27 7 800

24

/

1

2013 31

38,024

Q

OL 1.

5

4

21

WG

CKD

2013 CKD G3b

2015

2

2

( )

2

KDB

64 2

P14 15

10

4 (1 ) 1 2

2

1 1 P10 13

4 (RCT)

30 79

2 2 ( 60 ) 3 1

( 56 ) 1 (

519 )

0.8 0.91g/kg/

1.2g/kg/ 1

5 2

1 1)(12 ) 6

-0.05 0.21g/kg

+0.03 0.19g/kg(p=0.02)

14

11 (p=0.01)

2

(28 ) 1 2)

6

0.08g/kg/

3

1 3)( 3.5 )

HbA1c sCr eGFR

(

1 1 )

3

8RCT 4

eGFR CC

(p=0.003)

1 5 (

32 ) 2

2

130/85( Hg)

2 1 10 /

2 1 6)

1 7)

( bupropion)

12

193 120

22.5 72.6

52 11

(17 )

0 eGFR

-1.79 -1.30

-1.54

2 8)9 eGFR15 59(ml/

min/1.73 ) 2

12

8) sCr

eGFR

9

QOL

/

10 40 74

CKD

(1,206 ) CKD

(2 ) 6

IT 3

(1,

211 ) CKD

3.5

88.5 83.2

34.3 16.0 eGFR

CKD 1 2 4 5

CKD

Cr 4.4

6.7 eGFR50

5.6 8.1

5 8

12

12

203

181

240 4 P18

578 53

2 1

710 27

4

5

3 P

16 17

3

eGFR

210

181

HbA1c

2

4

HbA1c

HbA1c

30

2

20

20

6 HbA1c eGFR

52

6 60 95.6

6 HbA1c

eGFR

1

2

O 2011

P40 42

40 74

7,956

126 /dl HbA1c6.5

3 61

24

1 2 646 311

372 37

HbA1c

HbA1c

5

HbA1c

HbA1c7.0

35.6 HbA1c8.0

37.2 22.6

P 23 43

P23 24

5

P19 20

P25 28

2

126 /dl 200 /dl

HbA1c6.5

+

eGFR 30 4

P28 31

6

P32 34

QOL

KDB

P35 42

2

(

)

/

2

CCr eGFR

(1 10) )

1 10)

(

)

HbA1c eGFR

1

2 3

4

7

3

1

2

28

( )

40

2016.02.27

58

2015.5

2

( ) 62

2015.9

22

2015.10

Kazawa K., Yamane K., Yorioka N.,Moriyama M. Development and Evaluation of

Disease Management Program and ServiceFramework for Patients with Chronic Diseases.Health, 7(6), 729-740, 2015.(DOI:10.4236/health.2015.76087)

8

1

2

3

1) Loek T, J Pijls, Hendrik de Vries et al.: The effect

of protein restriction on albuminuria in patients

with type 2 diabetes mellitus: a randomized trial.

Nephrol Dial Transplant 1999, 14:1445-1453.

2) LTJ Pijls, H de Vries, JThM van Eijk et al.: Protein

restriction, glomerular filtration rate and albuminuria

in patients with type 2 diabetes mellitus: a randomized

trial. European Journal of Clinical Nutrition 2002, 56:

1200-1207.

3) Koya M, Haneda S, Inomata Y et al.: Long-term

effect of modification of dietary protein intake on the

progression of diabetic nephropathy: a randomized

controlled trial. Diabetologia 2009, 52:2037-2045.

4) Yu pan, Li Li Guo, Hui Min Jin et al.: Low- protein

diet for diabetic nephropqthy: a meta-analysis of

randomized controlled trials. Am J Clin Nutr 2008, 88:

660-6.

5) Masahito Imanishi, Takashi Morikawa, Katsunobu

Yoshioka et al.: Sodium Sensitivity Related to

Albuminuria Appearing Before Hypertension in Type

2 Diabetic Patients 2001, 24: 111-115.

6) Voulgari C, Katsilambros N, Tentolouris N et al.:

Smoking cessation predicts amelioration of

microalbuminuria in newly diagnosed type 2 diabetes

mellitus: a 1-year prospective study. Metabolism 2011,

60:1456-64.

