( )

( )
ISBN
1

978-974-422-577-1
2553
2,000

- ()























( )

( )






( )

11

12

14

15

16



(Guidelines for Detection, Prevention, and Treatment
of Diabetic Nephropathy)

-

17

19

19

20

22

24

27

- (References)

28

30

31

19

41

44

44

44

44

45

46

43

46

46

47

47

48

- (appropriate topical therapy)

48

- (wound dressing)

49

49

50

51

- Care After Cure

52

- (Daily Foot Care)

53

- 1

54

- 2

55

- 3

56

57

59

69

70

WHO(1) .. 2543 171
366 .. 2573 50
15 2

10
32(2)


(fasting plasma glucose : FPG) .. 2540(3) 4.8

35
.. 2543(4) 9.6 35

2.4



(Disability Adjusted Life Year: DALY)
435,749 DALY(5)
3 DALY ( 7) 5 DALY

(3)

the Wisconsin
Epidemiological Study of Diabetic Retinopathy (WESDR)

( )

 1 15 3 12
30 2 7 20-24 (6)


(vitreous)
(diabetic retinopathy: DR)

(optic neuropathy) DR

(macula)

1. DR

2.


3.

4.

5. DR

(7)

1. 1 (type 1 diabetes mellitus)



2. 2 (type 2 diabetes mellitus)




( )


3. (other specific types of diabetes mellitus)


3.1 genetic defects in -cell function
3.2 genetic defects in insulin action
3.3 diseases of the exocrine pancreas
3.4 drug induced or chemical induced conditions
3.5 miscellaneous

4. (gestational diabetes mellitus, GDM)

(8)

1.

200 /

11.1 /

2. 8 126 /
7.0 / 2

3. (oral glucose tolerance test, OGTT)
2 75 200 /

11.1 /

4. HbA 1C 6.5% American Diabetes Association (ADA)

DR


( )

glucose metabolism(9,10)
sorbital
protein kinase C prostaglandin(11,12)
permeability

fibroblast growth factor, vascular endothelial growth factor, platelet-derived
growth factor

(13)

DR

(microangiopathy)

vitreous hemorrhage, retinal fibrovascular proliferation,
traction retinal detachmaent maculopathy


1. No retinopathy DR

2. Mild NPDR (nonproliferative DR)
(microaneurysm)



3. Moderate NPDR mild NPDR severe NPDR

4. Severe NPDR
l Microaneurysm 20 quadrant fundus 4
quadrant
l Venous beading 2 quadrant fundus
l Intraretinal microvascular abnormalities (IRMA) 1 quadrant

5. PDR (proliferative DR) (neovascularization)
(preretinal hemorrhage) (vitreous
hemorrhage)


( )

2





microaneurysm ( )

microaneurysm ( ), retinal heomrrhage


( ) hard exudates ( * )

4 Venous beading

( )

(
) ( )

Cotton


wool spot (
)

6





optic disc (neovascularization on optic


disc: NVD) ( )

7





(neovascularization elsewhere : NVE)

8





( )

( )

 9 PDR

1. 5

2.

3. (diabetic nephropathy) microalbuminuria,
macroproteinuria

4.

5. (dyslipidemia)

6. (puberty)

7.

(8)

1. 1 (type 1 diabetes mellitus)
1.1 10

5

(puberty)
1.2 1-2


1.3


( )


2. 2 (type 2 diabetes mellitus)
2.1 2

2.2 1-2

2.3




l 1 2


l





3. 3
(1st trimester)
1

4. (GDM)

126 /

5.

10

( )

(14)



Glycemic control

90-130 /
1-2 <180 /
Lipid
Triglyceride
<150 /
Cholesterol
<200 /
LDL-cholesterol
<100 /
HDL-cholesterol
> 40 /
Blood Pressure
Systolic
<130
Diastolic
< 80


Abbreviation
Ma
: microaneurysm
NPDR : nonproliferative diabetic retinopathy
PDR : proliferative diabetic retinopathy
HEx : hard exudate
CWS : cotton wool spots
VB
: venous beading
IRMA : intraretinal microvascular abnormalities
NVE : neovascularization elsewhere
NVD : neovascularization on optic disc
CSME : clinically significant macular edema

11
( )

12

2

fluorescein angiography


1. (Laser photocoagulation)
3
1. panretinal (scatter) photocoagulation PDR
(neovascularization on retina surface)
(neovascularization on iris; NVI) severe
NPDR

