新版高血压与糖尿病肾病停顿课件

《新版高血压与糖尿病肾病停顿课件》由会员上传分享，免费在线阅读，更多相关内容在教育资源-天天文库。

HypertensionandDiabeticKidneyDiseaseProgressionGeorgeL.Bakris,MDProfessorandVice-ChairmanDept.ofPreventiveMedicineDirector,Hypertension/ClinicalResearchCenterRushUniversityMedicalCenterChicago,IL60612©2006.AmericanCollegeofPhysicians.AllRightsReserved.绎经恒蚌矫者哼缀淀借好褥瘟摈脚痕渐陆氛盅错拢摸剁淡裔贴托刚决施曲高血压与糖尿病肾病进展DiabeticNephropathy DisclosureofRelationshipswithCommercialCompanies:GeorgeL.Bakris,MD,FACPResearchGrants/Contracts:NIH(NIDDK/NHLBI),AstraZeneca,Abbott,Alteon,Boehringer-Ingelheim,GlaxoSmithKline,Merck,Novartis,Lilly,SankyoConsultantship:Astra-Zeneca,AusAm,Abbott,Alteon,Biovail,Boehringer-Ingelheim,BMS/Sanofi,GlaxoSmithKline,Merck,Novartis,LillySpeakersBureau:Boehringer-Ingelheim,BMS/Sanofi,GlaxoSmithKline,Merck,Novartis,Lilly©2006.AmericanCollegeofPhysicians.AllRightsReserved.酉谨赁昧举兑怀啃荤衰族遣皇安辆线祝日妮裙绳随同般赡瘤叉鞋影绳删豫高血压与糖尿病肾病进展DiabeticNephropathy IncreasingPrevalenceofDiagnosedDiabetesinUSAdultsCentersforDiseaseControlandPreventionWebsite.Availableat:http://www.cdc.gov/diabetes/statistics/prev/state/fig61994and2002.htm.AccessedAugust30,2004.19942002<4%4–4.9%5–5.9%6%©2006.AmericanCollegeofPhysicians.AllRightsReserved.淳嫉丰簇杨伤宰缄坊铣胖郧键驰甫眩寡园竖铺焙氧蓟擒棺团寄烙丽缘韧侩高血压与糖尿病肾病进展DiabeticNephropathy IncreasingPrevalenceofObesity*AmongUSAdultsCentersforDiseaseControlandPreventionWebsite.Availableat:http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm.AccessedAugust30,2004.*BMI≥30kg/m2.10%–14%15%–19%20%–24%≥25%19942002©2006.AmericanCollegeofPhysicians.AllRightsReserved.字概石炊叹陡汀长舅扣妓恬撑舞绷以婴糟泊蜘滦恕赴锨畜询宠乱勇换柯纺高血压与糖尿病肾病进展DiabeticNephropathy Walkingthedog©2006.AmericanCollegeofPhysicians.AllRightsReserved.纶锯称职眉俄箱慎橇毡勉卢破秀遭爽浇刨歇饺葬孰绒伪堂衰馈隅斗掂枪龟高血压与糖尿病肾病进展DiabeticNephropathy IncidenceofKidneyFailurepermillionpopulation,1990,byHSA,unadjusted©2006.AmericanCollegeofPhysicians.AllRightsReserved.趣猛顶次耙喉边镊奢籽拜炭离琳洲演留纷逗班勾濒艇涛偷冰烩消蒋材戎穆高血压与糖尿病肾病进展DiabeticNephropathy IncidenceofKidneyFailurepermillionpopulation,2000,byHSA,unadjusted©2006.AmericanCollegeofPhysicians.AllRightsReserved.塑井鸣兔删浑阮锹产戌弱剧炊耿港册肃帆讨半逻畸魁叫柒嫁烷碗痕狈隋耽高血压与糖尿病肾病进展DiabeticNephropathy Diabetes:TheMostCommonCauseofESRDPrimaryDiagnosisforPatientsWhoStartDialysisDiabetes50.1%Hypertension27%Glomerulonephritis13%Other10%UnitedStatesRenalDataSystem.Annualdatareport.2000.No.ofpatientsProjection95%CI19841988199219962000200420080100200300400500600700r2=99.8%243,524281,355520,240No.ofdialysispatients(thousands)©2006.AmericanCollegeofPhysicians.AllRightsReserved.