igan肾病的诊断与治疗教材.ppt

ACEI治疗 大剂量ACEI的抗蛋白尿和肾保护作用优于常规剂量 KI 2002，NEJM 2002，AJKD，2002 推荐用病人可以耐受的最大剂量 JAMA 2003，NEJM 2002，AJKD，2002 对低剂量ACEI耐药时增加剂量可以克服 J Am Coll Cardiol 2002 ARB治疗 对ACEI不能耐受的病人（咳嗽、血管神经性水肿、过敏）ARB往往可以耐受 KI 2001 ARB升高血钾的作用较ACEI轻 KI 2000 ARB对2型糖尿病具有良好肾保护作用，而ACEI在这一组人群尚无大样本临床研究证据 Diabetes Care 2002， KI 2001， 2000 ARB治疗 ARB剂量 大剂量ARB的抗蛋白尿作用优于常规剂量 KI 2002，NEJM 2001 大剂量较常规剂量ARB更有可能逆转左心室肥厚 J Hypertens 2001 ACEI和ARB联合用药 ACEI/ARB的抗蛋白尿作用优于两药单用 KI 2003，Lancet 2003， BMJ 2000 ACEI/ARB时高血钾发生率与单用ACEI相似 Lancet 2003， KI 2003 ACEI and ARB for IgAN Among patients with IgA nephropathy, both ACE inhibitors and ARBs reduce the transglomerular passage of large, but not small, molecules, reducing proteinuria. The antiproteinuric effects of ACE inhibitors and ARBs are probably equivalent. Dual ACE inhibitor-ARB therapy reduces proteinuria by 54% to 73% and is more effective than either agent alone. Semin Nephrol 2004,24(3):218-224 ACEI and ARB for IgAN To determine whether ACEI or ARBs preserve renal function long-term, one must rely on trials studying nondiabetic, proteinuric renal diseases rather than on trials specific to IgA nephropathy. Among this group of patients, several randomized, controlled trials, including the AIPRI trial, the REIN trial, and a metaanalysis of 11 randomized, controlled trials, have established clearly that the ACEIs preserve renal function. There is no reason to believe that this information is not applicable to IgA nephropathy. ACEI and ARB for IgAN The COOPERATE trial, in which 50% of the subjects had IgA nephropathy, established that ACEIs and ARBs preserve renal function equally, and that dual ACE inhibitor-ARB therapy preserves renal function more effectively than either therapy alone. These data suggest that most individuals with proteinuric renal diseases, including IgAN, should be treated with ACEIs and ARBs, ideally in combination. DD genotype, could predict a favorable response to renin-angiotensin blockade. COOPERATE试验 236例非糖尿病肾病（日本） 随机分为三组 Losartan