2. focal laser photocoagulation microaneurysm


1 Screening guideline
Age of onset of DM Recommended time of first exam Routine minimal FU

Less than 30
5 years after onset
Yearly

31 and older
At time of diagnosis
Yearly
Prior to pregnancy
Prior to conception
3 4 months

Early in the first trimester

2 Management Recommendation
Severity of Retinopathy Presence of Follow up Scatter(Panretinal) Focal Laser

CSME
(Months)
Laser
1. Normal
No
12
No
No
2. Mild to moderate NPDR
No
6-12*
No
No

Yes
2-4
No
Usually
3. Severe NPDR
No
2-4
uncertain
No

Yes
2-4
uncertain
Usually
4. PDR
No
2-4
Yes
No

Yes
3-4
Yes
Usually

CSME Clinically significant macular edema ETDRS

*
macular

macular edema

12

( )

 3. grid photocoagulation (diffuse

capillary leakage)


1. (no regression)
2. (increase neovascularization)
3. (new vitreous hemorrhage)
4. (new area of neovascularzation)

2. (Cryoretinopexy)



3. (intravitreal injection)
steroid triamcinolone acetonide
anti-vascular endothelial growth factors


1. (diabetic macular edema, DME)
2 diffuse type
2. proliferative diabetic retinopathy
(PDR) / (vitreous hemorrhage, VH)
(adjunctive
therapy) (new vessels, NV)
3. (parplana vitrectomy, PPV)


4. (vitreoretinal surgery)

1. non-resorbing vitreous opacities
2. traction retinal detachment or involving the macula
3. combined rhegmatogeneous and traction retinal detachment
4. progressive fibro-proliferative diabetic retinopathy

13
( )


1. severe progressive fibrovascular proliferation
2. anterior hyaloidal fibrovascular proliferation
3. red blood cell-induced (erythrocytic) glaucoma
4. anterior segment neovascularization with media opacities
preventing photocoagulation
5. macular edema associated with contraction of premacular cortical
vitreous
6. dense premacular (subhyaloid) hemorrhage
7. cataract and vitreous hemorrhage precluding a view of posterior
segment complication

(neovascular glaucoma, NVG)


NVG

DR
macular edema




2

14

( )

References

1. WHO Ecobal NCD Info Base (NCD Info Base ), 11 MAY 2004.
2. Nitiyanant W, Chandraprasert S, Puavilai G, Tandhanand S. A survey study on

diabetes management in Thailand. J Asean Fed Endocr Soc 2001;19:35-41
3. Report of the second National Health Examination Survey in 1997. Thai Health

Research Institute. Ministry of Public Health, Bangkok 2000.
4. Aekplakorn W, Stolk RP, Neal B, Suriyawongpaisal P, Chongsuvivatwong

V, Cheepudomwit S, et al. The prevalence and management of diabetes in Thai

adults: The International Collaborative Study of Cardiovascular Disease in Asia.

Diabetes Care 2003; 26: 2758-63.
5. Bundhamcharoen K, Teerawataananon Y, Vos T, Begg S. editors. Burden of disease

and injuries in Thailand. House of the War Veterans Organization of Thailand

Under Royal Patronage of His Majesty the Kings. November 2002: 58.
6. Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The Wisconsin epidemiologic

study of diabetic retinopathy, III: Prevalence and risk of diabetic retinopathy when

age at diagnosis is 30 or more years. Arch Ophthalmol 1984;102:527-32.
7. American Diabetes Association. Standards of medical care in diabetes-2009.

Diabetes care 2009;32(suppl 1):S13-61.
8. American Diabetes Association. Executive summary: Standards of medical care in

diabetes-2010. Diabetes care 2010;33(suppl 1):S4-10.

9. Green DA, Lattimer SA, Sima AA. Sorbital, phosphoinositides, and sodium-

potassium-ATPase in the pathogenesis of diabetic complications. N Engl J Med

1987;316:599-606.
9. Brownlee M. Glycation and diabetic complications. Diabetes 1994;43:836-41.
10. Koya D, King GL. Protein kinase C activation and the development of diabetic

complications. Diabetes 1998;47:859-66.
11. Aiello LP, Bursell SE, Clermont A, Duh E, Ishii H, Takagi C. Vascular endothelial

growth factor-induced retinal permeability is mediated by protein kinase C in vivo
and suppressed by an orally effective -isoform-selective inhibitor. Diabetes

1997;46:1473-80.
12. . Diabetic retinopathy (

). Thai J Ophthalmol 2008;22(2):154-7.
13. Fong DS, Aiello L, Gardner TW, King GL, Blankenship G, Cavallerano JD, et al.