沾河雄图烟酥沈蓬力将呆傲忧兜渣炭刻捍谱凶栈苫企霓癣瑰贾丹拂是掠框高血压与糖尿病肾病进展DiabeticNephropathy CardiovascularComorbidities,5%Medicaresample,byDiabetesandCKDstatus,1999-2000%Stroke/TIA%ASHD%Amputation/PVD%HeartFailure©2006.AmericanCollegeofPhysicians.AllRightsReserved.冠带晌市眨畸瞧将隅乱既睁掌穴拈寸幕剃胰药膘啼瞄夫基均痕田舜椎勺装高血压与糖尿病肾病进展DiabeticNephropathy LevelofKidneyFunctionIsanIndependentRiskFactorForCVRiskN=15,350Meanfollow-up=6.2yearsAge-45-64StageofKidneyDiseaseNStage2(GFR-60-89)7,665Stage3&4(GFR-15-59)4441.01.251.751.52.01.381.16ManjunathGet.alJACC2003;41:47-550.75©2006.AmericanCollegeofPhysicians.AllRightsReserved.砸量酥固用醚潭辣更凶腊卖企脆凛镣杏消俭枫缩馋党此响斑纹午舱挽轮狈高血压与糖尿病肾病进展DiabeticNephropathy Go,A.S.etal.NEnglJMed2004;351:1296-1305©2006.AmericanCollegeofPhysicians.AllRightsReserved.寓吮了依烯有凑文无榆汝巳违澡的弓翌赚铭袄蔗余墓上忻表似拳己琅农盖高血压与糖尿病肾病进展DiabeticNephropathy CKDHospitalizationRatesforCardiovascularDiseaseCHFadmissionratesare5timeshigherinpatientswithadiagnosisofCKDvsnon-CKDIschemicheartdiseaseadmissionsat2-2.5timeshigherintheCKDpopulationCardiacarrhythmiaadmissionratesaretwiceascommoninCKDpopulations©2006.AmericanCollegeofPhysicians.AllRightsReserved.溢苫欺禹烧锁裕匝壳昼缴镣蛤卸泡橡猛谚让詹枚翻提辜觉篆邓踩及层修湖高血压与糖尿病肾病进展DiabeticNephropathy CKDPrevalenceinUS(AJKD2002)GFR(ml/min)<1515-2930-5960-89>90©2006.AmericanCollegeofPhysicians.AllRightsReserved.物律樊樱瞄韩箍窝梢逸瘦蹋狼滤欢匡殖掘轨车苞擅符洱吭不宪江瞪标怂凸高血压与糖尿病肾病进展DiabeticNephropathy CVDRiskFactorsHypertension*CigarettesmokingObesity*(BMI>30kg/m2)PhysicalinactivityDyslipidemia*Diabetesmellitus*MicroalbuminuriaEstimatedGFR<60ml/minAge(olderthan55formen,65forwomen)FamilyhistoryofprematureCVD(menunderage55orwomenunderage65)*Componentsofthemetabolicsyndrome.ChobanianAet.alHypertension,Dec.2003©2006.AmericanCollegeofPhysicians.AllRightsReserved.咳鼎瞩伙凛赦卓咽雇叉丢笨叶挽尉耪概珠蝎跋悍询踪店茸哦傀醇匡锋段铂高血压与糖尿病肾病进展DiabeticNephropathy MicroalbuminuriaAlbuminuria(Proteinuria)mg/dayCVRiskandVascularDysfunctionCVRiskandPresenceofRenalDysfunctionandVascularDysfunctionNormal©2006.AmericanCollegeofPhysicians.AllRightsReserved.穿泌喀森抡闽呼降雏凡谓抖会奎院介峰滨兑烙涨物某蔽命食或卷崭解枢副高血压与糖尿病肾病进展DiabeticNephropathy ProteinuriaPredictsStrokeandCHDEventsinType2DiabetesP<0.001403020100StrokeCHDEvents8060402000.50.60.70.80.91SurvivalCurvesForCVMortalityOverall:P<0.001CBAIncidence(%)MonthsMiettinenHetal.Stroke.1996;27:2033-2039.B:U-Prot150–300mg/LA:U-Prot<150mg/LC:U-Prot>300mg/L0U-Prot=Urinaryproteinconcentration.100©2006.AmericanCollegeofPhysicians.AllRightsReserved.泻秀哎炮骆兼苫盛苑甲拘志遣挖菱姬蹈坐铬洁攻丧此臂企户共医晃达击堕高血压与糖尿病肾病进展DiabeticNephropathy BertonGet.al.Diabetologia,Aug.2004Kaplan-Meiercurvesof3-yearall-causemortalityintheAMIpatientsstratifiedbyDMstatusandACR>30µg/mgor<30µg/mgonthe3rddayafteradmission©2006.AmericanCollegeofPhysicians.AllRightsReserved.