慢性腎臟病與糖尿病－臨床上如何處理此共病症

10.6666/ClinMed.202005_85(5).0055

連澤仁；施君儒

慢性腎臟病（chronic kidney disease, CKD） ； 糖尿病腎病變（diabetic kidney disease, DKD） ； 腎源性糖質新生作用（renal gluconeogenesis） ； 血糖監測（glycemic monitoring）

臨床醫學月刊

85卷5期（2020 / 05 / 29）

299 - 315

繁體中文

慢性腎臟病（chronic kidney disease, CKD）與糖尿病（diabetes mellitus, DM）分別是目前全球健康體系所面臨的兩個重要的慢性疾病，不僅在其流病學上的高盛性率，而且這兩個族群也會造成高併發症罹病率，因為這些狀況所造成醫療資源的支出更是全球面對的重要公衛議題。更有甚者，我們在臨床上常遇到同時有CKD與DM合併存在的共病症病患，常困擾許多臨床醫療人員，因為這兩個疾病皆為因果，相互影響，形成一種危險的聯繫。在這族群病人的臨床治療上有下列議題值得在本文中提出：首先，CKD是否由糖尿病腎病變（diabetic kidney disease, DKD）所造成，其中是否有非DKD的其他病因；其次，CKD本身如何影響血糖的監測與控制。換言之，CKD的存在是否會改變DM患者原本的監測方式與常規治療模式，包括生活型態、飲食與藥物治療，這個議題包括當病人進入透析階段之後，在臨床上都極富挑戰性。本文嘗試藉由此共病症的臨床表現、生理病理學的變化、血糖的監控工具、治療的原則（包括血糖、血壓、血脂）、營養建議、以及藥物的選擇來回答這些議題。