Diabetic retinopathy. Diabetes Care 2003;26(Suppl 1); S99-102.
14. LH Ginsburg, LM Aiello: Diabetic Retinopathy: Classification, Progression, and

Management in Focal Points: Clinical Modules for Ophthalmologists, American

Academy of Ophthalmology, 1993.

15
( )




1.

2.

3.

4.

5.
6.

7. ()
8.

9.
10.

11.

12.
()
13.
()
14.
()
15.
()
16.
()
17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

16

( )

(Guidelines for Detection, Prevention,

and Treatment of Diabetic Nephropathy)

17
( )

(Guidelines for Detection, Prevention,

and Treatment of Diabetic Nephropathy)

1.

2.


3.

/


(diabetic nephropathy) (diabetic retinopathy)
(diabetic neuropathy)
19
( )


(Diabetic nephropathy)



1. (albuminuria)
(microalbuminuria) (macroalbuminuria overt
proteinuria)

2. ( 130/80 )

3.

()(1)


1. 8 16
(fasting plasma glucose) 126 2

2. (random plasma glucose)
200


3. 2 75 (75 gram oral
glucose tolerance test) 200 2

200


(Diabetic nephropathy)(2)





1. ()

2.

3.

Microalbuminuria(2,3)

(dipstick)
(microalbuminuria dipstick) 20200
30300 /creatinine (albumin/
creatinine ratio) 30300 2 3 6

20

( )


Macroalbuminuria/overt proteinuria/overt
nephropathy(3,4)

(dipstick) trace 200

300 /creatinine
(albumin/creatinine ratio) 30300 2 3 6


(Hypertension)(5,6)

130/80 2

3 6

(Chronic kidney disease)(7,8)



1. 3
(glomerular filtration rate, GFR)

1.1 2 3

l microalbuminuria macroalbuminuria

l (hematuria)
1.2
1.3

2. GFR 60 1.73 2

3
estimated GFR (eGFR) serum creatinine
(SCr) Modification of Diet in Renal Disease (MDRD) Equation
eGFR (//1.73 2) =
186.3 x SCr (jaffe)-1.154 x -0.203 x (0.742 )
MDRD equation eGFR

Crockcoft-Gault equation 1 1.73 2
CCr (/) = (140-) x x (0.85 )

72 x SCr
Body surface area (Mosteller formula) =

() X ()
3,600
21
( )


(End-stage kidney disease)

GFR 5
1.73 2

(hemodialysis) (continuous ambulatory peritoneal
dialysis, CAPD) (kidney transplantation)

9.6 35
(9)

(acute) (chronic)
95 2
1

3050

2
microalbuminuria 18.743.5 overt nephropathy

1.65.1(10,11,28)
30.1 (12)
(2)

(2-4)


50 1
microalbuminuria 510
80 overt
nephropathy 1 microalbuminuria
1 3
overt nephropathy 1 3
1 3
overt nephropathy
20 1

20

5060 1 40


22

( )


2
microalbuminuria overt nephropathy

2 microalbuminuria
2040 overt nephropathy 20

20
2 1 2



2
1 20 overt nephropathy
2

microalbuminuria overt
nephropathy

2
UKPDS(13) 20
2 1.4

3.0 microalbuminuria, 4.6

overt nephropathy 19.2
(

2.02.8 )

(2)

1.

2.


3.

4.

5.

6.

7.

23
( )

 1. (2)

: normoalbuminuria

30

1.




l
l
l ( hemoglobin A1C 7 fasting
plasma glucose 130 )
l ( 130/80 )
24

( )

 l ()
l
l (diabetic retinopathy)
l

2.

3. (dipstick)
(macroalbuminuria)

1
l trace




2 6

4. microalbuminuria


microalbuminuria

microalbuminuria







5. microalbuminuria



microalbuminuria

microalbuminuria monitoring parameter




25
( )


(4-7)

1. fasting plasma glucose
90130 hemoglobin A1C 7

2. 130/80


(
)
2.1 Angiotensin-converting enzyme inhibitors(14-16)
2.2 Angiotensin II receptor blockers(17-19)
2.3 Calcium channel blockers(20-24)
2.4 Beta-blockers(25-26)
2.5 Diuretics(27)
2.6


angiotensin II receptor
blockers(17-19) angiotensin II receptor blockers

angiotensin-converting enzyme inhibitors(14-16)
2 ()

3. dipstick / micro-

albuminuria

130/80 dipstick /
microalbuminuria angiotensin-converting enzyme inhibitors
angiotensin II receptor blockers

4.


