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Importance of Target Blood Pressure Management in Diabetic Kidney Disease

당뇨병성 신장질환 환자에서 적정 혈압 관리의 중요성

  • 김희성 (단국대학교 의과대학 제일병원 진단검사의학과)
  • Received : 2019.03.25
  • Accepted : 2019.06.12
  • Published : 2019.06.28

Abstract

In diabetes mellitus, renal disease is a common complication, characterized by increased urinary albumin excretion and reduced eGFR. According to KDIGO CKD stage classification, Korean characteristics were analyzed according to urinary albumin and eGFR using the National Health and Nutrition Examination Survey VI raw data. According to KDIGO classification, diabetic patients were classified as Low risk 72.0%, Moderate risk 19.3%, High risk 5.6% and Very high risk 3.0%. Low risk decreased from 74.7% to 52.2%, and moderate to very high risk increased from 25.4% to 47.8% as the duration of diabetes mellitus was prolonged. The risk factors were CKD stage 1 (HR 2.064) to stage 4 (HR 11.049), the highest risk of hypertension. The incidence of renal disease was elevated according to duration of hypertension and HR 0.42 of kidney disease was decreased in the group maintaining proper blood pressure. In the hypertensive patients, the group administered with target blood pressure had a reduction of the kidney disease by 42% than the group with the hypertension. Therefore, controlling and managing hypertension to target blood pressure is important for the prevention of kidney disease.

신장질환은 당뇨병환자에서 흔한 합병증이며, 알부민뇨 배설의 증가, 사구체여과율의 감소가 특징적이다. KDIGO 분류에 따라 6기 국민건강영양조사 원시자료를 이용하여 알부민뇨와 사구체여과율에 따라 특성을 분석하였다. 당뇨환자를 KDIGO의 분류에 따라, Low risk 72.0%, Moderate risk 19.3%, High risk 5.6%, Very high risk 3.0%이었다. 당뇨병 유병기간이 길어질수록 Low risk는 74.7%에서 52.2%로 감소하였고, Moderate~Very high risk는 25.4%에서 47.8%로 상승하였다. 위험요인은 CKD stage 1 (HR 2.064) ~ stage 4 (HR 11.049)로 고혈압의 위험도가 가장 높았다. 고혈압 유병기간에 따라 신장질환의 발생빈도는 상승하였고, 적정 혈압을 유지하는 군에서 신장질환의 위험도 0.42가 감소하였다. 고혈압 환자에서 적정 혈압으로 관리하는 군이 그렇지 않은 군보다 42%의 신장질환의 감소효과가 있었다. 그러므로 고혈압을 적정혈압으로 조절 및 관리하는 것이 신장질환의 예방에 있어 중요하다.

Keywords

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그림 1. KDIGO 분류에 따른 CKD 위험도 분석 (1) KDIGO 분류 (2) 당뇨유병기간에 따른 KDIGO 위험도 분석

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그림 2. 고혈압 유병기간에 따른 특성분석 (1) CKD와 No-CKD 그룹간의 빈도 (2) 고혈압 약제의 사용 특성 (3) 목표치 혈압 (SBP <140, DBP <90) 달성율 (4) 목표치 혈압 달성군과 미달성군의 위험비 분석