7) Phisitkul K, Hegazy K, Chuahirum T et al.:

Continued smoking exacerbates but cessation

ameliorates progression of early type 2 diabetic

nephropathy. Am J Med Sci 2008, 335:284-91.

8) Kana Kazawa, Yae Takeshita, Noriaki Yorioka et

al.: Efficacy of a disease management program

focused on acquisition of self-management skills in

pre-dialysis with diabetic nephropathy: 24 months

follow-up. J Nephrol 2015, 28: 329-38.

9) Kana Kazawa, Kiminori Yamane, Noriaki Yorioka

et al.: Development and Evaluation of Diease

Management Program and Service Framework for

Patients with Chronic Disease. Health 2015, 7:

729-740.

10) .:

/

2014

9

1 LPDKoya D.et al.

2009

2 LPDPijls LT,

et al.1999

RCT

3 LPDPijls LT,

et al.2002

RCT

4 LPDPan Y, et

al.2008

RCT

5ImanishiM, et al. 2001 cross-over

6VoulgariC, et al.

2011

7PhisitkulK, et al.

2008

NO

10

HbA1c

sCreGFR

Alb

ESRD

0.19g/kg(p=0.02)

2

- - - - -ECGhs-CRP

- - - - -

11

8KazawaK et al.

2014

non-randomized, controlled trial

9KazawaK et al.

2015

>6.5%, FBS> >30mg/dl,eGFR<60

single-group pre-test and post-test design

10

NO

2012,2014

12

HbA1c

sCreGFR

Alb

primary

endpoint

BUN, Hgb, TP, alb, K, P, nonHDL-c,

primary

endpoint

primary

endpoint

primary

endpoint

BUN, Hgb, TP, alb, K, P, nonHDL-c,

50- - -

50

13

1 Renal function following three distinct weight loss dietary strategies during 2 years of a randomized controlledtrial. DIRECT Diabetes Care Tirosh A, et al.

2 Altered dietary salt intake for preventing and treating diabetic kidney disease. Cochrane Database Syst Suckling RJ, et al.

3 Sodium restriction and blood pressure in hypertensive type II diabetics:Randomised blind controlled and crossover studies of moderate sodium restriction and sodium supplementation BMJ Dodson PM, et al

4 Salt-sensitive blood pressure-an intermediate phenotype predisposing to diabetic nephropathy? Nephrol Dial Transplant Strojek K, et al.5 A Low-Sodium Diet Potentiates the Effects of Losartan in Type 2 Diabetes Diabetes Care Houlihan CA, et al.

6 Long-term effect of modification of dietary protein intake on the progression of diabetic nephropathy: arandomised controlled trial. Diabetologia Koya D, et al

7 Prevalence and correlates of post-prandial hyperglycaemia in a large sample of patients with type 2 diabetesmellitus. Diabetologia E Bonora, et al

8 Contributions of fasting and postprandial plasma glucose increments to the overall diurnalhyperglycemia of type 2 diabetic patients: variations with increasing levels of HbA(1c). Diabetes Care Monnier L, et al

9 The Loss of Postprandial Glycemic Control Precedes Stepwise Deterioration of Fasting With Worsening Diabetes Diabetes Care Monnier L, et al

10 Impact of fasting and postprandial glycemia on overall glycemic control in type 2 diabetes Importance ofpostprandial glycemia to achieve target HbA1c levels. GL24 Diabetes Res Clin Pract Woerle HJ, et al.

11 Prospective Analysis of Mortality,Morbidity, and Risk Factors in Elderly Diabetic Subjects Diabetes Care M Katakura,et al.

