[1], 1., 2. 3. (renoprotective (end-stage renal disease, ESRD) therapies) (JAMA) (multiple risk (renal replacement therapy, RRT) factors intervention treatment MRFIT) [2] ( 1) % (ESRD) ( ) ( 1) 2001 (120 ml/min) (1 ml/min) (90 ml/min) (3 ml/min) ( ) ( ) 1 136
(Renoprotective Therapies) (glomerulosclerosis) [5-8] (Hebert (Scr 2.5 mg/dl Ccr 30 ml/min) LA) 2001 (K.I.) ACEIs [3] 24 50 meq (MRFIT) (Levels I III) ( 1) Kayexalate Kalimate 1. (MRFIT) (Level 1) 1. 2. (ACEIs-Angiotensin converting enzyme inhibitors, ACEIs) (Cr 1.5 mg/dl) (renal progression) 3. (HbA1C 6.5 7.0%) 4. (Level 2) 1. 1. 1994 (NEJM) 2. 3. 125/75 (mmhg) 4. 135/85 mmhg (Level 3) 1. (homocysteine) 2. (Nonsteroidal antiinflammatory drugs) [4] ( ) 3. (hyperinsulinemia) 4. (antioxidants) 5. (ACEIs) 6. (Calcium channel antagonists 7. nondihydropyridine non-dhp, CCBs) 8. (BP 125/75 mmhg) 9. Angiotensin ( 1 g/day) II receptor antagonists, AIIAs Angiotensin 2. (ACEIs) receptor blockers, ARBs) 10. 137
6. (RAA system-renin-angiotensin-aldosterone system) (AIIAs ARBs) (RENAAL IRMA2 IDNT) [9-11] 7. ( ) 10 g/dl 10 11 ACEIs (DOQI ) ARBs 11 12 mg/dl [17] [12-15] 3. [18-19] (hyperfiltration) (left ventricular hypertrophy LVH) 70% (rhu-epo) (incipent nephropathy) (microalbuminuria) (HbA 1C ) (chronic hypoxia therapy) ( ( 6.5 7%) [15-16] ) [20] 4. [21-22] (Ccr 20 ml/min ) (CREATE ) 0.6 (0.8 8. ) 3 [4] 5 9. (homocysteine) 5. (Apo B) (2 15 ) B 12 10. (NSAIDs) HMG (statins) (fibric acids) (rhabdomyolysis) 11. (hyperinsulinemia) X B 6 138
(syndrome X) Thiazolidinediones (Avandia ) 12. (antioxidants) (not-indicated) 1. (steroid-re- minimal change disease) (Vit. C 200 mg)sponsive (Vit. E) 2. 13. ( ) 3. ( ) (cyst growth) 4. (thin basement membrane disease) 14. (Vit. D) 5. ( 1.4 2.0 mg/dl) ( 1 g/day) 70 ( 55) [ 3,23] 6. 15. (aspirin) 81 (HOT study) [24] ACEIs 16. (MRFIT) 17. (ARBs) [11-13] 18. 1. Levin A: Identification of patients and risk factors in chronic kidney disease: evaluating risk factors and therapeutic strategies. Nephrol Dial Transplant 2001; 16 (suppl 7): 57-60. 2. Anonymous: Multiple risk factor intervention trial (MRFIT): Risk factor changes and mortality results. JAMA 1982; 248: 1465-77. 139
3. Hebert LA, Wiber MA, Falksman ME: Renoprotection: one or many therapies. Kidney Int 2001; 59: 1211-26. 4. Klahr S, Levey A, Beck J, et al: The effects of dietary protein restriction and blood pressure control on the progression of chronic disease. N Engl J Med 1994; 330: 877-84. 5. Dasgupta I, Madeley RJ, Pringle MAL, Savill J, Burden RP: Management of hypertension in patients developing endstage renal failure. Q J Med 1999; 92: 519-25. 6. Schwenger V, Ritz E: Audit of antihypertensive treatment in patients with renal failure. Nephrol Dial Transplant 1998; 13: 3091-5. 7. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD for the Collaborative Study Group: The effect of angiotensin-convertingenzyme inhibition on diabetic nephropathy. N Engl J Med 1993; 329: 1456-62. 8. Russo D, Pisan A, Balletta M, et al: Additive antiproteinuric effect of converting enzyme inhibitor and losartan in normotensive patients with IgA nephropathy. Am J Kidney Dis 1999; 33: 851-6. 9. The GISEN Group: Randomised placebo-controlled trial of effect of ramipril on decline in glomerular filtration rate and risk of terminal renal failure in proteinuric non-diabetic nephropathy. Lancet 1997; 349: 1857-63. 10. Muirhead N: The rational for early management of chronic renal insufficiency. Nephrol Dial Transplant 2001; 10(suppl 7): 51-6. 11. Brenner BM, Cooper ME, de Zeeuw D, et al: Effects of losartan on renal and cardiovascular outcomes in patients with type II diabetes and nephropathy (RENAAL Study). New Engl J Med 2001; 345: 861-9. 12. Lewis EJ, Hunsicker LG, Clarke WR, et al: Renoprotective effect of ARB - Irbesartan in patients with nephropathy due to type 2 diabetes (IRMA2 Study). New Engl J Med 2001; 345: 851-60. 13. Parving HH, Lehnert H, Brochner-Mortensen J, et al: The effect of Irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes (IDNT study). New Engl J Med 2001; 345: 870-8. 14. Russo D, Minutolo R, Risani A, et al: Coadministration of losartan and enalapril exerts additive antiproteinuric effect in IgA nephropathy. Am J Kidney Dis 2001; 38: 18-25. 15. Remuzzi G, Schieppati A, Ruggenenti P: Nephropathy in Patients with Type 2 Diabetes. N Engl J Med 2002; 346: 1145-51. 16. American Diabetes Association: Standards of medical care for patients with diabetes mellitus. Diabetes Care 2002; 25: 213-29. 17. DOQI (Dialysis Outcomes Quality Initiative) guidelines, National Kidney Foundation 2000. 18. Obrador GT, Ruthazer R, Arora P, et al: Prevalence of and factors associated with suboptimal care before initiation of dialysis in the United States. J Am Soc Nephrol 1999; 10: 1793-800. 19. Fink JC, Blahut S, Reddy M, Light PD: Use of erythropoietin before the initiation of dialysis and its impact on mortality. Am J Kidney Dis 2001; 37: 348-55. 20. Fine L, Orphanides C, Norman J: Progressive renal disease: the chronic hypoxia hypothesis. Kidney Int 1998; 53: S74-8. 21. Jungers P, Choukroun G, Oualim Z, Robino C, Nguyen AA, Man NK: Beneficial influence of recombinant human erythropoietin therapy on the rate of progression of chronic renal failure in predialysis patients. Nephrol Dial Transplant 2001; 16: 307-12. 22. Kuriyama S, Tomonari H, Yoshida H, et al: Reversal of anemia by erythropoietin therapy retards the progresson of chronic renal failure, especially in nondiabetic patients. Nephron 1997; 77: 76-85. 23. Katrin Uhlig, Mark JS, Ajay KS, et al: New approaches to the treatment of calcium and phosphorus abnormalities in patients on hemodialysis. Curr Opin Nephrol Hypertens 2001; 10: 793-798. 24. Hansson L, Zanchetti A, Carruthers SG, et al: Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998; 351: 1755-62. 140