5. 1.5
(8)

26

( )

1.
(2)
l 1 5
2
l
dysmorphic red blood cell casts
l 5

l
l

2.

3.


4.

27
( )

 (References)

1. American Diabetes Association: Diagnosis and classification of diabetes mellitus

(Position statement). Diabetes Care 2004; 27 (Suppl 1): S5-10.
2. International Diabetes Federation and International Society of Nephrology.

Diabetes and Kidney Disease: Time to Act (2003).
3. Mogensen CE. Microalbuminuria and hypertension with focus on type 1 and type

2 diabetes. J Intern Med 2003; 254: 45-66.

4. American Diabetes Association: Diabetic nephropathy (Position statement).

Diabetes Care 2004; 27 (Suppl 1): S79-83.
5. National High Blood Pressure Education Program. The seventh report of the Joint

National Committee on Prevention, Detection, Evaluation, and Treatment of High

Blood Pressure (The JNC 7 Report). JAMA 2003; 289: 2560-72.

6. American Diabetes Association: Hypertension management in adults with

diabetes (Position statement). Diabetes Care 2004; 27 (Suppl 1): S65-67.
7. Levey AS, Coresh J, Balk E, et al. National Kidney Foundation Practice Guidelines

for Chronic Kidney Disease: Evaluation, Classification, and Stratification (Clinical

Guideline). Ann Intern Med 2003; 139: 137-47.
8. , . .

2547; 33: 30-36.
9. Aekplakorn W, Stolk RP, Neal B, for the InterASIA Collaborative Group. The

prevalence and management of diabetes in Thai adults (The International

Collaborative Study of Cardiovascular Disease in Asia). Diabetes Care 2003;

26: 2758-63.
10. Suwanwalaikorn S, et al. Vascular complications in type 2 diabetics in Thailand.

A preliminary report from a multicenter research study group.
11. Suwanwalaikorn S, et al. High prevalence of microalbuminuria in Thai type 2

diabetes patients: Results form DEMAND Campaign (A collaborative multicenter

DEMAND Study). Annual Meeting of the Royal College of Physicians of Thailand

2004 (Abstracts).
12. (

). (Thailand Renal

Replacement Therapy Registry, TRT Registry): 2540 2543.

2545; 8: 167-79.
13. Adler AI, Stevens RJ, Manley SE, Bilous RW, Cull CA, Holman RR, on behalf of the

UKPDS GROUP. Development and progression of nephropathy in type 2 diabetes:

The United Kingdom Prospective Diabetes Study (UKPDS 64). Kidney Int 2003;

63: 225-32.
28

( )

14. Lewis EJ, Hunsicker, LG, Bain RP, Rohde RE. The effect of angiotensin-converting

enzyme inhibition on diabetic nephropathy. N Engl J Med 1993; 329: 1456-1462.
15. The ACE Inhibitors in Diabetic Nephropathy Trialist Group. Should all patients

with type 1 diabetes mellitus and microalbuminuria receive angiotensin-

converting enzyme inhibitors? A metaanalysis of individual patient data. Ann

Intern Med 2001; 134: 37079.

16. Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on

cardiovascular and microvascular outcomes in people with diabetes mellitus:

results of the HOPE study and MICRO-HOPE substudy. Lancet 2000; 355: 253-259.
17. Parving HH, Lehnert H, Brochner-Mortensen J, Gomis R, Andersen S, Arner P. The

effect of irbesartan on the development of diabetic nephropathy in patients with

type 2 diabetes. N Engl J Med 2001; 345: 87078.
18. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the

angiotensinreceptor antagonist irbesartan in patients with nephropathy due

to type 2 diabetes. N Engl J Med 2001; 345: 85160.
19. Brenner BM, Cooper ME, de Zeeuw D, et al. Effects of losartan on renal and

cardiovascular outcomes in patients with type 2 diabetes and nephropathy.

N Engl J Med 2001; 345: 861-69.
20. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure

lowering and low-dose aspirin on patients with hypertension: principal results of

the Hypertension Optimal Treatment (HOT) randomized trial. Lancet 1998;

351: 1755-62.
21. Bakris GL, Weir RM, Shanifar S, et al for the RENAAL Study Group. Effects of blood

pressure levels on progression of diabetic nephropathy. Arch Intern Med 2003;

163: 1555-65.
22. Bakris GL. Effects of diltiazem or lisinopril on massive proteinuria associated with

diabetes mellitus. Ann Intern Med 1990; 112: 707-8.
23. Bakris GL, Mangrum A, Copley JB, Vicknair N, Sadler R. Effect of calcium channel

or beta-blockade on the progression of diabetic nephropathy in African

Americans. Hypertension 1997; 29: 744-50.

