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The latest research shows that diabetic nephropathy (DKD) has replaced primary glomerular disease as the leading cause of chronic kidney disease (CKD) in my country.
Xiaojie invited Professor Sun Lin from the Nephrology Institute of Central South University/Department of Nephrology, Xiangya Second Hospital, to share with us the interpretation of the Chinese Guidelines for Clinical Diagnosis and Treatment of Diabetic Kidney Diseases formulated by the Nephrology Professional Committee of the Chinese Medical Association.
Professor Sun Lin proposed that diabetic nephropathy is a common disease in our country.
The latest research shows that diabetic nephropathy (DKD) has replaced primary glomerular disease as the leading cause of chronic kidney disease (CKD) in my country.
DKD is also the main cause of end-stage renal disease (ESRD) in developed countries.
Therefore, the standardized diagnosis and treatment of DKD has become a topic of great concern in the field of kidney disease at home and abroad.
Diabetic retinopathy is not a prerequisite for diagnosing DKD.
Guidelines recommend: Diabetic nephrotic retinopathy is an important basis for the diagnosis of DKD, but diabetic retinopathy is not a prerequisite for diagnosing diabetic kidney disease.
The results of a recent Meta analysis showed that the sensitivity of diabetic retinopathy to predict diabetic nephropathy was 0.
65, the positive predictive value was 0.
72, and the negative predictive value was 0.
69.
For proliferative diabetic retinopathy, the sensitivity was 0.
25 and the specificity was 0.
98.
In addition, the research conducted by Chinese academician Chen Xiangmei and other scholars also found that diabetic nephropathy and retinopathy are not completely parallel in the occurrence and development process.
It is suggested that diabetic retinopathy can be used as an important basis for diabetic nephropathy, but it is not a necessary condition for diagnosis, because some patients with diabetic nephropathy may not be accompanied by retinopathy in the early stage.
The level of creatinine cannot determine whether to dialysis.
The guidelines put forward: Patients with diabetic nephropathy have severe renal impairment, such as hypertension that is difficult to control or correct, intractable edema, heart failure, and symptoms of severe anemia, gastrointestinal poisoning, protein For energy expenditure or severe metabolic disorders, hemodialysis or peritoneal dialysis is recommended.
However, without the above conditions and signs, dialysis cannot be started based on the level of renal function.
Many doctors believe that creatinine is significantly increased, and dialysis is needed when it reaches 800.
However, if there are no signs and symptoms of uremia, dialysis should not be started just because of a significant increase in creatinine.
On the contrary, if the patient has the above symptoms, even if the creatinine is more than 300, it is recommended to start dialysis treatment.
Studies have found that although dialysis can relieve the symptoms of patients with renal failure, early dialysis may increase the risk of death, and early dialysis should be avoided as much as possible.
A foreign study also suggested that 60% of patients regretted early dialysis.
The guidelines also suggest that early dialysis is not recommended for elderly patients with diabetic nephropathy and renal failure.
The reason is that elderly patients with diabetic nephropathy and renal failure are at increased risk of dialysis, and lung infections are particularly common.
In general, the level of creatinine cannot be used to determine whether the patient is transparent or not.
This point must be paid special attention to.
What is the trend of changes in renal function in DKD patients with normal proteinuria? Disease diagnosis criteria for DKD patients with normal proteinuria: 3 renal function tests in DM patients within half a year, at least 2 eGFR<60 ml/(min·1.
73m²), and the reduction of eGFR caused by acute kidney injury and other reasons is excluded.
At least 2 urine tests within 6 months are normal (UACR<30mg/g; or UAER<30mg/24h; or urine protein excretion rate<20μg/min; or random urine protein<17mg/L).
Kidney tissue biopsy conforms to DKD pathological changes.
Studies have shown that diabetic patients with normal proteinuria show a progressive decline in renal function after CKD3, which is why eGFR<60 ml/(min·1.
73m²) is regarded as the cut-off value of normal proteinuria diabetes.
The light blue line in the figure below represents the development of normal proteinuria diabetic patients during CKD3 stage follow-up for ten years.
The results indicate that CKD3 stage follow-up for 10 years, the average annual decrease in eGFR of normal proteinuria type 1 and type 2 diabetes patients is 1.
9 ml/ min/1.
73 m².
The dark blue line and the red line respectively represent the 10-year follow-up of CKD patients with microalbuminuria and macroalbuminuria.