广鸵焉舱妻孤趴台肾蛮拳镁慷嘱枫雍坟软滦骚冤绍取悔鸥辫富譬溉囤炉抉高血压与糖尿病肾病进展DiabeticNephropathy 00.511.52345MortalityHazardRatio(95%CI)forValuesAbove80thPercentileUseofMAU,CRP,andBNPasPredictorsofMortalityandCVEventsNT-proBNPCRPMAUFirstMajorCVEventNT-proBNPCRPMAUP=.007P=014P=.008P=.003P=.96P=<.001Adjustedforage,sex,smoking,DM,HTN,Afib,LVEF<50%,LVH,totalcholesterol,serumcreatinine.Mortalityanalysisbasedon91deaths,andCVeventdatabasedon63eventsduetomissingcovariates.The80thpercentilecorrespondstovaluesmorethan5.85pg/mLforNT-proBNP,5.76mg/LforCRP,and18.4mg/gforMAU.KistorpK,etal.JAMA.2005;293:1609-1616.©2006.AmericanCollegeofPhysicians.AllRightsReserved.宵儿迢拳呵耙民四置菌尸谗毖钎荆辱完演蚜榆肾秒海嚷涕湿先愤苑映贾戏高血压与糖尿病肾病进展DiabeticNephropathy 0-551015-100-50050100RateofdeclineinGFR(ml/min/year)r=0.47p<0.011deltaProteinuria(%changefrompretreatment)PredictivevalueofantiproteinuriceffectonrenalprotectionApperlooAJetal;KidneyInt1994;45:S174-8.RossingPetal.Diabetologia.1994;37:511-516.151050-5-100-50050100r=0.73p<.001.DiabetesNon-Diabetes©2006.AmericanCollegeofPhysicians.AllRightsReserved.邹脓发韵涉萨坠凄暖彤拾匿绥坞惭舅可戒褐飞欠柱芜饱愉凌旷愁额渴含垃高血压与糖尿病肾病进展DiabeticNephropathy ClinicalTrialsandRenalOutcomesBasedonProteinuriaReductionIncreasedTimetoDialysis(30-35%proteinuriareduction)CaptoprilTrial-NEnglJMed,1993AASKTrial-JAMA,2001RENAAL-NEnglJMed,2001IDNT-NEnglJMed,2001COOPERATE-Lancet,2003NoChangeinTimetoDialysis(NOproteinuriareduction)DHPCCBarm-IDNTDHPCCBarm-AASKHartP&BakrisGLManagingHypertensionintheDiabeticPatient.IN:EganBM,BasileJN,andLacklandDT(eds.)HotTopicsinHypertensionHanleyandBelfus,Philadelphia,2004,pp.249-252.©2006.AmericanCollegeofPhysicians.AllRightsReserved.练饶秽息虞骄银府惮敝婪喧酷随涎坷玉锐艳锦彻焚艺撩稽吮淤静擂百抓古高血压与糖尿病肾病进展DiabeticNephropathy IDNTProportionofPatientswiththePrimaryCompositeEndpoint*Proportionwithprimaryendpoint061218243036424854579555528496400304216146655655425084743852871871284656855151247140128019012253Irbesartan(n)Amlodipine(n)Placebo(n)MonthsofFollow-up*Compositeofadoublingofserumcreatinine,endstagerenaldisease,ordeathP=0.02forirbesartancomparedtoplaceboLewisEJ,etal.NEnglJMed.2001;345(12):851-860.©2001MassachusettsMedicalSociety.Allrightsreserved.©2006.AmericanCollegeofPhysicians.AllRightsReserved.兔侗瓤厚洪讹规稀友爵威钻蕉败掌辞躁挪死币湍谜谰纤递镍断电玖雅驾振高血压与糖尿病肾病进展DiabeticNephropathy RelationshipBetweenRateofDeclineinRenalFunctionandChangeinProteinuriainIDNTLewisEJetal.NEnglJMed.2001;345:851-860.AmlodipineIrbesartanPlaceboCreatinineclearance(mL/min/1.73m2)Proteinuria(g/d)-8-7-6-5-4-3-2-10©2006.AmericanCollegeofPhysicians.AllRightsReserved.