24. Bakris GL, Copley JB, Vicknair N, Sadler R, Leurgrans S. Calcium channel blockers

versus other antihypertensive therapies on progression of NIDDM associated

nephropathy. Kidney Int 1996; 50: 164150.
25. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of

macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.

BMJ 1998; 317: 703-13.

26. UK Prospective Diabetes Study Group. Efficacy of atenolol and captopril in

reducing the risk of macrovascular and microvascular complications in type 2

diabetes: UKPDS 39. BMJ 1998; 317: 713-20.
27. Arauz-Pacheco C, Parrott MA, Raskin P. The treatment of hypertension in adult

patients with diabetes (Technical review). Diabetes Care 2002; 25: 134-47.
28. Thai Multicenter Research Group on Diabetes Mellitus: Vascular complications in

noninsulin dependent diabetes in Thailand. Diabetes Res Clin Pract 1994; 25: 61-9.
29
( )

1. ..
2. ..
3. ..
4. ..
5. ..
6. ..
7. .

1. ..
2. ..
3. ..
4. ..
5. ..
6. .
7. .
8. .
9. ..
10. ..
11. .

1. ..
2. ..
3. ..
4. .
5. .

1. .
2. .
3. .

()

()

( )

30

( )

31
( )



1. ()

(glomerular filtration rate)
5 - 10


(dipstick)
30 - 300 /
microalbuminuria incipient nephropathy

( 300 /) overt nephropathy
(clinical albuminuria macroproteinuria)

(end stage renal disease)


10 - 30 microalbuminuria


10 - 20 20
25 20 40 incipient nephropathy overt
nephropathy 10 - 15 5 - 10
(
5 - 10 //) microalbuminuria

2. microalbuminuria

microalbuminuria

dipstick albumin excretion rate

33
( )

(AER) 20 / (15 /)
microalbuminuria 30 - 300 / (20 - 200 /)

albuminuria

glomerular capillary wall ( anionic macromolecules)

microalbuminuria
(large pores)
heparan sulfate


overt nephropathy(1,2)

microalbuminuria

1. Microalbuminuria diabetic nephropathy

diabetic nephropathy
angiotensin-converting enzyme inhibitor

(ACEI) angiotensin II receptor blocker (ARB) 1
microalbuminuria 5 microalbuminuria 5
- 10 2 microalbuminuria
30
2
75 microalbuminuria 25 overt
diabetic nephropathy (3,4)

2. Microalbuminuria progressive nephropathy
microalbuminuria diabetic nephropathy

1 2 1
microalbuminuria overt nephropathy

microalbuminuria overt
nephropathy 4 14 9 23 (20)
34

( )


3. Microalbuminuria cardiovascular disease
microalbuminuria
(cardiovascular morbidity) cardiovascular mortality


1 1 2 microalbuminuria

overt nephropathy
Author (reference)
Type 1
Viberti et al.(5)
Laffel et al.(6)
Crepaldi et al.(7)
Euclid Study Group(8)
Mathiesen et al. (9)
Atlantis Study Group(10)
Type 2
Mogensen et al.(11)
Nelson et al.(12)
Revid et al.(13)
Gaede et al.(14)
Ahmad et al.(15)
Estacio et al.(16)
HOPE Study Group(17)
Parving et al.(18)
Parving et al.(19)

N

46
70
34
34
23
46

59
50
49
80
51
150
1140
201
86

Observation
Patients developing
Period (years) Nephropathy (% / year)


2
13
2
9.3
3
6.9
2
10.2
4
7.5
2
5.5


9
2.4
4
9.3
5
8.4
4
5.8
5
4.8
5
4.0
4.5
4.5
2
7.5
5
7.0

Data based on the placebo arm in randomized double-blind studies lasting 2 years.

