左旋氨氯地平干预伴高血压2型糖尿病肾病的弥散加权成像研究

A study on diffusion-weighted imaging evaluation of levamlodipine treatment in diabetic nephropathy patients accompaniedwith hypertension

目的利用功能磁共振中的弥散加权成像（DWI）检测技术，评估左旋氨氯地平干预对伴高血压的2型糖尿病肾病患者的肾损伤保护作用。方法采用随机’、对照的前瞻性研究方法，50例符合纳入标准的伴高血压2型糖尿病肾病（III期）患者，按随机数字表法分为A组（左旋氨氯地平组，n=26）及B组（氨氯地平组，n=24），两组在继续服用常规治疗剂量血管紧张素II受体阻滞剂（ARBs）类药物的基础上，分别加用左旋氨氯地平（2．5mgqd）或氨氯地平（5mgqd）干预24周。比较两组干预前后DWI检测的肾实质表观弥散系数（ADC）的差异，以及尿白蛋白排泄率（UAER）、血肌酐（sCr）、胱抑素C（CysC）等的变化；每4周随访患者服药情况，同时记录收缩压（SBP）舒张压（DBP）、心率以及不良反应等。结果干预24周的结果显示，两组sCr、CysC与基线比较差异均无统计学意义（P〉0．05），A组UAER、SBP及DBP较基线显著下降[42．5（25．3—91．0）Ug／minVS49．2（29．7—96．8）Ug／min，（112．6±6．4）mmHgvs（135．3±7．6）mmHg，（71．4±10．7）mmHgVS（80．3±11．6）mmHg，P〈0．05]，ADC则较基线显著上升[（2．45±0．12）vs（2．17±0．09），P〈0．05]。B组DBP及UAER与基线比较差异均无统计学意义（P〉0．05），SBP较基线显著下降[（121．5±11．6）mmHgvS（134．8±9．2）mmHg，P〈0．05]，ADC较基线显著上升[（2．28±0．15）vs（2．14±0．09），P〈0．05]，但其干预后SBP的下降幅度（△SBP）及ADC的上升幅度（AADC）均显著性低于A组（P=0．02，0．01）；A组总的不良反应发生率低于B组，差异有统计学意义（15．4％vs41．7％，X2=4．27，P=0．0387）。结论对于伴高血压的2型糖尿病肾病（III期）患者，在ARB的基础上联用左旋氨氯地平，与联用氨氯地平比较，前者可能具有更佳的全面降低血压、减少尿白蛋白排泄、改善肾脏局部微循环、总体不良反应更少的优势。

Objective To evaluate the effect of levamlodipine intervention in diabetic nephropathy patients which accompanied with hypertension, using the technology of diffusion-weighted imaging （DWI） of functional magnetic resonance （fMRI）. Methods A controlled prospective method was taken, and fifty diabetic nephropathy （phase III） patients which accompanied with hypertension were randomized assigned to two groups of A （ n = 26） and B （ n = 24）. Levamlodipine （2. 5 mg qd） was taken by patients of group A and amlodipine （5 mg qd） was taken by patients of group B for 24 weeks, respectively. Two groups both took angiotensin I1 receptor blockers （ARBs） as the first line antithypertensive agents, their urinary albumin excretion rate （UAER）, serum creatinine （sCr）, eystatin C （Cys C） , and DWI scanning were detected before and after intervention. The levels of UAER, apparent diffusion coeffi- cient （ADC） value were compared between two groups before and after intervention. During the 24th week, two groups＂ adverse reac- tion to the medicines and the levels of blood pressure were recorded in each follow-up visit. Results The levels of UAER, systolic blood pressure（ SBP）, and diastolic blood pressure（DBP） were Significantly lower in group A after 24-week intervention compared to baseline [ 42. 5 （25.3 ± 91.0 ） ug/min vs 49. 2 （ 29. 7 ± 96. 8 ） Ixg/min, （ 112. 6 ~ 6.4 ） mmHg vs （ 135.3 ± 7. 6 ） mmHg, （ 71.4 ±10. 7 ） mmHg vs （80. 3 ±11.6） mmHg, P 〈 0. 05, respectively ]. DWI scanning showed that ADC value of renal parenehyma was sig- nificantly improved than that of baseline [ （2. 45 ±0. 12）vs（2. 17 ±0. 09）, P 〈0. 05]. In Group B, the level of SBP was also signifi- cantly lower than that of baseline [ （ 121.5 ± 11.6） mmHg vs （ 134. 8 ± 9. 2） mmHg, P 〈 0. 05 ], and ADC value of renal parenchyma was significantly improved than that of baseline [ （2. 28 ±0. 15） vs （2. 14 ±0. 09）, P 〈0. 05]. No difference was found in DBP andUAER before and after intervention（ P 〉0. 05）. Group A had a better improvement of SBP （ASBP） and ADC （AADC） after inter- vention compared to group B （ P = 0. 02,0. 01, respectively）. The overall adverse reaction incidence was 15.4% （4/26） in group A and 41.7% （10/24）in group B, respectively （X2 = 4. 27, P = 0. 0387）. Condusiorts For the diabetic nephropathy （phase III） pa- tients accompanied with hypertension, levamlodipir^e likely showed better effects on reducing comprehensive blood pressure and UAER, improving renal microcirculation, with less overall adverse reaction ompared to amlodiDine.