社账纲颊灭得氖愧乐没硬呵赎蚜眠釜鳞赞苛褂晋戮借棍诊皱递炙靡腥嘻稠高血压与糖尿病肾病进展DiabeticNephropathy RENAAL;BaselineProteinuriaasaDeterminantforCardiacEventsinType2diabetesCVEndpointHeartFailure0246Hazardratio5.25Albuminuria(g/g)0246<.52.02.954.4³5.25Albuminuria(g/g)<.52.02.954.4³HazardratioDeZeeuwetal;Circulation2004(adjustedforallconventionalriskfactors)©2006.AmericanCollegeofPhysicians.AllRightsReserved.鸥人壁霖窟妻牙肌指圭颊渊欣溢彼棉郭厄碳葱舆跟综锯宛淳不曼接摄吾迄高血压与糖尿病肾病进展DiabeticNephropathy RENAAL;BaselineProteinuriaasaDeterminantforRENALEventsinType2DiabetesDeZeeuwetal;KidneyInt2004PrimarycompositeEndpoint010155Hazardratio<.52.02.954.4³5.25³³³³³³³BaselineAlbuminuria(g/g)BaselineAlbuminuria(g/g)0<.52.02.954.45.25ESRD102030³Hazardratio(adjustedforallconventionalriskfactors)©2006.AmericanCollegeofPhysicians.AllRightsReserved.扶吏匪会垫逸禁钞织氨桨躯貌疟善尾澈唯雇幕迫毒理赡料拓逝牵妓俐垣辨高血压与糖尿病肾病进展DiabeticNephropathy DeZeeuwD,etal.KidneyInt.2004;65:2309.6050403020100%withERSD012243648Month6050403020100%withrenalendpoint012243648Month<0%³0<30%³30%<0%³0<30%³30%ΔAlb:³0<30vs.<0%ΔAlb:³30vs.<0%ΔAlb:³30vs.³0<30%0.880.600.680.1570<.00010.0003HRPvaluesUnadjustedRenalEndPoint0.760.460.610.0028<.0001<.0001HRPvaluesAdjustedΔAlb:³0<30vs.<0%ΔAlb:³30vs.<0%ΔAlb:³30vs.³0<30%0.820.510.620.1242<.00010.0019HRPvaluesUnadjustedRenalEndPoint0.620.370.600.0003<.0001<.0010HRPvaluesAdjustedRENAAL:RenalEndPointsBy6-MonthChangesinAlbuminuria©2006.AmericanCollegeofPhysicians.AllRightsReserved.分博鸿膊暮骂抽驰唾寇挣阉庞瑰醇徘锦赚周烩意焦只步摆劲旷萍挖棋趴捕高血压与糖尿病肾病进展DiabeticNephropathy DeZeeuwD,etal.Circulation.2004;110:921.40%withCVendpoints3020100012243648MonthCVEndpoint40%withCVendpoints3020100012243648MonthHeartFailure<0%>30%<0%>30%RENAAL:CardiovascularEndPointsby6-MonthChangesinAlbuminuria©2006.AmericanCollegeofPhysicians.AllRightsReserved.挺貌宵施尖戏谱姆瞒萄找笆姐缆舱兑色鹏畜钮趾酸纯童淳黑仍汲饱咬平辫高血压与糖尿病肾病进展DiabeticNephropathy MostCommonCauseofFailingtoReduceProteinuriawithACEInhibitororARBHighSALTintake(>5grams/day)DeZeeuwDet.alKidneyInt.,1989,MishraSIet.al,CurrHypertensRep,2005©2006.AmericanCollegeofPhysicians.AllRightsReserved.纲殴股琉巴牌诊剖巴针伴建蓝注睛谗蔗户播椒局辕尼瀑贞晰肝忌和摇寥名高血压与糖尿病肾病进展DiabeticNephropathy WhatistheGoalBPandInitialTherapyinKidneyDiseaseorDiabetestoReduceCVRisk?GroupGoalBP(mmHg)InitialTherapyAm.DiabetesAssoc(2006)<130/80ACEInhibitororARB*KDOQI(NKF)(2004)<130/80ACEInhibitororARB*JNC7(2003)<130/80ACEInhibitororARB*CanadianHTNSoc.(2002)<130/80ACEInhibitororARBAm.DiabetesAssoc(2002)<130/80ACEInhibitororARBNatl.KidneyFdn.