HOPE Study (Heart Outcomes Prevention Evaluation)
55
1 9,000
microalbuminuria primary aggregated point myocardial infarction,
stroke cardiovascular death 1.97 (95% CI 1.68 - 2.31)
1.61 (95% CI 1.36-1.90)
35
( )

 cardiovascular event baseline urine albumin/creatinine ratio

(ACR) (p for trend < 0.001) 2 (21)

population-based cohort study

12,239 15 - 20 cardiovascular
mortality urinary albumin excretion 21 / creatinine
4.4 (95% CI 2.6 - 7.6) microalbuminuria(22)

40,548 28 - 75
dose-response urine albumin concentration
(UAC) cardiovascular non-cardiovascular mortality
UAC 2 1.29 (95% CI 1.18-1.40) cardiovascular mortality
1.12 (95% CI 1.04-1.21) non-cardiovascular mortality(23)


new microalbuminuria proteinuria
HOPE Study proteinuria (new
microalbuminuria new overt nephropathy) (odd ratio
1.34, 95% CI 1.04-1.75) (odd ratio 1.26, 95% CI 1.11-1.44) body mass
index (BMI) 10 / (odd ratio 1.18, 95% CI 1.03-1.37)
(24)

microalbuminuria

microalbuminuria
microalbuminuria

microalbuminuria Von Willebrand factor (vWF) vWF
(25)


extracellular matrix glomeruli heparan sulfate proteoglycans
microvascular permeability microalbuminuria (2)

microalbuminuria


36

( )

HDL hyperhomocysteinemia
atherosclerosis (26,27)

3. (screening)

(albuminuria) ()
30 / 20 /
microalbuminuria microalbuminuria
incipient diabetic nephropathy

proteinuria dipstick ()

overt diabetic nephropathy
(progressive renal insufficiency)


2
1 microalbuminuria dipstickpositive proteinuria
20 - 40
2 microalbuminuria overt nephropathy

20 overt nephropathy
5 - 20 microalbuminuria
cardiovascular morbidity mortality
cardiovascular risk factors LDL cholesterol



(quantitative) microalbuminuria

3
3.1 (spot urine)
(urine albumin/creatinine concentration ratio)

3.2 24
1
3.3 (timed collection) 24
4
1 (albumin excretion rate)
37
( )

 2 (microalbuminuria


clinical albuminuria)


(spot urine) creatinine
24 24
(/)
(/)
(/)
< 30
< 30
< 20
Normal
30 299
30 299
20 199
Microalbuminuria
300
300
200
Macroalbuminuria
clinical albuminuria
2 (microalbuminuria)


3

(qualitative) microalbuminuria


(microalbuminuria strip test) (semi-quantitative)
(sensitivity) (specificity) ( 95 93
) quantitative
(dipstick)


microalbuminuria strip test
microalbuminuria
microalbuminuria 2 3

microalbuminuria microalbuminuria
2 American
Diabetes Association(ADA) (expert consensus) prospective
randomized controlled trial (cost-effectiveness)
microalbuminuria (28) microalbuminuria

(proteinuria) microalbuminuria
38

( )

2 2
(proteinuria)
dipstick ( 1+)

proteinuria (
)




2 dipstick

microalbuminuria ( 1
ADA microalbuminuria 5 )
ACEI ACEI 2
50 (29,30)

microalbuminuria
dipstick proteinuria

()
ACEI microalbuminuria
quality-adjusted life expectancy

microalbuminuria
ACEI
ACEI 3-14
30-50 bilateral renal
artery stenosis ACEI
ACEI (volume depletion)
volume depletion
(hyperkalemia)

(nonsteroid antiinflammatory
agents) (potassium sparing diuretics)
(beta blockers)
39
( )

41
( )

()



2
(sensory nerve)
(motor nerve)

43
( )

2.8 2000
4.4 2030 171 2000
366 20301

11 .. 2546

94.6 2 5.9
3.9 1.5-1.62-3
..2547-2549 32

4



1.

2.

3.

3 5

1. (infective ulcer)





2. (neuropathic ulcer)

(peripheral neuropathy)

44

( )

()
5

3. (ischemic ulcer)

(intermittent claudication)
(toe gangrene) (dry
gangrene) 5
()
(wet gangrene)

5

1.
l
l
l ( 5 )
l
l
l
l

2. 6


l
l
()
l Ankle brachial index (ABI) < 0.97
l Semmes-Weinstein 5.07 Monofilament
Test 128
l
45
( )

8 ( 1)

1.



2.

/


3.

6

3

(Podiatrist)

( 2)






1.




(deep culture)
aerobe anaerobe ()

pedal pulse
46

( )

 (wet gangrene)




2.
2.1 (Neuropathic ulcer)

5
5



2.2 (Ischemic ulcer) 5

9-11

1.
2. (debride necrotic tissue)
3. (appropriate topical therapy)
4. neuropathic ischemic ulcer
5. (consider advance technology)

1.
2.
3.