12 Prevalence and determinants of anemia in older people with diabetes attending an outpatient clinic: a cross-sectional audit. Clinical Diabetes Trevest K, et al

13 Effects of dietary protein restriction on albumin and fibrinogen synthesis macroalubuminuric type 2 diabeticpatients Diabetologia M. Giordano, et al

15 Weight-loss diets in people with type 2 diabetes and renal disease:a randomized controlled trial of the effect ofdifferent dietary protein amounts Am J Clin Nutr David R Jesudason, Eva Pedersen,

and Peter M Clifton

16 Age Affects Outcomes in Chronic Kidney Disease Clin Epidemiol

17 Impact of Age and Overt Proteinuria on Outcomes of Stage 3 to 5 Chronic Kidney Disease in a Referred Cohort Am Soc Nephrol Yoshitsugu Obi, et al

18 Risks for glomerular filtration rate decline in association with progression of albuminuria in type 2 diabetes Nephrol Dial Transplant Hiroki Yokoyama, et al

182 6 (Outcomes

of 6 years of activities by the Tokushima Medical Association's Steering Committee for Diabetes Prevention toprevent type 2 diabetes in the general population of Tokushima Prefecture)

Diabetology International Shima Kenji, et al

19

20 ( )

21

22 Long-term effects of a randomised trial of a 6-year lifestyle intervention in impaired glucose torelance on diabetesrelated microvascular complications:the China Da Qing Diabetes Prevention Outcome Study

Diabetologia Q Gong, et al.

23 The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes PreventionStudy: a 20 year follow-up study Lancet Li G, et al

24 A simple meal plan emphasizing healthy food choices is as effective as an exchanged-based meal plan for urbanAfrican Americabs with type 2 diabetes Diabetes Care Ziemer DC, et al.

25 Translating lifestyle intervention to practice in obese patients with type 2 diabetes: improving Control withActivity and Nutrition (ICAN) study Diabetes Care Wolf AM, et al.

26 Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drugtreatment-Lifestyle Over and Above Drugs in Diabetes(LOADD) study: randomised controlled trial BMJ Coppell KJ, et al.

27 Low-protein diet for diabetic nephropathy: ameta-analysis of randomized cntrolled trials Am J Clin Nutr Pan Y, et al.

28 Smoking cessation predicts amelioration of microalbuminuria in newly diagnosed type 2 diabetes mellitus: a 1-year prospective study Metabolism Voulgari C, et al.

29 Continued smoking exacerbates but cessation ameliorates progression of early type 2 diabetic nephropathy Am J Med Sci Phisitkul K, et al.

30 Prediction of Cardiovasucular Disease Mortality by Proteinuria and Reduced Kidney Function: Pooled Analysisof 39,000 Individuals From 7 Cohort Studies in Japan

American Journal ofEpidemiology Nagata N et al.

31 Smoking increases the risk of all-cause and cardiovascular mortality in patients with chronic kidney disease International Society ofNephrology Nakamura K et al.

32 Impact of kidney Disease and Blood Pressure on the Development of Cardiovasucular Disease Circulation Ninomiya T et al.

33 Revisit frequency and its association with quality of care among diabetic patients: Translating Research IntoAction for Diabetes(TRIAD) J Diabetes Complications Asao K

34 Effects of long- term behavioural weight loss intervention on nephropathy in overweight or obese adults with type2 diabetes: a secondary analysis of the Look AHEAD randomised clinical trial

Lancet DiabetesEndocrinol

The look AHEADResearch Group

35 Risk of developing end-stage renal disease in a cohort of mass screening. Kidne Int Iseki K, et al36 Proteinuria and the risk of developing end-stage renal disease. Kidne Int Iseki K, et al

14

37 Chronic kidney disease and cardiovascular disease in a general Japanese population: the Hisayama Study. Kidne Int Ninomiya T, et al

38 The relationships of proteinuria, serum creatinine, glomerular filtration rate with cardiovascular disease mortalityin Japanese general population. Kidne Int Irie F, et al

39 Chronic kidney disease is a risk factor for cardiovascular death in a community-based population in Japan:NIPPON DATA90. Circ J Nakamura K, etal

40 Kidney dysfunction as a risk factor for first symptomatic stroke events in a general Japanese population--theOhasama study. Nephrol Dial Transplant Nakayama M, et al

41 Slower decline of glomerular filtration rate in the Japanese general population: a longitudinal 10-year follow-upstudy. Hypertens Res Imai E, et al

42 Relationship between blood pressure category and incidence of stroke and myocardial infarction in an urbanJapanese population with and without chronic kidney disease: the Suita Study. Stroke Kokubo Y, et al

43 Albuminuria is an independent predictor of all-cause and cardiovascular mortality in the Japanese population: theTakahata study.