-CKD(2002)<130/80ACEInhibitororARB*Natl.KidneyFdn.(2000)<130/80ACEInhibitor*BritishHTNSoc.(1999)<140/80ACEInhibitorWHO/ISH(1999)<130/85ACEInhibitorJNCVI(1997)<130/85ACEInhibitor*Indicatesusewithdiuretic©2006.AmericanCollegeofPhysicians.AllRightsReserved.穿饶奥远丘辟旋碘愈旗败圭详盲秽温收止卜茄孪峙笔脂昭屏竣肝疡嵌域主高血压与糖尿病肾病进展DiabeticNephropathy DETAIL,aprospective,multicenter,non-inferioritytrialrandomized250patientswithtype2diabetes,hypertension(BP<180/95mmHg),andevidenceofearlynephropathy(GFR>70mL/min/1.73m2)toeithertelmisartanorenalapril.Followedfor5yearsBarnettAHet.alNEnglJMed2004;351:1952-1961.Angiotensin-ReceptorBlockadeversusConverting–EnzymeInhibitioninType2DiabetesandNephropathy©2006.AmericanCollegeofPhysicians.AllRightsReserved.嗓贼砰扫晋争往蝉碰赁涛朱仕恶蓬文逸私崖刊敷啦蹋陶脉域湃串超供汝判高血压与糖尿病肾病进展DiabeticNephropathy BarnettAHet.alNEnglJMed2004;351:1952-1961.Angiotensin-ReceptorBlockadeversusConverting–EnzymeInhibitioninType2DiabetesandNephropathy-RESULTSBaselineGFR91ml/min©2006.AmericanCollegeofPhysicians.AllRightsReserved.妈袒赐悟亡轻牺寅榴仲萨降部壁侨听迪紊呢盐泊滋售甲孰励搔逞料戈喇痪高血压与糖尿病肾病进展DiabeticNephropathy EffectsofACEInhibitorsorARBsonRenalDiseaseProgression:AMeta-AnalysisCasesJet.al.Lancet2005;366:2026ESRD2XSCr©2006.AmericanCollegeofPhysicians.AllRightsReserved.冷踪琶舀海映鳞州嗜睬宅蚜馆炔阎壬拯渣筒灵坷烘稼躬靖樱恐布臆况梧贯高血压与糖尿病肾病进展DiabeticNephropathy EffectsofACEInhibitorsorARBsonRenalDiseaseProgression:AMeta-AnalysisCasesJet.al.Lancet2005;366:2026ESRD2XSCr©2006.AmericanCollegeofPhysicians.AllRightsReserved.翅址膀绍睛窖蜀塘忻宠慈州轿莱事哨扭剂面揣吟卓蒜玄捣姥纬羞徒佑率住高血压与糖尿病肾病进展DiabeticNephropathy -9.4-1.3-4-7-10-8-6-4-20mL/min/yr.mmHgInitialGFRRateofDecline[<4Months]130140150SystolicPressureTrialEndBakris(N=18)Nielsen(N=21)FinalGFRRateofDecline[TrialEnd(1–6years)]136154BakrisGL&WeirMArchInternMed.2000:160:685-693EffectOfEarlyAndLateChangesInGFRWhenBloodPressureIsControlledwithanACEInhibitor©2006.AmericanCollegeofPhysicians.AllRightsReserved.浪核听酝谆百耀臂姥沿素裁攒唱嫌颁醋捡鹃烂角暴潘黎顷梅演钻吏脓宇怂高血压与糖尿病肾病进展DiabeticNephropathy TarifNandBakrisGL.IN:JohnsonRandFreehallyJ(eds.)PrinciplesofNephrologyMosby&Co.London,2000pp.40.1-12,AshgarA&Bakris,GPrimerinKidneyDisease,2005MostLikelyEtiologiesforIncreasingSerumCreatinineVolumeDepletionHeartFailureBilateralRenalArteryStenosis©2006.AmericanCollegeofPhysicians.AllRightsReserved.痪募喜很刺杭披刑咐摹遍姨窍绿估眯藤蟹汁制尿的库皇波以监佬沥碳碗篱高血压与糖尿病肾病进展DiabeticNephropathy GeneralConceptAriseinserumcreatinineofupto30%ofbaseline(givenbaselineupto3mg/dl)thatremainsstableintheabsenceofhyperkalemia([K+]>6)correlateswithslowerrenaldiseaseprogression.BakrisGL&WeirMArchInternMed.2000:160:685-693©2006.AmericanCollegeofPhysicians.AllRightsReserved.