1. (2019).2019 Taiwan Clinical Practice Guideline for Diabetic Kidney Disease.
2. (2015).Taiwan Chronic Kidney Disease Clinical Guidelines.
3. (2015).2015 Taiwan Chronic Kidney Disease Clinical Guidelines.
4. Aber, G,Morris, L,Housley, E(1966).Gluconeogenesis by the human kidney.Nature,212,1589-1590.
5. ACCORD study group,Cushman, WC,Evans, GW,Byington, RP,Goff, DC,Grimm, RH(2010).Effects of intensive blood-pressure control in type 2 diabetes mellitus.N Engl J Med,362,1575-1585.
6. Bergman H, Drury DR. The relationship of kidney function to the glucose utilization of the extra abdominal tissues. Am J Physiol 1938;124:279-84.
7. Bode, BW(2007).Use of rapid-acting insulin analogues in the treatment of patients with type 1 and type 2 diabetes mellitus: insulin pump therapy versus multiple daily injections.Clin Ther,29,135-144.
8. Brenner, BM,Cooper, ME,de Zeeuw, D(2001).Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy.N Engl J Med,345,861-869.
9. Chen, HS,Wu, TE,Lin, HD(2010).Hemoglobin A(1c) and fructosamine for assessing glycemic control in diabetic patients with CKD stages 3 and 4.Am J Kidney Dis,55,867-874.
10. de Zeeuw, D,Remuzzi, G,Parving, HH(2004).Proteinuria, a target for renoprotection in patients with type 2 diabetic nephropathy: lessons from RENAAL.Kidney Int,65,2309-2320.
11. Fineberg, D,Jandeleit-Dahm, KA,Cooper, ME(2013).Diabetic nephropathy: diagnosis and treatment.Nat Rev Endocrinol,9,713-723.
12. Freeman, JS(2013).Review of insulin-dependent and insulin-independent agents for treating patients with type 2 diabetes mellitus and potential role for sodium-glucose co-transporter 2 inhibitors.Postgrad Med,125,214-226.
13. Fried, LF,Emanuele, N,Zhang, JH(2013).Combined angiotensin inhibition for the treatment of diabetic nephropathy.N Engl J Med,369,1892-1903.
14. Garg, R,Williams, ME(2013).Diabetes management in the kidney patient.Med Clin North Am,97,135-156.
15. Glasziou, PP,Irwig, L,Heritier, S(2008).Monitoring cholesterol levels: measurement error or true change?.Ann Intern Med,148,656-661.
16. Gosmanov, AR,Gosmanova, EO(2011).Long-term renal outcomes of patients with type 1 diabetes mellitus and microalbuminuria: an analysis of the DCCT/EDIC cohort.Arch Intern Med,171,412-420.
17. Hayward, RA,Krumholz, HM(2012).Three reasons to abandon low-density lipoprotein targets: an open letter to the Adult Treatment Panel IV of the National Institutes of Health.Circ Cardiovasc Qual Outcomes,5,2-5.
18. Hill, CJ,Maxwell, AP,Cardwell, CR(2014).Glycated hemoglobin and risk of death in diabetic patients treated with hemodialysis: a meta-analysis.Am J Kidney Dis,63,84-94.
19. Holmes, G,Galitz, L,Hu, P(2005).Pharmacokinetics of insulin aspart in obesity, renal impairment, or hepatic impairment.Br J Clin Pharmacol,60,469-476.
20. Houlihan, CA,Allen, TJ,Baxter, AL(2002).A low-sodium diet potentiates the effects of losartan in type 2 diabetes.Diabetes Care,25,663-671.
21. Jha, V,Garcia-Garcia, G,Iseki, K(2013).Chronic kidney disease: global dimension and perspectives.Lancet,382,260-272.
22. KDIGO(2013).Clinical practice guideline for lipid management in chronic kidney disease.Kidney Inter,3,259-305.
23. Koenig, RJ,Peterson, CM,Jones, RL(1976).Correlation of glucose regulation and hemoglobin AIc in diabetes mellitus.N Engl J Med,295,417-420.
24. Lubowsky, ND,Siegel, R,Pittas, AG(2007).Management of glycemia in patients with diabetes mellitus and CKD.Am J Kidney Dis,50,865-879.
25. Mazzucco, G,Bertani, T,Fortunato, M(2002).Different patterns of renal damage in type 2 diabetes mellitus: A multicentric study on 393 biopsies.Am J Kidney Dis,39,713-720.
26. Nathan, D,Davidson, MB,Defronzo, RA(2007).Impaired fasting glucose and impaired glucose tolerance: implications for care.Diabetes Care,30,753-759.
27. Nerby, CL,Stickle, DF(2009).1,5-anhydroglucitol monitoring in diabetes: a mass 4. balance perspective.Clin Biochem,42,158-167.
28. Okada, T,Nakao, T,Matsumoto, H(2009).Influence of age and nutritional status on glycated albumin values in hemodialysis patients.Intern Med,48,1495-1499.
29. PalmerSuetonia, C,Mavridis, D,Navarese, EP(2015).Comparative efficacy and safety of blood pressure-lowering agents in adults with diabetes and kidney disease: a network meta-analysis.Lancet,385,2047-2056.
30. Parving, HH,Lehnert, H,Brochner-Mortensen, J(2001).The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes.N Engl J Med,345,870-878.
31. Patel, A,Group, AC,MacMahon, S(2007).Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus(the ADVANCE trial): a randomised controlled trial.Lancet,370,829-840.
32. Porcellati, F,Rossetti, P,Busciantella, NR(2007).Comparison of pharmacokinetics and dynamics of the longacting insulin analogs glargine and detemir at steady state in type 1 diabetes: a double-blind, randomized, crossover study.Diabetes Care,30,2447-2452.
33. Ricks, J,Molnar, MZ,Kovesdy, CP(2012).Glycemic control and cardiovascular mortality in hemodialysis patients with diabetes: a 6-year cohort study.Diabetes,61,708-715.
34. Ruggenenti, P,Flores, C,Aros, C(2003).Renal and metabolic effects of insulin lispro in type 2 diabetic subjects with overt nephropathy.Diabetes Care,26,502-509.
35. Sarnak, MJ,Bloom, R,Muntner, P(2015).KDOQI US commentary on the 2013 KDIGO clinical practice guideline for lipid management in CKD.Am J Kidney Dis,65,354-366.
36. Shaw, JE,Sicree, RA,Zimmet, PZ(2010).Global estimates of the prevalence of diabetes for 2010 and 2030.Diabetes Res Clin Pract,87,4-14.
37. Stevens, LA,Coresh, J,Greene, T(2006).Assessing kidney function-measured and estimated glomerular filtration rate.N Engl J Med,354,2473-2483.
38. UK Prospective Diabetes Study. (UKPDS) 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.
39. Urata, H,Mori, K,Emoto, M(2015).Advantage of insulin glulisine over regular insulin in patients with type 2 diabetes and severe renal insufficiency.J Ren Nutr,25,129-134.
40. Uzu, T,Hatta, T,Deji, N(2009).Target for glycemic control in type 2 diabetic patients on hemodialysis: effects of anemia and erythropoietin injection on hemoglobin A(1c).Ther Apher Dial,13,89-94.

1. 李麗君,何育菁(2023)。照顧一位末期腎病患者轉換透析治療模式適應過程之護理經驗。臺灣腎臟護理學會雜誌，22(1)，1-14。
2. 趙家伶,郭宜芳,胡啟心(2023)。運用Watson關懷理論照護一位急性腎損傷病人之加護經驗。領導護理，24(3)，108-122。