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11
Погляд на проблему
Looking at the Problem
почки
НИРКИ KIDNEYS
UDC 616.61-002.27-616.43 DOI: 10.22141/2307-1257.6.1.2017.93781
D.D. Ivanov
Shupyk National Medical Academy of Postgraduate Education, Kyiv, Ukraine
When Should We Start Using Angiotensin Converting Enzyme Inhibitors/Angiotensin Receptor Blockers in Diabetic Kidney Disease?
For cite: Pochki. 2017;6:31-5. doi: 10.22141/2307-1257.6.1.2017.93781
Abstract. International guidelines do not recommend angiotensin converting enzyme (ACE) inhibitors/angio-tensin receptor blockers (ARBs) usage in the first stage of diabetic kidney disease. It shows the view, based on a small statistical sample, that olmesartan (or possibly other ACE inhibitors/ARBs) should be used to prevent the transition of the first stage of diabetic kidney disease to the second one in type 2 diabetes mellitus. Keywords: diabetic kidney disease; angiotensin converting enzyme inhibitors/angiotensin receptor blockers; olmesartan; international guidelines
Current guidelines for diabetic kidney disease (DKD) KDIGO, 2012 and the ADA, 2017 state the following:
— We recommend not using an angiotensin-convert-ing enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) for the primary prevention of DKD in normotensive normoalbuminuric patients with diabetes
(IA).
— We suggest using an ACE inhibitor or an ARB in normotensive patients with diabetes and albuminuria levels > 30 mg/g who are at high risk of DKD or its progression (2C) [1].
— We suggest that an ARB or ACE inhibitor are used in adults with diabetes and CKD ND with urine albumin excretion of 30 to 300 mg per 24 hours (or equivalent*) (2D).
— We recommend that an ARB or ACE inhibitor are used in adults with diabetes and CKD ND with urine albumin excretion 4300 mg per 24 hours (or equivalent*)
(IB) [2].
— In nonpregnant patients with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor blocker is recommended for those with modestly elevated urinary albumin-to-creatinine ratio (30—299 mg/g creatinine) B and is strongly recommended for those
with urinary albumin-to-creatinine ratio > 300 mg/g creatinine and/or estimated glomerular filtration rate < 60 mL/min/1.73 m2 (A).
— An ACE inhibitor or an angiotensin receptor blocker is not recommended for the primary prevention of diabetic kidney disease in patients with diabetes who have normal blood pressure, normal urinary albumin-to-creatinine ratio (< 30 mg/g creatinine), and normal estimated glomerular filtration rate (B) [3].
Treatments that produce a lasting decrease in urinary albumin excretion may slow the progression of DKD even in the absence of hypertension [1]. It is well known that the first phase of DKD that is characterized by normoalbuminuria, normotension and glomerular hyperfiltrationis going to enter the next albuminuria stage and be accompanied by hypertension. Our experience shows that within a year from the hyperfiltration debut there is the appearance of albuminuria, or BP over 130/80 mm Hg in 64 % of patients. The data obtained from a retrospective analysis of 22 patients with DKD type 2 diabetes. These people made up the comparison group to those, which according to current recommendations were not treated with ACE inhibitors/ARB. 21 patients with 1 stage by Mogensen DKD received 10 mg
© «Kidneys», 2017 © «Нирки», 2017
© Publisher Zaslavsky O.Yu., 2017 © Видавець Заславський О.Ю., 2017
For correspondence: Dmytro D. Ivanov, MD, PhD, Professor, Head of the Department of nephrology and renal replacement therapy, Shupyk National Medical Academy of Postgraduate Education, Doro-hozhytska st., 9, Kyiv, 04112, Ukraine; e-mail: ivanovdd@i.kiev.ua
Для кореспонденци: 1ванов Дмитро Дмитрович, доктор медичних наук, професор, завщувач кафедри нефрологи i нирково-замкно!' терапи, Нацюнальна медична академт тслядипломноТ освгга ¡меш П.Л. Шутка, вул. Дорогожицька, 9, м. Кшв, 04112, Укра'ша; e-mail: ivanovdd@i.kiev.ua
Том 6, № 1, 2017
www.mif-ua.com,http://kidneys.zaslavsky.com.ua
31
Погляд на проблему / Looking at the Problem
Table 1
Group7 To DKD 2 stage DKD 1 stage Total X2
Base, treatment free 14 8 22 8,97
To compare, patients with olmesartan 10 mg qd 3 18 21
Total 17 26 43
olmesartan once at night with a duration of 1 year. Gly-cemic control in both groups was compared with the level of glycated hemoglobin that was 6.4 ± 0.1 % and 6.5 ± 0.1 %, respectively. The comparison groups are shown in the table.
