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Углеводный обмен и функциональное состояние почек при артериальной гипертонии высокого риска. 
Возможности фармакологической коррекции ренометаболического профиля

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Древаль A.B., Мисникова И. В., Барсуков И. А., Пончакова Г. В., Кузнецов A.B. Распространенность сахарного диабета 2 типа и других нарушений углеводного обмена в зависимости от критериев диагностики. Сахарный диабет, 2010; 1: 116−121. Балаболкин М. И., Клебанова Е. М. Новые возможности в достижении компенсации углеводного обмена при сахарном диабете 2 типа: янувия ингибитор дипептидилпептидазы IV… Читать ещё >

Углеводный обмен и функциональное состояние почек при артериальной гипертонии высокого риска. Возможности фармакологической коррекции ренометаболического профиля (реферат, курсовая, диплом, контрольная)

Содержание

  • ВЫВОДЫ

1. Частота нарушений углеводного обмена у пациентов АГ высокого риска (АБА2010) по результатам ПГТТ составляет 73%, из них состояние предиабета встречается в 50%, впервые выявленный СД 2 типа — в 23%. Частота нарушений углеводного обмена по результатм ПГТТ и НЬА1с составляет 82%, из них состояние предиабета наблюдается в 49%, впервые выявленный СД 2 типа в 33% случаях. Включение НЬА1с в оценку состояний углеводного обмена у пациентов АГ высокого риска повышает диагностику впервые выявленного СД 2 типа на 10% и не влияет на частоту выявления предиабета.

2. Выявлены различные пути эволюции нарушений углеводного обмена. Частота новых случаев СД 2 типа у пациентов АГ высокого риска и предиабетом составила 40%, восстановление нормогликемии наблюдалось в 20% случаев, в 40% состояние углеводного обмена не изменилось. Прогностическая ценность показателя НЬА1с в отношении новых случаев СД 2 типа у пациентов АГ высокого риска сопоставима с показателями гликемии натощак и/или гликемии через 2 часа. Предрасполагающими факторами развития СД 2 типа у пациентов АГ высокого риска являются клиническое САД и ДАД, выраженность неспецифического воспаления, предиктором восстановления нормогликемии — достижение и удержание целевого АД.

3. Частота нарушений функции почек у пациентов АГ высокого риска с нарушениями углеводного обмена сопоставима с частотой у пациентов без нарушений углеводного обмена и составляет 39% и 41% соответственно. Наибольшая частота субклинических почечных нарушений наблюдается у пациентов с впервые выявленным СД 2 типа и состояниями предиабета, выявленными на основании изолированной гликемии через 2 часа и изолированным повышением НЬА1с.

4. Частота МАУ была наибольшей в группе пациентов АГ и известным СД 2 типа при сопоставимой выявляемое&trade- МАУ у пациентов с предиабетом и впервые выявленным СД 2 типа. Диагностически значимое снижение СКФ<60 мл/мин/1,73 м очень редко сочеталось с МАУ у больных АГ вне зависимости от состояния углеводного обмена. Сочетание МАУ и снижения СКФ<60 мл/мин/1,73 м отмечено у 2% больных АГ и предиабетом, у 8% и 4% больных с впервые выявленным и известным СД соответственно. Предрасполагающими факторами для развития нарушений функции почек у пациентов АГ высокого риска являются клиническое САД и ДАД, наличие избыточного веса тела/ожирения и нарушения углеводного обмена. Присоединение нарушений липидного обмена и фактора неспецифического воспаления способствуют развитию сочетанных нарушений — сниженной СКФ<60 мл/мин/1,73 м² и МАУ.

5. У больных АГ и СД, установлена взаимосвязь между показателями функции почек, инсулиночувствительностью и параметрами неспецифического воспаления. Выявлена положительная взаимосвязь индекса инсулиночувствительности с противовоспалительным цитокином адипонектином, и отрицательная — с провоспалительным ИЛ-6. Цистатин С был независимо ассоциирован с провоспалительными маркерами ИЛ-1 и ФНО-а. У больных с субклиническим поражением почек обнаружена обратная связь СКФМшш и адипонектина.

