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Dr. Wittmann István

dr_wittmann.jpgDr. Wittmann István elöljáróban hangsúlyozta: nem tudja különválasztani nefrológiai (a vese betegségeivel foglalkozó) és diabetológusi munkáját. A tanár úrtól a cukorbetegek veseszövődményeiről, illetve azok felismeréséről és megelőzéséről kértünk felvilágosítást.

"A magas vérnyomás ördögi köre"

Mi az összefüggés a magas vérnyomás és a vesekárosodás között?
− A vesében az elsődleges vizelet kiválasztásának helyén, az érgomolyagban a vérnyomás jóval alacsonyabb, mint a vérkeringés verőeres részének egyéb területein. Ennek fenntartásában az érgomolyagba bevezető erek szűkülése és tágulása játszik szerepet. Ha a vérkeringés vesén kívüli verőeres nyomása emelkedik (vérnyomás-emelkedés, magas vérnyomás), akkor az érgomolyag előtti ér összehúzódik, és ezzel megakadályozza a vérnyomás-növekedés áttevődését az érgomolyagra. Cukorbetegségben az érgomolyag előtti ér kóros tágulata, a vesén kívüli vérkeringés nyomásának emelkedése és az érgomolyagból kivezető ér szűkülete az érgomolyag nyomásának növekedéséhez vezet, ami az érgomolyagfal károsodását okozza, s elősegíti a fehérjemolekulák kikerülését a vérből a vizeletbe. Ezért a cukorbetegek vesekárosodásának korai jele a fehérje, különösen az albuminnak nevezett fehérje megjelenése a vizeletben.

Amikor magas az érgomolyagban a vérnyomás, az érgomolyag utáni erek nyomása is megnövekszik, ami a vesecsövecskék körüli hajszálerek károsodását és ezzel a vese kötőszöveti állományának kiszélesedését okozza. Ennek következtében a cukorbetegek veséje nem tudja a sót (nátriumot) kiválasztani, növekszik a test nátriumtartalma, ami vizet tart vissza az erekben, ezért a keringő vérmennyiség növekszik és ez tovább emeli a vérnyomást. Összefoglalva tehát: a cukorbetegségben kialakuló magas vérnyomás károsítja a vesét, ami tovább növeli a vérnyomást és ezzel egy ördögi kör keletkezik.

Milyen gyakori a cukorbetegek körében a veseszövődmény?
− Magyarországon a veseelégtelenségben szenvedők hozzávetőlegesen 20−30 százalékának van cukorbetegsége. Nyugat-Európában és az Egyesült Államokban ugyanez a szám 50 százalék körüli. Elmondhatjuk tehát , hogy a veseelégtelenség leggyakoribb oka a cukorbetegség, a diabétesz előfordulása a vesebetegek körében folyamatosan emelkedik és valószínű, hogy hazánkban is hamarosan megközelíti az 50 százalékot. A kérdést a másik oldaláról vizsgálva megállapíthatjuk, hogy az 1-es típusú cukorbetegek 20−30 százalékában és a 2-es típusú cukorbetegek 10−20 százalékában fordul elő veseérintettség. Ez azonban távolról sem jelenti minden esetben a veseelégtelenséget, hiszen közöttük sokkal nagyobb arányban fordul elő − a veseérintettség korai jeleként − kóros fehérjevizelés, mint veseelégtelenség.

Melyek a cukorbetegség okozta vesebetegségek főbb tünetei?
− A diabétesz okozta vesebetegség fő formái a következők: cukorbetegséggel összefüggő veseszövődmény, amit diabeteszes nefropátiának hívunk; cukorbetegség okozta érelmeszesedés miatti veseszövődmény, amit iszkémiás nefropátiának nevezünk; végül cukorbetegség miatti idült vesemedence-gyulladás. A diabeteszes nefropátiának nincs specifikus klinikai tünete, éppen ezért nagyon veszélyes, hiszen teljesen tünetmentesen teszi tönkre a beteg veséjét. Laboratóriumi jele korai stádiumban a kóros albuminvizelés, később a jelentős fehérjevizelés, és a vese kiválasztó működésének beszűkülése. Még egyszer hangsúlyozom, hogy a beteg mindebből semmit sem észlel mindaddig, amíg súlyos veseelégtelensége nem alakul ki. Hasonlóan tünetszegény az iszkémiás nefropátia is. A cukorbetegséghez társuló idült vesemedence-gyulladás is gyakran tünetmentes, csak a heveny fellángolások esetén érez a beteg vizeletcsípést, gyakori vizelési ingert, magas lázat, hidegrázást és ekkor észlelhet vérvizelést is.

Hogyan lehet a veseszövődményeket megelőzni és kezelni?
− A legfontosabb törekedni az optimális vércukor-beállításra. Sajnos azonban ideális vércukor mellett is előfordul cukorbetegekben veseszövődmény. Ennek hátterében örökletes hajlam állhat. Másrészt fontos a vérnyomás 130/80 Hgmm alatt tartása, illetve a jelentős fehérjevizelést mutató betegeknél törekedni kell a 125/75 Hgmm alatti értékekre. Léteznek olyan vérnyomáscsökkentő szerek, amelyek különösen alkalmasak a vesebeteg-cukorbeteg magas vérnyomásának kezelésére, mert speciálisan kedvező hatással bírnak a vesekárosodásra, csökkentik a fehérjevizelés mértékét.

Ezek a gyógyszerek az úgynevezett angiotenzin-konvertáló enzimgátlók és az angiotenzinreceptor-blokkolók csoportjába tartoznak. Harmadrészt fontos a veseszövődményes cukorbeteg diétájának megváltoztatása, a diéta fehérje- és sótartalmának csökkentése. Végül, de nem utolsó sorban a cukorbetegek vizeletének bakteriológiai vizsgálatát is rendszeresen (fél évente, évente) el kell végezni, és pozitivitás esetén a betegeket antibiotikummal szükséges kezelni.

Wittmann István 1984-ben summa cum laude eredménnyel végzett a Pécsi Orvostudományi Egyetemen. Később belgyógyászati, nefrológiai szakvizsgát tett és diabetológusi minősítést szerzett, 1999-ben lett egyetemi docens. 2003 óta a PTE ÁOK oktatási dékánhelyettese.
1994-től a PTE II. számú Belgyógyászati Klinika Diabetes Munkacsoportjának vezetője, 1996-ban lett a Nephrologia-Diabetologia Osztály vezetője, 2006 óta a II. számú Belgyógyászati Klinika és Nephrologiai Centrum megbízott igazgatója.
Első tudományos közleménye (1982) óta folyamatosan a szabad gyökök biológiai és klinikai jelentőségével foglalkozik, a diabetológia, a nefrológia és az angiológia területén végez kutatásokat. Aktív résztvevője a családorvosi, valamint a szakorvosi továbbképzésnek, több magas szakmai díj és kitüntetés tulajdonosa.
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