-1: Definition: Chronic kidney disease (CKD) caused by diabetes . When 2 diabetes is diagnosed, renal lesions should be screened and screened at least once a year later, including urine routine, urinary albumin/creatinine ratio (UACR) and serum creatinine (calculated eGFR) to detect kidney damage early.
2: diabetic nephropathy risk factors include : bad living habits, age, course of disease, obesity (especially abdominal obesity), blood sugar, blood pressure, blood lipids , uric acid, environmental pollutants, etc.
3: Diagnosis:
Clinical diagnosis was made based on the increase of urinary albumin/creatinine ratio (UACR) and (or) eGFR decreases while excluding other CKD. The following situations should be considered: ① Abnormal active urinary sediment (hematuria, proteinuria with hematuria , tube type urine); UACR rapidly increases or nephrotic syndrome in the short term; ② rapid decrease in eGFR in the short term; ③ no diabetic retinopathy (DR, especially T1DM); DR is not a necessary condition for diagnosing T2DM in the diagnosis of sugar renal renal. Pathological diagnosis is the gold standard, and renal puncture is difficult to distinguish, but routine puncture in patients with diabetes is not recommended.
recommended random urine measurement UACR: 24 h urine albumin quantification is comparable to that of UACR diagnostic value, but the former is more cumbersome. When albumin levels of random urine specimens are measured separately and urine creatinine is measured simultaneously, changes in urine concentration caused by hydration of are easily caused by false negative and false positive . random urine UACR ≥30 mg/g is an increase in urinary albumin excretion. 2 of the three repeated examinations within 3 to 6 months have increased urinary albumin excretion. Albuminuria can be diagnosed by eliminating infection and other factors. In clinical practice, UACR 30~300 mg/g is often called microalbuminuria, and UACR 300 mg/g is called large-scale albuminuria . Elevated UACR is associated with decreased eGFR, cardiovascular events, and increased risk of death. There are many influencing factors in UACR assay, such as infection, fever, significant hyperglycemia, uncontrolled hypertension, 24 h exercise, heart failure , menstruation, etc. These factors should be considered in the analysis of the results.
Recommended determination of serum creatinine : Calculate eGFR using the formula of the kidney disease dietary improvement test (MDRD). GFR drop can be diagnosed when eGFR60 ml·min⁻¹·(1.73 m²)⁻¹. Decreased eGFR is closely related to increased risk of cardiovascular disease and death.
glomerular filtration rate (GFR) estimate (simplified MDRD formula):
GFR(ml/min1.73m2)=186×(Scr-1.154)×(Age-0.203)×(0.742 female)
(GFR is glomerular filtration rate ; Scr is Serum creatinine (mg/dl); Ccr endogenous muscle clearance rate ; age is in years; creatinine is converted to 1 mg/dL=88.41umoI/L; blood sugar is converted to 1 mmol/L=18 mg/dL)
(eGFR is the estimated glomerular filtration rate. By calculating how many milliliters of creatinine in the blood can be clearly cleaned (ml/min) per minute, the patient's kidneys can evaluate the ability of the body's metabolic waste to be cleared).
After the diagnosis and diagnosis of diabetes nephropathy is confirmed: Further judge the severity of CKD according to eGFR. The Global Prognosis Guidelines for the Improvement of Kidney Disease (KDIGO) recommends combining CKD staging and albuminuria staging to evaluate the progression risk and review frequency of diabetic nephropathy (Table 15). For example, if an eGFR of diabetic patients is 70 ml·min⁻¹·(1.73 m²)⁻¹ and a UACR of 80 mg/g, it is diabetic nephropathy G2A2, and the risk of CKD progression is medium risk and should be reviewed once a year.
Table 15 CKD progress risk and frequency of consultation
IV: Treatment : Adjust adverse lifestyle and reasonable nutrition; control risk factors such as: hyperglycemia, hypertension, lipid metabolism disorders, etc. ( comprehensive treatment based on lowering glycemic, lowering blood pressure and lipid regulation ).
1: Change the bad lifestyle: quit smoking, exercise appropriately and control weight reasonably; Reasonable nutrition: dialysis intake 0.8 g·kg⁻¹·d⁻¹. Excessive intake of (such as 1.3 g·kg⁻¹·d⁻¹) is associated with increased proteinuria, decreased renal function, and increased risk of cardiovascular and mortality. Protein intake below 0.8 g·kg⁻¹·d⁻¹ cannot delay the progression of diabetic nephropathy. dialyzers can appropriately increase the protein intake of to avoid malnutrition. The vitamin D level of T2DM and albuminuria in my country is low. Supplementing vitamin D to can reduce UACR, but there is no evidence whether it can delay the progression of diabetic nephropathy. Protein source is mainly high-quality animal protein/supplemented with compound α-ketoic acid if necessary.