Director Sun Lin proposed that for diabetic patients with normal proteinuria, there is less intervention in lipid-lowering, RAS blockers and other antihypertensive treatments.
Insufficient heart and kidney protection may be the reason for the continued deterioration of renal function, suggesting that we should increase Understanding and concern about normal proteinuria DKD.
Figure 1: Changes in albuminuria in diabetic patients with normal proteinuria during CKD3 stage of follow-up for 10 years.
A large RCT study showed that the incidence of normal proteinuria in diabetic patients after CKD3 stage is high.
The study selected 15773 patients with type 2 diabetes.
Among 1673 patients with eGFR less than 60ml/min / 1.
73 m², 56.
6% were normal proteinuria, 30.
8% were microalbuminuria, and 12.
6% were macroalbuminuria.
The difference in urine metabolomics changes in DKD patients with normal proteinuria suggests a different pathophysiological process from that in patients without DKD.
Studies have shown that there are 65 different metabolites between the simple diabetes group, the normal albuminuria DKD group and the proteinuria DKD group; the normal albuminuria DKD group and the proteinuria DKD group have linoleic acid and γ-linolenic acid , L-malic acid and L-proline levels are different.
Do patients with DKD need a kidney biopsy? There is controversy in China on whether a kidney biopsy is required for diabetic kidney disease and when a kidney biopsy should be done.
This guide combs the indications of kidney biopsy for diabetic nephropathy in China, including: DM with a history of less than 5 years, large proteinuria or renal insufficiency; large proteinuria or nephrotic syndrome in a short period of time; urine sediment indicates "active" renal small Globular hematuria; unexplained rapid decline in eGFR or more than 30% decline in eGFR within 3 months after ACEI/ARB treatment; massive proteinuria but no diabetic retinopathy; refractory hypertension.
Or have clinical symptoms, signs or laboratory tests of a systemic disease.
If pathological staging or condition evaluation of DKD is needed, kidney biopsy can be considered as appropriate for the above situations.
Before treatment, the diabetic kidney needs to be staged.
The combined evaluation method of eGFR and UACR is recommended for clinical staging of DKD.
It is recommended to use the Mogensen T1DKD staging method as appropriate for clinical staging of T2DKD.
However, it is still recommended that conditional units try their best to carry out kidney biopsy and pathological staging of DKD.
The specific clinical/pathological staging recommendations are shown in the table below for reference.
Table 1: Interpretation of the Chinese Guidelines for DKD Clinical/Pathological Stages and Key Points of Prevention and Treatment Diabetic Nephropathy (Part I) is over here.
Next week, we will prepare the same wonderful part next for everyone.
You can also directly log in to the "Doctor Station" to search.
"Interpretation of the Chinese Guidelines for Diabetic Nephropathy" by Professor Sun, listen to Professor Sun's personal explanation! Course viewing 1.
Log in to the medical doctor station (If the medical doctor station is not installed, click the QR code or read the original download) 2.
Find the "Courses" page 3.
Enter the name of the course you want to see in the search box 4.
Enter "Diabetic Kidney Disease" Interpretation of the Chinese Guide" to watch Scan the QR code to download the Doctor Station App Famous Doctor Class for you to watch for free to read the original text, watch it now↓↓↓↓
Xiaojie invited Professor Sun Lin from the Nephrology Institute of Central South University/Department of Nephrology, Xiangya Second Hospital, to share with us the interpretation of the Chinese Guidelines for Clinical Diagnosis and Treatment of Diabetic Kidney Diseases formulated by the Nephrology Professional Committee of the Chinese Medical Association.
Professor Sun Lin proposed that diabetic nephropathy is a common disease in our country.
The latest research shows that diabetic nephropathy (DKD) has replaced primary glomerular disease as the leading cause of chronic kidney disease (CKD) in my country.
DKD is also the main cause of end-stage renal disease (ESRD) in developed countries.
Therefore, the standardized diagnosis and treatment of DKD has become a topic of great concern in the field of kidney disease at home and abroad.
Diabetic retinopathy is not a prerequisite for diagnosing DKD.
Guidelines recommend: Diabetic nephrotic retinopathy is an important basis for the diagnosis of DKD, but diabetic retinopathy is not a prerequisite for diagnosing diabetic kidney disease.
The results of a recent Meta analysis showed that the sensitivity of diabetic retinopathy to predict diabetic nephropathy was 0.
