- 期刊
慢性腎臟病照護的新里程碑－SGLT2抑制劑
The Milestone of Improving Quality of Care in Chronic Kidney Disease Patients - Sodium Glucose Cotransporter 2 Inhibitors
摘要
慢性腎臟病是一個全球性且高盛行率的疾病。然而在慢性腎臟病患的死亡率上，近二十年來的改善可說十分有限。此外在延緩腎功能惡化的藥物上，特別是針對非糖尿病腎病變的部分，有足夠證據力的藥物治療同樣是很少。近期一些大型的隨機對照臨床研究顯示，SGLT2抑制劑在糖尿病慢性腎臟病患身上具有減緩腎功能惡化、降低蛋白尿、減少腎病及心因性因素相關的死亡率的效果，部分研究亦顯示其在改善整體死亡率上也有顯著的好處。另外在DAPA-CKD針對非糖尿病慢性腎臟病患的分析中，也同樣看到類似改善腎臟預後的效果。在腎臟保護相關機轉方面，SGLT2抑制劑的護腎效果並不能單純由其降血糖的效果來解釋，可能的潛在機制包含透過：（1）恢復腎小管腎絲球回饋機制；（2）減少近曲小管的負荷以及缺氧性損傷；（3）減少腎臟間質性水腫；（4）減少發炎反應及組織纖維化等等來達成。另一方面，雖然研究證據顯示SGLT2抑制劑有腎臟與心臟的保護效果，臨床使用上仍須仔細評估相關可能的藥物副作用，包括低血糖（與合併胰島素或胰島素分泌促進劑使用）、生殖泌尿道感染與糖尿病酮酸中毒等。另外臨床照護的重點若遇重症、進食不佳或需禁食病患身上時，則需考慮暫時停用SGLT2抑制劑，以避免酮酸中毒的風險提高。
並列摘要
Chronic kidney disease is a high prevalence disease worldwide but the improvement on all caused mortality in recent decades was unsatisfactory. The evidence-based renal protective agents for chronic kidney disease patients were also relatively scarce, especially for those with non-diabetic kidney disease patients. In recent large randomized controlled trials, Sodium-glucose cotransporters 2 (SGLT2) inhibitors are shown to ameliorate the decline of glomerular filtration rate, reduce proteinuria, death from renal or cardiovascular causes and even improve all-cause mortality rate. In addition, results from the DAPA-CKD study also revealed similar protective effect on renal outcomes. The possible mechanism of renoprotective effects includes: (1) reducing glomerular capillary pressure through restoring tubuloglomerular feedback; (2) ameliorating renal tubules injury by decreasing proximal tubules oxidative stress; (3) reducing renal interstitial edema; (4) diminish inflammatory response and tissue fibrosis. Furthermore, despite emerging evidence of cardiorenal protective effects, SGLT2 inhibitors is associated with several adverse events including hypoglycemia (especially when combined use of insulin or insulin secretagogues), genitourinary tract infection and diabetic ketoacidosis. Among patients with critical illness, poor intake, or prolong fasting, the temporary discontinued use of SGLT2 inhibitors is suggested to avoid the risk of ketoacidosis.