47
( )

1. (Surgical or sharp debridement)



2. Mechanical Debridement wound irrigation
remove surface eschar surface debris

3. Autolytic Debridement hydrocolloids Hydrogel
remove

surgical or sharp debridement

Mechanical or wound irrigation
autolytic debridement

(appropriate topical therapy)

wound dressing product


1

Staphylococci Psudomonas Proteus E.coli Streptococci Clostridium Candida

Silver Sulphadiazine
Mafinide

+++

+++

+++

++

+++

++

++ +++

Silver nitrate

+++

++

Nitrofuzazone

++

+++

++

Cholorhexidine

+++

++

++

+++

Providine Iodine

+++

+++

+++

+++

+++ = excellent, ++ = active, + = some activity, N = no activity

48

( )

+++
+++

++
+
N
+++

+
+++

+++


providine Iodine
Chlorhexidine Streptococci
Clostridium

(wound dressing)

1. (high exudate )
--->

2. (low exudate )
--->

3. (no exudate )
--->

4. (infected)
---> dressing

5. (immunosuppressed) --->

Transparent film (Tegaderm),
Hydrocolloid, Foam, hydrogel, Antimicrobial dressing, Gauze-plain and impreganted,
Collagen and composite material

1. Tegaderm (Transpaent film) polyurethane



tegaderm

2. Gauze dressing

Normal saline Lactated Ringers solution

3. Hydrogel dressing Propylene glycol 20% 80%
Autolytic




4. Hydrocolloid dressing

1-2 3-5

(granulation tissue)

49
( )

 2




Granulation, no exudate protect wound bed
gauze with NSS

maintain moist wound
Hydrogel, Tegaderm

Granulation with exudate absorb exudate
gauze with NSS

control moist wound
Hydrocolloid

protect surrounding skin


Necrotic, no exudate
sharp debridement
Gauze with NSS

maintain moist
Hydrogel, Hydrocolloid

Necrotic with exudate
remove infection
Gauze with NSS

sharp debridement
Hydrogel, Hydrocolloid

control moist

protect surrounding skin

( 3)

1. 3
l (mild) 2 .
24-48 . 3-7

l (moderate) > 2 .
(lymphangitis)
fasciitis, deep tissue abscess, myositis, arthritis, osteomyelitis

24-48 . 7-10
24-48 2

50

( )

 l (severe)
-
-
- (necrosis) (bleb)
- (loss of

plantar arch)



2. (neuropathic ulcer)

(off loading)



3. (ischemic ulcer)
()

12-14

Erythromycin,
Ciprofloxacin Aminoglycoside
S.aureus
80-91 Streptococcus sp. 100 Erythromycin





1.
(mild) Clindamycin, Ampicillin plus Clavulanate, Erythromycin
Ciprofloxacin, oral cephalosporins
Metronidazole
Clindamycin

2. (moderate)
2.1 Ampicillin-Clavulanate 1.2 8 .
Metronidazole 500 8 .
51
( )

 3-7


2.2 Clindamycin 600 6-8 .
Ceftriaxone 2
Gentamicin 240 5% D/W 100

3





Mild
Moderate

(oral)
(parenteral and oral)
1. Clindamycin
l
l
l
l
2. Ampicillin plus clavulanate
3. Erythromycin
l

4. Ciprofloxacin
l

l

5. Oral cepharosporins
6. Metronidazole
l
l
7. Gentamicin

l

Care After Cure15-18

50 2-5

1. (self or daily foot care)


2. (proper footwear)



3. foot care



4.

52

( )

 (Daily Foot Care)

1. Inspection



2. Washing


15-20



3. Lotion

4. Nails


5. Corns and calluses Neuropathy









6.



(impact force) (sheering force)

7.






53
( )

/
/
/

3
6

Podiatrist

1



54
( )
l
l
l
l

l
l

l
l

l
l
l

pedal pulse

/
/

l
l
l

(deep culture)
aerobe anaerobe
()

l
l
l
l

l
l

gangrene

neuropathic

l
l

l
l

(off loading)

pulse

55
( )

(mild)

< 2 cm

(moderate)
l

l
l

24-48 .

> 2 cm

(lymphangitis)

(fasciitis,
deep tissue abscess, myositis,
arthritis, osteomyelitis)

(severe)

l
l

l (necrosis)
(bleb)
l

(loss of plantar arch)

3-7

l
l
l

24-48 .