Clin Exp Nephrol;17:805-10, 2013. Konta T, et al

44Comparison of predictability of future cardiovascular events between chronic kidney disease (CKD) stage basedon CKD epidemiology collaboration equation and that based on modification of diet in renal disease equation inthe Japanese general population--Iwate KENCO Study.

Circ J Ohsawa M, et al

45 Prediction of cardiovascular disease mortality by proteinuria and reduced kidney function: pooled analysis of39,000 individuals from 7 cohort studies in Japan. Am J Epidemiol Nagata M, et al

46 Clinical impact of albuminuria and glomerular filtration rate on renal and cardiovascular events, and all-causemortality in Japanese patients with type 2 diabetes Clin Exp Nephrol Wada T, et al.

47 Diabetic Nephropahty remission and regression Team Trial in Japan(DNETT-Japan):Rationale and study design Diabetes Researech andClinical Practice Shikata K. et al

48 Development and progression of nephropathy in type 2 diabetes :the United Kingdom Prospective DiabetesStudy UKPDS 64 Kidne Int Adler AI, et al

49 Remission to normoalbuminuria during multifactorial treatment preserves kidney function in patients with type 2diabetes and microalbuminuria Nephrol Dial Transplant Gaede P, et al

50 Protein restriction, glomerular filtration rate and albuminuria in patients with type 2 diabetes mellitus: arandomized trial

European Journal ofClinical Nutrition LTJ Pijls, et al

51 The effect of protein restriction on albuminuria in patients with type 2 diabetes mellitus: a randomized trial Nephrol Dial Transplant LTJ Pijls, et al

52 Sodium Sensitivity Related to Albuminuria Appearing Before Hypertension in Type 2 Diabetic Patients Diabetes Care M Imanishi, et al

53 Develoment and Evaluation of Diease Management Program and Service Framework for Patients with ChronicDiease Health K Kazawa, et al

54 Efficacy of a disease management program focused on acquisition of self-management skills in pre-dialysispatients with diabetic nephropathy:24 months follow-up J Nephrol K Kazawa, et al

55 /

56 Disease Management Diabetes Journal

57 -5859 Japanese model of Disease Management Medinfo Nakashima N,60 - - Diabetes Journal6162 / Disease Management63 Disease Management64 Diabetes Frontier

15

2

16

22.57

28.02

17

1 2013(H25)

2 2014-2015

3 2013-2015

4 2013-2015

5 2013-2015

6 2013-2015

7 2013-2015

8 2013-2015

9 2014-2015

10 2014-2015

11 2014-2015

12

13 2011

14

15

16 2012

17

18

19 2010

20 2011

21 2012

22 2013

23 2014

24 2015

25

26

27

28

29

30

31

32

33 2015

34 2015

35 2015

36 2015

37 2015

38 2015

39 2015

40 2012

41

42

43

44

45 2016

46 2015

47

48

49

50

51 2010

52

53 2011

54 2011

55 2013

56 2014

57 2014

58 2015

59

60

240

18

5

19

20

2

2020 800 24

23

KDB

2014 15,809

43.5 67.2 5 1.4 10

2.6

4 2014

CKD 2013 CKD G3b

2015

CKD

eGFR

( )

24

2014

2 126mg/dl ( 200mg/dl)