표 1. 당뇨병 환자에서 만성신장질환 분류 단계의 임상적 특성

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표 2. 만성신장질환에서의 위험요인 분석

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References

  1. KDOQI, "KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease," Am J Kidney Dis, Vol.49, No.2, Suppl.2, pp.S12-154, 2007. https://doi.org/10.1053/j.ajkd.2006.12.005
  2. P. H. Marathe, H. X. Gao, and K. L. Close, "American Diabetes Association Standards of Medical Care in Diabetes 2017," J Diabetes, Vol.9, No.4, pp.320-324, 2017. https://doi.org/10.1111/1753-0407.12524
  3. R. Rabkin, "Diabetic nephropathy," Clin Cornerstone, Vol.5, No.2, pp.1-11, 2003. https://doi.org/10.1016/S1098-3597(03)90029-9
  4. S. L. White, K. R. Polkinghorne, R. C. Atkins, and S. J. Chadban, "Comparison of the prevalence and mortality risk of CKD in Australia using the CKD Epidemiology Collaboration (CKD -EPI) and Modification of Diet in Renal Disease (MDRD) Study GFR estimating equations: the AusDiab (Australian Diabetes, Obesity and Lifestyle) Study," Am J Kidney Dis, Vol.55, No.4, pp.660-670, 2010. https://doi.org/10.1053/j.ajkd.2009.12.011
  5. C. A. White, A. Akbari, S. Doucette, D. Fergusson, and G. A. Knoll, "Estimating glomerular filtration rate in kidney transplantation: is the new chronic kidney disease epidemiology collaboration equation any better?," Clin Chem, Vol.56, No.3, pp.474-477, 2010. https://doi.org/10.1373/clinchem.2009.135111
  6. L. Mihardja, D. Delima, R. G. Massie, M. Karyana, P. Nugroho, and E. Yunir. "Prevalence of kidney dysfunction in diabetes mellitus and associated risk factors among productive age Indonesian," Journal of Diabetes & Metabolic Disorders, Vol.17, No.1, pp.53-61, 2018. https://doi.org/10.1007/s40200-018-0338-6
  7. L. C. Plantinga, D. C. Crews, J. Coresh, E. R. Miller 3rd, R. Saran, J. Yee, E. Hedgeman, M. Pavkov, M. S. Eberhardt, D. E. Williams, and N. R. Powe. "Prevalence of chronic kidney disease in US adults with undiagnosed diabetes or prediabetes," Clin J Am Soc Nephrol, Vol.5, No.4, pp.673-682, 2010. https://doi.org/10.2215/CJN.07891109
  8. L. Mihardja, Delima, H. S. Manz, L. Ghani, and S. Soegondo, "Prevalence and determinants of diabetes mellitus and impaired glucose tolerance in Indonesia (a part of basic health research/Riskesdas)," Acta Med Indones, Vol.41, No.4, pp.169-174, 2009.
  9. K. H. Ha and D. J. Kim. "Current status of managing diabetes mellitus in Korea," The Korean journal of internal medicine, Vol.31, No.5, p.845, 2016. https://doi.org/10.3904/kjim.2016.253
  10. A. American Diabetes, "Standards of medical care in diabetes-2015 abridged for primary care providers," Clin Diabetes, Vol.33, No.2, pp.97-111, 2015. https://doi.org/10.2337/diaclin.33.2.97
  11. P. A. James, S. Oparil, B. L. Carter, W. C. Cushman, C. Dennison-Himmelfarb, J. Handler, D. T. Lackland, M. L. LeFevre, T. D. MacKenzie, O. Ogedegbe, S. C. Smith Jr., L. P. Svetkey, S. J. Taler, R. R. Townsend, J. T. Wright Jr., A. S. Narva, and E. Ortiz, "2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8)," JAMA, Vol.311, No.5, pp.507-520, 2014. https://doi.org/10.1001/jama.2013.284427
  12. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, "Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III)," JAMA, Vol.285, No.19, pp.2486-2497, 2001. https://doi.org/10.1001/jama.285.19.2486
  13. K. Tziomalos and V. G. Athyros, "Diabetic nephropathy: New risk factors and improve -ments in diagnosis," The review of diabetic studies: RDS, Vol.12, No.1-2, p.110, 2015. https://doi.org/10.1900/RDS.2015.12.110
  14. K. D. I. G. Outcomes and C. W. Group, "KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease," Kidney Int, Vol.3, No.1, pp.5-14, 2013. https://doi.org/10.1038/kisup.2012.77
  15. "Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: executive summary. Expert Panel on the Identification, Evaluation, and Treatment of Overweight in Adults," Am J Clin Nutr, Vol.68, No.4, pp.899-917, 1998. https://doi.org/10.1093/ajcn/68.4.899
  16. A. S. Levey, L. A. Stevens, C. H. Schmid, Y. L. Zhang, A. F. Castro 3rd, H. I. Feldman, J. W. Kusek, P. Eggers, F. Van Lente, T. Greene, and J. Coresh, "A new equation to estimate glomerular filtration rate," Ann Intern Med, Vol.150, No.9, pp.604-612, 2009. https://doi.org/10.7326/0003-4819-150-9-200905050-00006
  17. O. Gheith, N. Farouk, N. Nampoory, M. A. Halim, and T. Al-Otaibi, "Diabetic kidney disease: world wide difference of prevalence and risk factors," Journal of nephropharmacology, Vol.5, No.1, p.49, 2016.