7-10
24-48

56

( )

()

()

1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes:
Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;
27:104753.
2. Rawdaree P, Ngarmukos C, Deerochanawong C, Suwanwalaikorn S, Chetthakul

T, Krittiyawong S, et al. Thailand Diabetes Registry (TDR) Project: Clinical status

and long term vascular complications in diabetic patients. J Med Assoc Thai 2006;
89 (Suppl 1): S1-9.
3. Krittiyawong S, Ngarmukos C, Benjasuratwong Y, Rawdaree P, Leelawatana R,
Kosachunhanun N, et al. Thailand Diabetes Registry Project: Prevalence and risk
factors associated with lower extremity amputation in Thai diabetics. J Med Assoc
Thai 2006; 89 (Suppl 1):S43-8.
4. Tantisiriwat N, Janchai S. Common Foot Problems in Diabetic Foot Clinic. J Med
Assoc Thai 2008; 91:1097-101.
5. .
. 2548. 30-36.
6. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes.
JAMA 2005; 293(2):217-28.
7. Diabetes/Metabolism Research and Reviews. Practical guidelines on the
management and prevention of the Diabetes foot. Diabetes Metab Rev 2008;
24Z(Suppl 1): S184
8. . ..2551.

48-54.
9. . Modern Wound Dressing: .
2. Update Practice in Wound Management 2550; 31-36.
10. Dressing for clinical and post-operative application. International advanced
wound care closure 2008; 87-96.
11. , . Modern Wound Dressing. Update of Wound
Care 2009; 45-60.

57
( )

12. Gadepalli R, Dhawan B, Sreenivas V, Kapil A, Ammini AC, Chaudhry R. A clinicomicrobiological study of diabetic foot ulcers in an Indian tertiary care hospital.
Diabetes Care 2006;29:1727-32.
13. Raymundo MFP, Mendoza MT. The microbiologic features and clinical outcome
of diabetic foot infections among patients admitted at UP-PGH. Phil J Microbiol
Infect Dis 2002;31(2):51-63.
14. Raja NS. Microbiology of diabetic foot infections in a teaching hospital in Malaysia:
a retrospective study of 194 cases. J Microbiol Immunol Infect 2007; 40:39-44.
15. Kumar S, Ashe HA, Fernando DJS, et al. The prevalence of foot ulceration and its
correlates in type 2 diabeticpatients: a population-base study. Diabet Med 1994;
11:480-4.
16. American Diabetes Association. Consensus Development Conference on Diabetic
Foot Wound Care. Diabetes Care 1999; 22:1354-60.
17. American Diabetes Association. The diabetes ready reference guide for health
care professional. Alexandria, Va:2000.
18. Laughlin RT, Caljoun JH, Mader JT. The diabetic foot. Am Acad Orthop Surg 1995;
3:218-25.
19. Anderson RB, Davis AM. The podorthic and orthotic care of the diabetic foot. Foot
Ankle Clin 1997; 2:137-51.
20. Fritschi EP. Surgical reconstruction and rehabilitation in leprosy 2nd edition, 1984.











58

( )

59
( )

1. (Dry skin)
( 1)






1


2. (Callus)

( 2)






2 Callus


3. (Charcot foot)

( 3)






3
61
( )


4. (Bunions)


( 4)







4


5. (Claw toes)


( 5)






5


6.







6
62

( )

1.

7-8

2. neuropathic








9-10 neuropathic


3. gangrene








11-12 gangrene
63
( )

: Semmes-Weinstein Monofilament 5-8

Semmes-Weinstein neuropathy test 5.07 (10-gram) nylon monofilament
10-gram
(sensitivity) 66-91% (specificity) 34-86% positive
predictive value 18-39% negative predictive value 94-95% monofilament
10 24
stocking distribution

Monofilament (10gram)

1. Monofilament
Monofilament


2.
Monofilament

3. Monofilament
C 1 2 ( Monofilament )











13 monofilament

64

( )


4. ( 14)
1













14 monofilament


5. Monofilament


6. Monofilament 1-2

7.

65
( )

(Protective Footwear)18-19

65-80








1.

2.
1

3. 3
8 - 2

4.

5.



1. A soft insole
2

2. A wide and tough under sole
(rocker)


3. A well fitting and adjustable fastener

3



4. A big and wide toes box

66

( )


5. Soft and smooth lining


6. Heel counter/ back strap





















15
















16
67
( )

17

l Acceptable style

l Cost



l Weight

The university of Texas foot classification system

Category
Characters
Shoes
0
no pathology
possible shoe accommodation
1
neuropathy without deformity sport shoes/ simple sandal
2
neuropathy with deformity
extra depth shoe accommodation
3
history of pathology

Hx of ulceration and amputation extra depth shoe accommodation

with arch support/ insole

Hx of bone disorganization
custom mold with insole and rocker

outsole

68

( )

1.

2.
3.

4.
5.
6.

7.


8.


9.

10.

69
( )

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.

70

( )