HbA1c 6.5%

+

3

2

CVD

eGFR

CVD (CKD

2013 P80)

25

4

eGFR 30 44ml/ /1.73m2 CKD G3b

eGFR

4

QOL

4

1

26

eGFR

27

3

HbA1c7.0 1

3 4

1 2

HbA1c

28

3 4

1 2

1

29

75

1

30

3 HbA1c7.0 1

CKD 2012/Cr 0.50g/gCr

GFR50mL/ /1.73m2

31

KDB

32

HbA1c eGFR

QOL

KDB

10

HbA1c 8.0

33

34

HbA1c 6.5

HbA1c 8.0

8.0

2

4 eGFR<30ml/min/1.73m2

KDB

KDB

HbA1c 5.6 100mg/dl

eGFR<60ml/min/1.73m2

CSV

35

REACH-J 2015

eGFR

QOL

1 3 6

2 1 1 3 6

1

ICT

36

3

or

QOL

HbA1c eGFR

1

HbA1c LDL

non-HDL

* eGFR* *

QOL

eGFR HbA1c

10

37

38

39

40 74 7,956

3 61 24

2 646 311 HbA1c

2

HbA1c 169 147

eGFR CKD

372 37

75 2,037

3 33 9

130 24

FPG 126 or HbA1c NGSP 6.5 372 4.68% UP 37 0.47% 335 4.21% UP 24 0.30% UP 61 0.77%

n=707) UP 335 4.21% UP 311 3.91% UP 646 8.12%

FPG 126 & HbA1c(NGSP) 6.5 150 1.89% UP 22 0.28% 7,099 89.23% UP 147 1.85% UP 169 2.12%

n=7,249 UP 127 1.60% UP 6,952 87.38% UP 7,079 88.98%

7,956

O 2011 40 64 n=3,367

FPG 126 or HbA1c NGSP 6.5 105 3.12% UP 13 0.39% 114 3.39% UP 6 0.18% UP 19 0.56%

n=219) UP 92 2.73% UP 108 3.21% UP 200 5.94%

FPG 126 & HbA1c(NGSP) 6.5 30 0.89% UP 3 0.09% 3,118 92.60% UP 53 1.57% UP 56 1.66%

n=3,148 UP 27 0.80% UP 3065 91.03% UP 3,092 91.83%

3,367

O 2011 65 74 n=4,589

FPG 126 or HbA1c NGSP 6.5 267 5.82% UP 24 0.28% 221 4.82% UP 18 0.39% UP 42 0.92%

n=488) UP 243 5.30% UP 203 4.42% UP 446 9.72%

FPG 126 & HbA1c(NGSP) 6.5 120 2.61% UP 11 0.24% 3,981 86.75% UP 94 2.05% UP 105 2.29%

n=4,101 UP 109 2.38% UP 3,887 84.70% UP 3,996 87.08%

4,589

O 2011 75 n=2,037

FPG 126 or HbA1c NGSP 6.5 UP 24 0.64% UP 9 0.44% UP 33 1.62%

n=244) UP 106 5.20% UP 105 5.15% UP 211 10.36%FPG 126 & HbA1c(NGSP) 6.5 UP 9 0.44% UP 83 4.07% UP 92 4.52%

n=1,793 UP 51 2.50% UP 1,650 81.00% UP 1,701 83.51%

2,037

O 2011 75-79 n=1,231

FPG 126 or HbA1c NGSP 6.5 UP 11 1.06% UP 7 0.57% UP 18 1.46%

n=158) UP 70 5.69% UP 70 5.69% UP 140 11.37%

FPG 126 & HbA1c(NGSP) 6.5 UP 6 0.49% UP 35 2.84% UP 41 3.33%

n=1073 UP 34 2.76% UP 998 81.07% UP 1,032 83.83%

1,231

O 2011 80 n=806

FPG 126 or HbA1c NGSP 6.5 UP 13 1.61% UP 2 0.25% UP 15 1.86%

n=86) UP 36 4.47% UP 35 4.34% UP 71 8.81%

FPG 126 & HbA1c(NGSP) 6.5 UP 3 0.37% UP 48 5.96% UP 51 6.33%

n=720 UP 17 2.11% UP 652 80.89% UP 669 83.00%806

81 6.58% 77 6.26%

40 3.25% 1033 83.92%

49 6.08% 37 4.59%

130 6.38% 114 5.60%

60 2.95% 1,733 85.08%

20 2.48% 700 86.85%

40

40-74 n=7,938HbA1 5.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9 9.0

UP 76 90 13 25 11 7 222

UP 3,984 3,114 287 214 71 46 7,716

4,060 3,204 300 239 82 53 7,938

40 64 n=3,359

HbA1 5.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9 9.0UP 35 22 5 3 5 5 75

