con diabetes tipo 2 con normoalbuminuria pueden tener una tasa de filtración glomerular < 60 ml/min. Por ello es conveniente determinar simultáneamente ambas para la detección sistemática de nefropatía. El incremento de excreción de albúmina urinaria predice la progresión a nefropatía terminal e incrementa el riesgo vascular del paciente diabético. Recientemente describimos en nuestra población que tanto el incremento de la excreción de albúmina urinaria como la disfunción renal leve son capaces de predecir la aparición de eventos cardiovasculares. Los factores de riesgo más consistentes para la aparición y progresión de la nefropatía son la hiperglucemia (sobre todo en fases iniciales) y la hipertensión (principalmente en fases avanzadas). Hay nivel de evidencia A para recomendar en pacientes con nefropatía: optimización del control de la glucosa (HbA1c < 7%), optimización del control de la presión arterial (< 130/80 mm Hg) y uso de fármacos inhibidores del sistema renina-angiotensina. Debido a su elevado riesgo vascular, podría ser conveniente además lograr objetivos de colesterol asociado a lipoproteínas de baja densidad < 70 mg/dl. En cualquier caso lo fundamental es una actuación simultánea y agresiva sobre todos los factores de riesgo vascular.

Palabras clave
Nefropatía diabética, enfermedad cardiovascular, factores de riesgo


Artículo completo

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Abstract
Diabetic nephropathy is the kidney disease due to chronic hyperglycaemia. Although elevation of urinary albumin excretion rate (UAER) is the earlier manifestation of diabetic nephropathy, it has been described that 30% of normoalbuminuric type 2 diabetic patients have a glomerular filtration rate (GFR) of less than 60 ml/minute. So, it is recommended to determine simultaneously UAER and GFR in the screening for diabetic nephropathy. The elevation of UAER is a predictor of chronic renal failure and a predictor of cardiovascular disease. We have recently described that both, microalbuminuria and mild renal failure, are involved in the incidence of cardiovascular events. The main risk factors for the development and progression of diabetic nephropathy are hyperglycaemia and hypertension. There is Level A of evidence in diabetic nephropathy to recommend a HbA1c level of less than 7%, a blood pressure level of less than 130/80 and the utilization of ACE inhibitors or angiotensin blockers. Due to the very high vascular risk of these patients, it is also necessary to obtain a LDL cholesterol level of less than 70 mg/dl. In conclusion, it is necessary to act simultaneously and aggressively on all cardiovascular risk factors.

Key words
Diabetic nephropathy, cardiovascular disease, risk factors


Clasificación en siicsalud
Artículos originales > Expertos de Iberoamérica >
página   www.siicsalud.com/des/expertocompleto.php/

Especialidades
Principal: Nefrología y Medio Interno
Relacionadas: Bioquímica, Diabetología, Diagnóstico por Imágenes, Diagnóstico por Laboratorio, Endocrinología y Metabolismo, Farmacología, Medicina Farmacéutica, Medicina Interna