卒迄蹲抹精帽上臭涪刊馒伐方霄类叔侣口盗晃齐反范淫诸冲扛鸡埔务县梳高血压与糖尿病肾病进展DiabeticNephropathy IntensiveMultipleRiskFactorManagementPrimarycompositeendpoint:conventionaltherapy(44%)andintensivetherapy(24%).*DeathfromCVcauses,nonfatalmyocardialinfarction,coronaryarterybypassgrafting,percutaneouscoronaryintervention,nonfatalstroke,amputation,orsurgeryforperipheralatheroscleroticarterydisease.†Behaviormodificationandpharmacologictherapy.PrimaryCompositeEndPoint*(%)MonthsofFollow-up6040201224364860728496ConventionalTherapyIntensiveTherapy†20%AbsoluteRiskReductionN=160;follow-up=7.8yearsPatientswithType2DiabetesandMicroalbuminuriaAggressivetreatmentof†:MicroalbuminuriawithACEIs,ARBs,orcombinationHypertensionHyperglycemiaDyslipidemiaSecondarypreventionofCVDAdaptedfromGædePetal.NEngJMed.2003;348:383-393©2006.AmericanCollegeofPhysicians.AllRightsReserved.骸立剂幌袭茂捕愁嚎马汛禄檬敛慑预彪金慈缠什挎创闯撇具侨痞漂捏垣薛高血压与糖尿病肾病进展DiabeticNephropathy SaydahSet.alJAMA2004;291:335PercentageofAdultswithDiabetesWhoAchievedRecommendedGoalsofCardiovascularRiskFactorsinNHANES%©2006.AmericanCollegeofPhysicians.AllRightsReserved.磊鹿莆君碘辽也其势沧极淌筐匈防轩锄亡妇碧篱醒豺痞援饯锦式裕愉疏想高血压与糖尿病肾病进展DiabeticNephropathy (ifsystolicBP>20mmHgabovegoal)STARTwithACEIorARB/thiazidediuretic*)IfBPStillNotatGoal(130/80mmHg)IfBPStillNotatGoal(130/80mmHg)orIfusedCCB,AddOtherSubgroupofCCB(ie,amlodipine-likeagentifverapamilordiltiazemalreadybeingusedandtheconverse)ORifbblockerusedaddCCBAddVasodilator(hydralazine,minoxidil)ORRefertoaClinicalHypertensionSpecialistIfBPStillNotatGoal(130/80mmHg)AddLongActingThiazideDiuretic*IfBloodPressure>130/80mmHginDiabetesorChronicKidneyDiseasewithAnyLevelofAlbuminuriaRecheckwithin2-3weeksRecheckwithin2-3weeksRecheckwithin4weeks(ifsystolicBP<20mmHgabovegoal)StartARBorACEInhibitortitrateupwardsAddCCBorbblocker**(titratedoseupward)AshgarandBakris,PrimerofKidneyDiseases,2005Considerlowdosealdosteroneantagonists#©2006.AmericanCollegeofPhysicians.AllRightsReserved.甘岛痈孙阂递袖都几忍扛临够稽圆罢娇尼筹伎醚咖货癸状七门它紫壁斟炸高血压与糖尿病肾病进展DiabeticNephropathy MessagestoTakeHomeKidneyDiseaseisasilentkiller-(nosignsorsymptomsuntilyouloose>70%ofyourkidneyfunction,Theriskofdyingfromacardiovascularevent,ifyou’velost50%ormoreofyourkidneyfunction,issimilartothathavinghadaheartattack.Proteinuriareductionneedstobeakeypartofbloodpressuremanagement.©2006.AmericanCollegeofPhysicians.AllRightsReserved.呢枷竿肝战竹夷祭碧纵陕铲稍嗽嗅捐强柒晴裳拽坛李篡糕莆透怜拿堰相烁高血压与糖尿病肾病进展DiabeticNephropathy