UP 1,976 1,119 90 58 19 22 3,284

2,011 1,141 95 61 24 27 3,359

65 74 n=4,579

HbA1 5.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9 9.0UP 41 68 8 22 6 2 147

UP 2,008 1,995 197 156 52 24 4,432

2,049 2,063 205 178 58 26 4,579

75 n=2,052HbA1 5.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9 9.0

UP 32 61 9 10 11 2 125

UP 823 887 87 75 26 14 1,912

855 948 96 85 37 16 2,037

75 79 n=1,231

HbA1 5.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9 9.0UP 17 21 5 6 6 1 125

UP 494 544 59 48 17 10 1,912

511 568 64 54 23 11 1,231

80 n=806

HbA1 5.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9 9.0UP 15 37 4 4 5 1 59

UP 329 343 28 27 9 10 1,172

344 380 32 31 14 5 806

HbA1c

HbA1c

HbA1c 6.5 7.9 7.1

8.0 13.3

HbA1c 6.5 7.9 9.9

8.0 24.5

41

HbA1c 7.0

134 /376 35.6

HbA1c 8.0

51 /137 37.2 12 /53 22.6

40-74 n=7,953HbA1

12 0.29% 149 4.64% 120 40.00% 156 65.27% 62 75.61% 24 43.64% 523 6.58%

4,057 99.71% 3,059 95.36% 180 60.00% 83 34.73% 20 24.39% 31 56.36% 7,430 93.42%

4,069 3,208 300 239 82 55 7,953

40 64 n=3,366

HbA13 0.15% 33 2.89% 32 33.68% 40 65.57% 16 66.67% 12 42.86% 136 4.04%

2,014 99.85% 1,108 97.11% 63 66.32% 21 34.43% 8 33.33% 16 57.14% 3,230 95.96%

2,017 1,141 95 61 24 28 3,366

65 74 n=4,587

HbA1

9 0.44% 116 5.61% 88 42.93% 116 65.17% 46 79.31% 12 44.44% 387 8.44%

2,043 99.56% 1,951 94.39% 117 57.07% 62 34.83% 12 20.69% 15 55.56% 4,200 91.56%

2,052 2,067 205 178 58 27 4,587

75 n=2,052HbA1

6 0.70% 58 6.07% 36 37.11% 52 61.18% 29 78.38% 12 75.00% 193 9.41%

856 99.30% 897 93.93% 61 62.89% 33 38.82% 8 21.62% 4 25.00% 1,859 90.59%

862 955 97 85 37 16 2,052

75 79 n=1,237

HbA14 0.78% 37 6.49% 24 36.92% 32 59.26% 18 78.26% 8 72.73% 123 9.94%

510 99.22% 533 93.51% 41 63.08% 22 40.74% 5 21.74% 3 27.27% 1,114 90.06%

514 570 65 54 23 11 1,237

80 n=815

HbA1

2 0.57% 21 5.45% 12 37.50% 20 64.52% 11 78.57% 4 80.00% 70 8.59%

346 99.43% 364 94.55% 20 62.50% 11 35.48% 3 21.43% 1 20.00% 745 91.41%

348 385 32 31 14 5 815

UP n

9.05.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9

9.0

5.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9 9.0

5.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9

9.0

5.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9 9.0

5.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9

5.6 5.6 <6.5 6.5 <7.0 7.0 <7.9 8.0 <8.9 9.0

HbA1c

42

43

44