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José A. Gimeno Orna, Hospital Comarcal de Alcañiz, 50014, Calle Bielsa 27 6º A, Zaragoza, España
Bibliografía del artículo
1. Kramer HJ, Nguyen QD, Curhan G, Hsu CY. Renal insufficiency in the absence of albuminuria and retinopathy among adults with type 2 diabetes mellitus. JAMA 2003; 289:3273-7.
2. Dinneen SF, Gerstein HC. The association of microalbuminuria and mortality in non insulin dependent diabetes mellitus. A systematic overview of the literature. Arch Intern Med 1997; 157:1413-8.
3. Valmadrid CT, Klein R, Moss SE, Klein BE. The risk of cardiovascular disease mortality associated with microalbuminuria and gross proteinuria in persons with older onset diabetes mellitus. Arch Intern Med 2000; 160:1093-100.
4. Gimeno Orna JA, Boned Juliani B, Lou Arnal LM, Castro Alonso FJ. Microalbuminuria and clinic proteinuria as the main predictive factors of cardiovascular morbidity and mortality in patients with type 2 diabetes. Rev Clin Esp 2003; 203:526-31.
5. Mann JF, Gerstein HC, Pogue J, Bosch J, Yusuf S. Renal insufficiency as a predictor of cardiovascular outcomes and the impact of ramipril: the HOPE randomized trial. Ann Intern Med 2001; 134:629-36.
6. Gimeno Orna JA, Lou Arnal LM, Boned Juliani B, Molinero Herguedas E. Mild renal insufficiency as a cardiovascular risk factor in non-proteinuric type II diabetes. Diabetes Res Clin Pract 2004; 64:191-9.
7. Gross JL, De Azevedo MJ, Silveiro SP, Canani LH, Caramori ML, Zelmanovitz T. Diabetic nephropathy:diagnosis, prevention, and treatment. Diabetes Care 2005; 28:164-76.
8. Perkins BA, Ficociello LH, Silva KH, Finkelstein DM, Warram JH, Krolewski AS. Regression of microalbuminuria in type 1 diabetes. N Engl J Med 2003; 348:2285-93.
9. Adler AI, Stevens RJ, Manley SE, Bilous RW, Cull CA, Holman RR. Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney Int 2003; 63:225-32.
10. Wong TY, Choi PC, Szeto CC y col. Renal outcome in type 2 diabetic patients with or without coexisting nondiabetic nephropathies. Diabetes Care 2002; 25:900-5.
11. De Zeeuw D, Remuzzi G, Parving HH y col. Albuminuria, a therapeutic target for cardiovascular protection in type 2 diabetic patients with nephropathy. Circulation 2004; 110:921-7
12. De Zeeuw D, Remuzzi G, Parving HH y col. Proteinuria, a target for renoprotection in patients with type 2 diabetic nephropathy: lessons from RENAAL. Kidney Int 2004; 65:2309-20.
13. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long term complications in insulin dependent diabetes mellitus. N Engl J Med 1993; 329:977-86.
14. UK Prospective Diabetes Study (UKPDS) Group. 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 1998; 352:837-53.
15. Levin SR, Coburn JW, Abraira C y col. Effect of intensive glycemic control on microalbuminuria in type 2 diabetes. Diabetes Care 2000; 23:1478-85.
16. Fioretto P, Steffes MW, Sutherland DE, Goetz FC, Mauer M. Reversal of lesions of diabetic nephropathy after pancreas transplantation. N Engl J Med 1998; 339:69-75.
17. Lurbe E, Redon J, Kesani A y col. Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med 2002; 347:797-805.
18. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998; 317:703-13.
19. Estacio RO, Jeffers BW, Gifford N, Schrier RW. Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care 2000; 23(Suppl. 2):B-54-64.
20. Ruggenenti P, Fassi A, Ilieva AP y col. Preventing microalbuminuria in type 2 diabetes. N Engl J Med 2004; 351:1941-51.
21. Viberti G, Mogensen CE, Groop LC, Pauls JF. Effect of captopril on progression to clinical proteinuria in patients with insulin dependent diabetes mellitus and microalbuminuria. JAMA 1994; 271:275-9.
22. Parving HH, Lehnert H, Brochner-Mortensen J y col. The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001; 345:870-8.
23. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD. The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy: the Collaborative Study Group. N Engl J Med 1993; 329:1456-62.
24. Brenner BM, Cooper ME, De Zeeuw D y col. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001; 345:861-9.
25. Lewis EJ, Hunsicker LG, Clarke WR y col. Renoprotective effect of the angiotensin receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001; 345:851-60.
26. Barnett AH, Bain SC, Bouter P y col. Angiotensin-receptor blockade versus converting-enzyme inhibition in type 2 diabetes and nephropathy. N Engl J Med 2004; 351:1952-61.
27. Nakao N, Yoshimura A, Morita H, Takada M, Kayano T, Ideura T. Combination treatment of angiotensin-II receptor blocker and angiotensin-converting-enzyme inhibitor in non-diabetic renal disease (COOPERATE): a randomised controlled trial. Lancet 2003; 361:117-24.
28. Rossing K, Jacobsen P, Pietraszek L, Parving HH. Renoprotective effects of adding angiotensin II receptor blocker to maximal recommended doses of ACE inhibitor in diabetic neprhropathy. Diabetes Care 2003; 26:2268-74.
29. Sato A, Hayashi K, Naruse M, Saruta T. Effectiveness of adosterone blockade in patients with diabetic nephropathy. Hypertension 2003; 41:64-8.
30. Fried LF, Orchard TJ, Kasiske BL. Effect of lipid reduction on the progression of renal disease: a meta-analysis. Kidney Int 2001; 59:260-9.
31. Colhoun HM, Betteridge DJ, Durrington PN y col. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004; 364:685-96.
32. Gimeno Orna JA, Molinero Herguedas E, Sánchez Vaño R, Lou Arnal LM, Boned Juliani B, Castro Alonso FJ. Microalbuminuria presents the same vascular risk as overt CVD in type 2 diabetes. Diabetes Res Clin Pract 2006; 74:103-9.
33. Grundy SM, Cleeman JI, Merz NB y col. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. Circulation 2004; 110:227-39.
34. Bhatt DL, Marso SP, Hirsch AT, Ringleb PA, Hacke W, Topol EJ. Amplified benefit of clopidogrel versus aspirin in patients with diabetes mellitus. Am J Cardiol 2002; 90:625-8.
35. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2005; 28(Suppl. 1):S4-S36.
36. Gaede P, Vedel P, Larsen N, Jensen GU, Parving HH, Pedersen O. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003; 348:383-93.

 
 
 
 
 
 
 
 
 
 
 
 
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