2: Control of blood sugar: Effectively lowering glucose delays the development of diabetic nephropathy . Multiple studies have shown that sodium-glucose cotransporter 2 inhibitor (SGLT2i) has a renal protective effect other than lowering glucose. It is recommended to use it in patients with eGFR ≥45 ml·min⁻¹·(1.73 m²)⁻¹ to reduce the risk of diabetic nephropathy progression and (or) cardiovascular events. glucagon-like peptide-1 receptor agonist (GLP-1RA—liraglutide, etc.) can reduce the risk of new large amounts of albuminuria in patients with diabetes and is used in patients with eGFR ≥30 ml·min⁻¹·(1.73 m²)⁻¹. Some oral hypoglycemic drugs require to adjust the dosage according to renal function and preferential drugs that excrete less from the kidneys. Insulin is used for patients with severe renal insufficiency to treat .
3: Control blood pressure: Reasonably lower blood pressure and delay the development of diabetic nephropathy. It is recommended that blood pressure should be controlled below 130/80 mmHg . ① For those with hypertension and UACR300 mg/g or eGFR60 ml·min⁻¹·(1.73 m²)⁻¹, angiotensin converting enzyme inhibitor (ACEI) or angiotensin II receptor antagonist (ARB) drugs are highly recommended for treatment of . It can reduce cardiovascular events and delay the progression of renal disease, including the occurrence of end-stage renal disease. ② For patients with diabetes with hypertension and UACR of 30~300 mg/g, it is recommended to treat as the first choice. For these patients, ACEI or ARB drugs can delay albuminuria progression and reduce cardiovascular events, but there is insufficient evidence to reduce the risk of end-stage renal disease. ③ For diabetic patients without hypertension but UACR ≥30 mg/g, the use of ACEI or ARB drugs can delay the progression of albuminuria, but there is no evidence that ACEI or ARB can reduce major renal endpoint events (such as end-stage renal disease) . During the treatment period, UACR, serum creatinine, and blood potassium levels should be regularly followed up to adjust the treatment plan. The increase in serum creatinine by 30% within 2 months of taking the drug often indicates renal ischemia, and ACEI or ARB drugs should be discontinued. ④ For diabetic patients with urinary UACR and normal urinary UACR and eGFR, ACEI or ARB cannot delay the progression of nephropathy and may increase cardiovascular risk. It is not recommended to use ACEI or ARB drugs for primary prevention of diabetic nephropathy . ACEI and ARB have similar effects on diabetic nephropathy. Considering the rapid decline in hyperkalemia and eGFR, it is not recommended to use ACEI and ARB drugs in combination. ⑤ Aldosterone receptor antagonist can reduce urinary albumin and delay the decline of eGFR, but there is a risk of elevating blood potassium, and whether there is a benefit from renal endpoint events still needs further verification. Third-generation aldosterone receptor antagonists can reduce the risk of cardiovascular events in patients with diabetic nephropathy. (Fenelone is a third-generation aldosterone receptor antagonist, which mainly fights the progression of in chronic kidney disease in : inflammatory response and fibrosis in to delay disease progression. It effectively reduces the incidence of end-stage renal disease, and is also helpful to the risk of end-stage events in heart disease).
4: Correcting dyslipidemia : See guide to dyslipidemia.
5: Dialysis treatment and transplantation: When eGFR60 ml·min⁻¹·(1.73 m²)⁻¹¹, potential CKD complications should be assessed and treated; when 30 ml·min⁻¹·(1.73 m²)⁻¹, renal specialist should be actively consulted to evaluate whether renal replacement therapy should be received. Dialysis methods include peritoneal dialysis and hemodialysis . Patients with conditions can renal transplantation .
5: Follow-up and referral
1. Follow-up: checks UACR, serum creatinine, and blood potassium levels every year. People with stages 3~4 need to closely follow up on CKD-related metabolic disorders, such as vitamin D, hemoglobin, bicarbonate , calcium and phosphorus metabolism , parathyroid hormone , etc. . The follow-up frequency is determined based on the severity of the disease.
2. Referral: has the following conditions and is referred to the Nephrology Department: (1) Diabetic nephropathy progresses to stage 4 to 5, and renal replacement treatment is considered; (2) Non-diabetic nephropathy is considered clinically, such as rapid decline in eGFR in the short term, rapid increase in proteinuria in the short term, abnormal renal imaging manifestations, combined with refractory hypertension, etc.
3: GFR is divided into five periods according to the glomerular filtration rate:
serum creatinine does not take into account gender, age, and weight factors, and does not reflect renal function well, so it is rarely used. It is recognized that GFR objectively reflects renal function.
① Chronic kidney disease stage 1 (>90ml/min)
② Chronic kidney disease stage 2 (60~90)
③ Chronic kidney disease stage 3 (30~60)
④ Chronic kidney disease stage 4 (15~30)
⑤ Chronic kidney disease stage 5 (<15ml,>
General Department of Xiluoyuan Community Health Service Center, Fengtai District (Li Xuefeng) September 18, 2022
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