6. Пациенты неосложенной АГ характеризуются высокой частотой инсулинорезистентности, которая увеличивается по мере ухудшения состояния углеводного обмена. Использование расчетного индекса НОМА 2 в отличие от НОМА 1, позволяет выявить ИР у большего количества больных независимо от наличия и степени нарушений углеводного обмена. Инсулинорезистентные пациенты, выявленные по одному или обоим индексам, характеризуются более выраженным субклиническим поражением почек по сравнению с пациентами без ИР, независимо от состояния углеводного обмена.

7. Длительная терапия метформином 850−1700 мг/сут у пациентов АГ высокого риска и предиабетом является эффективной в отношении гликемии натощак, безопасной, снижает риск развития новых случаев СД 2 типа, характеризуется низкой частотой гипогликемий (7,6%) и способствует уменьшению ИМТ. Терапия секретагогом короткого действия натеглинидом у пациентов с предиабетом является эффективной в отношении снижения гликемии натощак, безопасной, однако способствует увеличению ИМТ. Монотерапия инсулином гларгином у пациентов АГ высокого риска с впервые выявленным СД 2 типа является эффективной в отношении гликемии натощак, HbAlc, безопасной и хорошо переносимой, не влияет на ИМТ пациента и характеризуется низким риском гипогликемий (10%).

8. Длительный прием блокаторов РААС у пациентов АГ высокого риска помимо прямого антигипертензивного эффекта приводит к снижению новых случаев СД 2 типа, и обладает нефропротективным потенциалом, уменьшая частоту развития МАУ, прогрессирование МАУ до протеинурии и способствуя обратному регрессу МАУ до нормоальбуминурии.

9. Системная экспозиция (максимальная концентрация в плазме крови и площадь под кинетической кривой) вилдаглиптина замедленного высвобождения 25−50 мг при однократном и многократном назначении у пациентов с умеренной/тяжелой почечной недостаточностью была в 2 раза выше в сравнении с лицами с нормальной функцией почек. Препарат был хорошо переносим и не оказывал влияния на параметры краткосрочной сердечно-сосудистой безопасности у пациентов с легкой, умеренной, тяжелой почечной недостаточностью и лиц с нормальной функцией почек.

ПРАКТИЧЕСКИЕ РЕКОМЕНДАЦИИ

1. Пациентам с осложненной АГ рекомендовано проведение расширенного обследования — определения НЬА1с в сочетании с пероральным глюкозотолератным тестом. Пациентам с неосложненной АГ для диагностики нарушений углеводного обмена достаточно сочетанного определения НЬА1с и гликемии натощак.

2. Определение НЬА1с, гликемии натощак и гликемии через 2 часа у пациентов АГ высокого риска имеет одинаковую прогностическую ценность в отношении новых случаев СД 2 типа.

3. Сочетанное определение СКФмэ1ш и МАУ рекомендовано всем пациентам АГ высокого риска независимо от степени нарушения углеводного обмена.

4. Пациентам с неосложненной АГ независимо от степени нарушения углеводного обмена целесообразно проводить оценку состояния инсулинорезистентности с помощью расчетного индекса НОМА2, что позволит увеличить выявляемость данного состояния.

5. Для косвенной оценки выраженности неспецифического воспаления у пациентов АГ и СД 2 типа рекомендовано использовать индекс ОШСКЬ

6. Больным АГ высокого риска и нарушениями углеводного обмена для улучшения функционального состояния почек и предупреждения новых случаев СД 2 типа рекомендовано назначение блокаторов РААС.

7. При применении вилдаглиптина замедленного высвобождения 25−50 мг/сутки требуется мониторирование функции почек.

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