Following the data in the table, the differences in the groups is shown on the basis of "the transition to the second stage of the DSB" was evident (RR 4.45, 95% DI 1.49-13.30, P < 0.05). The absolute risk in patients treated with olmesartan (CER) was 0.143, and in those who had expectant management — EER was 0.636, the number of patients needed to treat to prevent the transition to the second stage (NNT) was 2.026 with a sensitivity rate (Se) 0.824 and specificity (Sp) one — 0.692. The relative risk of reduction of 2 stage diabetic nephropa-thy progression (RRR) was 78 % with the absolute risk (ARR) of nearly 50 %.
There are two reasonable questions:
1. If the reason for the development of diabetic ne-phropathy is not eliminated, it is possible to expect that progression of DSB in its successive stages will not be observed?
2. If the reduction in the transition to the second stage is statistically significant, and olmesartan exhibits such a high efficiency, why won't we use an active strategy of
prevention using this drug (or another ARB/ACE inhibitor) already at the first stage of the DKD?
The data require randomized study, probably with PROMISE (randomized, double-blind, placebo-controlled trial) design to confirm the appropriateness of this practice. However, such approachas avoiding ACE inhibitors/ARBs usage in eGFR less than 15 mL/min [4], which is already used in practice ahead of being included to international guidelines.
Conflict of interests: Not declared.
References
1. National Kidney Foundation. KDOQI Clinical Practice Guideline for Diabetes i CKD: 2012 update. Am J Kidney Dis. 2012;60(5):850-86.
2. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney inter., Suppl. 2012; 2:337—414. Available from: http://www.kidney-international.org & 2012 KDIGO 340
3. Diabetes Care 2017 Jan; 40 (Suppl.1):S88-S98. doi: 10.2337/dc17-S001http://care.diabetesjournals.org/content/40/ Supplement_1/S88
4. Ivanov DD Next Step in Chronic Kidney Disease Therapy. Pochki. 2016;2(16):10-13. doi: 10.22141/2307-1257.0.2.16.2016.72205(in Russian).
Received 20.01.2017 ■
1ванов Д. Д.
Национальна медична академiя пюлядипломно! освти iMeH П.Л. Шупика, м. Кию, Украна
Коли починати використовувати шпбггори ангютензинперетворювального ферменту/блокатори рецепторiв ангютензину
при Aia6e^4HM хворобi нирок?
Резюме. Мiжнaроднi кер1вництва не передбачають викори-стання ÍHri6ÍTopÍB ангютензинперетворювального ферменту (1АПФ)/блокатор1в рецептор1в ангютензину (БРА) при першш стади д1абетично! хвороби нирок. Наведено погляд, що Грунтуеться на нечисленнш статистичнш виб1рщ, зпдно з яким доцшьно використовувати олмесартан (або, можливо,
шш1 1АПФ/БРА) для профшактики переходу першо! стади д1абетично! хвороби нирок у другу при цукровому д1абет1 2-го типу.
KTO40BÍ слова: д1абетична хвороба нирок; шпбитори ангютензинперетворювального ферменту/блокатори рецептор1в ангютензину; олмесартан; м1жнародш кер1вництва
Иванов Д. Д.
Национальная медицинская академия последипломного образования имени П.Л. Шупика, г. Киев, Украина
Когда начинать использовать ингибиторы ангиотензинпревращающего фермента/блокаторы рецепторов ангиотензина при диабетической болезни почек?
Резюме. Международные руководства не предполагают использование ингибиторов ангиотензинпревращающего фер-мента/блокаторов рецепторов ангиотензина (ИАПФ/БРА) при первой стадии диабетической болезни почек. Приведена точка зрения, основанная на немногочисленной статистической выборке, согласно которой целесообразно использовать
олмесартан (или, возможно, другие ИАПФ/БРА) для профилактики перехода первой стадии диабетической болезни почек во вторую при сахарном диабете 2-го типа. Ключевые слова: диабетическая болезнь почек; ингибиторы ангиотензинпревращающего фермента/блокаторы рецепторов ангиотензина; олмесартан; международные руководства
32 ПОЧКИ, p-ISSN 2307-1257, e-ISSN 2307-1265 Том 6, № 1, 2017