  18. R. J. MacIsaac, E. I. Ekinci, and G. Jerums, "Markers of and risk factors for the development and progression of diabetic kidney disease," American journal of kidney diseases, Vol.63, No.2, pp.S39-S62, 2014. https://doi.org/10.1053/j.ajkd.2013.10.048
  19. C. E. Mogensen, "Microalbuminuria predicts clinical proteinuria and early mortality in maturity-onset diabetes," N Engl J Med, Vol.310, No.6, pp.356-360, 1984. https://doi.org/10.1056/NEJM198402093100605
  20. A. S. Levey, P. E. de Jong, J. Coresh, M. El Nahas, B. C. Astor, K. Matsushita, R. T. Gansevoort, B. L. Kasiske, and K. U. Eckardt, "The definition, classification, and prognosis of chronic kidney disease: a KDIGO Controversies Conference report," Kidney Int, Vol.80, No.1, pp.17-28, 2011. https://doi.org/10.1038/ki.2010.483
  21. R. J. Macisaac and G. Jerums, "Diabetic kidney disease with and without albuminuria," Curr Opin Nephrol Hypertens, Vol.20, No.3, pp.246-257, 2011. https://doi.org/10.1097/MNH.0b013e3283456546
  22. R. A. Bailey, Y. Wang, V. Zhu, and M. F. Rupnow, "Chronic kidney disease in US adults with type 2 diabetes: an updated national estimate of prevalence based on Kidney Disease: Improving Global Outcomes (KDIGO) staging," BMC Res Notes, Vol.7, p.415, 2014. https://doi.org/10.1186/1756-0500-7-415
  23. A. I. Adler, R. J. Stevens, S. E. Manley, R. W. Bilous, C. A. Cull, and R. R. Holman, "Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS 64)," Kidney Int, Vol.63, No.1, pp.225-232, 2003. https://doi.org/10.1046/j.1523-1755.2003.00712.x
  24. M. Brownlee, "The pathobiology of diabetic complications: a unifying mechanism," Diabetes, Vol.54, No.6, pp.1615-1625, 2005. https://doi.org/10.2337/diabetes.54.6.1615
  25. "Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group," Lancet, Vol.352, No.9131, pp.837-853, 1998. https://doi.org/10.1016/S0140-6736(98)07019-6
  26. C. Writing Team for the Diabetes, I. Complications Trial/Epidemiology of Diabetes, and G. Complications Research, "Sustained effect of intensive treatment of type 1 diabetes mellitus on development and progression of diabetic nephropathy: the Epidemiology of Diabetes Interventions and Complications (EDIC) study," JAMA, Vol.290, No.16, pp.2159-2167, 2003. https://doi.org/10.1001/jama.290.16.2159
  27. V. Djordjevic, "Hypertension and nephropathy in diabetes mellitus: what is inherited and what is acquired?," Nephrol Dial Transplant, Vol.16 Suppl.6, pp.92-93, 2001. https://doi.org/10.1093/ndt/16.suppl_6.92
  28. J. Redon, G. Mancia, P. Sleight, H. Schumacher, P. Gao, J. Pogue, R. Fagard, P. Verdecchia, M. Weber, M. Bohm, B. Williams, K. Yusoff, K. Teo, and S. Yusuf, "Safety and efficacy of low blood pressures among patients with diabetes: subgroup analyses from the ONTARGET (ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial)," J Am Coll Cardiol, Vol.59, No.1, pp.74-83, 2012. https://doi.org/10.1016/j.jacc.2011.09.040
  29. R. W. Schrier, R. O. Estacio, A. Esler, and P. Mehler, "Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes," Kidney Int, Vol.61, No.3, pp.1086-1097, 2002. https://doi.org/10.1046/j.1523-1755.2002.00213.x
  30. A. J. Jenkins, T. J. Lyons, D. Zheng, J. D. Otvos, D. T. Lackland, D. McGee, W. T. Garvey, and R. L. Klein, "Lipoproteins in the DCCT/EDIC cohort: associations with diabetic nephropathy," Kidney Int, Vol.64, No.3, pp.817-828, 2003. https://doi.org/10.1046/j.1523-1755.2003.00164.x
  31. V. Harjutsalo and P. H. Groop, "Epidemiology and risk factors for diabetic kidney disease," Adv Chronic Kidney Dis, Vol.21, No.3, pp.260-266, 2014. https://doi.org/10.1053/j.ackd.2014.03.009
  32. "Abstracts of the 30th Meeting of the European Renal Cell Study Group (ERCSG)," Nephron, Vol.139, No.1, pp.83-111, 2018. https://doi.org/10.1159/000488293
  33. V. A. Chakkarwar, "Smoking in diabetic nephropathy: sparks in the fuel tank?," World J Diabetes, Vol.3, No.12, pp.186-195, 2012. https://doi.org/10.4239/wjd.v3.i12.186
  34. O. Of, "Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease," Kidney Int Suppl, Vol.3, No.1, pp.5-14, 2013. https://doi.org/10.1038/kisup.2012.77
  35. M. Bottomley, M. Bottomley, A. Kalachik, C. Mevada, M. Brook, T. James, and P. Harden, "Single estimated glomerular filtration rate and albuminuria measurement substantially overestimates prevalence of chronic kidney disease," Nephron Clinical Practice, Vol.117, No.4, pp.348-352, 2011.