65, the positive predictive value was 0.
72, and the negative predictive value was 0.
69.
For proliferative diabetic retinopathy, the sensitivity was 0.
25 and the specificity was 0.
98.
In addition, the research conducted by Chinese academician Chen Xiangmei and other scholars also found that diabetic nephropathy and retinopathy are not completely parallel in the occurrence and development process.
It is suggested that diabetic retinopathy can be used as an important basis for diabetic nephropathy, but it is not a necessary condition for diagnosis, because some patients with diabetic nephropathy may not be accompanied by retinopathy in the early stage.
The level of creatinine cannot determine whether to dialysis.
The guidelines put forward: Patients with diabetic nephropathy have severe renal impairment, such as hypertension that is difficult to control or correct, intractable edema, heart failure, and symptoms of severe anemia, gastrointestinal poisoning, protein For energy expenditure or severe metabolic disorders, hemodialysis or peritoneal dialysis is recommended.
However, without the above conditions and signs, dialysis cannot be started based on the level of renal function.
Many doctors believe that creatinine is significantly increased, and dialysis is needed when it reaches 800.
However, if there are no signs and symptoms of uremia, dialysis should not be started just because of a significant increase in creatinine.
On the contrary, if the patient has the above symptoms, even if the creatinine is more than 300, it is recommended to start dialysis treatment.
Studies have found that although dialysis can relieve the symptoms of patients with renal failure, early dialysis may increase the risk of death, and early dialysis should be avoided as much as possible.
A foreign study also suggested that 60% of patients regretted early dialysis.
The guidelines also suggest that early dialysis is not recommended for elderly patients with diabetic nephropathy and renal failure.
The reason is that elderly patients with diabetic nephropathy and renal failure are at increased risk of dialysis, and lung infections are particularly common.
In general, the level of creatinine cannot be used to determine whether the patient is transparent or not.
This point must be paid special attention to.
What is the trend of changes in renal function in DKD patients with normal proteinuria? Disease diagnosis criteria for DKD patients with normal proteinuria: 3 renal function tests in DM patients within half a year, at least 2 eGFR<60 ml/(min·1.
73m²), and the reduction of eGFR caused by acute kidney injury and other reasons is excluded.
At least 2 urine tests within 6 months are normal (UACR<30mg/g; or UAER<30mg/24h; or urine protein excretion rate<20μg/min; or random urine protein<17mg/L).
Kidney tissue biopsy conforms to DKD pathological changes.
Studies have shown that diabetic patients with normal proteinuria show a progressive decline in renal function after CKD3, which is why eGFR<60 ml/(min·1.
73m²) is regarded as the cut-off value of normal proteinuria diabetes.
The light blue line in the figure below represents the development of normal proteinuria diabetic patients during CKD3 stage follow-up for ten years.
The results indicate that CKD3 stage follow-up for 10 years, the average annual decrease in eGFR of normal proteinuria type 1 and type 2 diabetes patients is 1.
9 ml/ min/1.
73 m².
The dark blue line and the red line respectively represent the 10-year follow-up of CKD patients with microalbuminuria and macroalbuminuria.
Director Sun Lin proposed that for diabetic patients with normal proteinuria, there is less intervention in lipid-lowering, RAS blockers and other antihypertensive treatments.
Insufficient heart and kidney protection may be the reason for the continued deterioration of renal function, suggesting that we should increase Understanding and concern about normal proteinuria DKD.
Figure 1: Changes in albuminuria in diabetic patients with normal proteinuria during CKD3 stage of follow-up for 10 years.
A large RCT study showed that the incidence of normal proteinuria in diabetic patients after CKD3 stage is high.
The study selected 15773 patients with type 2 diabetes.
Among 1673 patients with eGFR less than 60ml/min / 1.
73 m², 56.
6% were normal proteinuria, 30.
8% were microalbuminuria, and 12.
6% were macroalbuminuria.
The difference in urine metabolomics changes in DKD patients with normal proteinuria suggests a different pathophysiological process from that in patients without DKD.
Studies have shown that there are 65 different metabolites between the simple diabetes group, the normal albuminuria DKD group and the proteinuria DKD group; the normal albuminuria DKD group and the proteinuria DKD group have linoleic acid and γ-linolenic acid , L-malic acid and L-proline levels are different.
Do patients with DKD need a kidney biopsy? There is controversy in China on whether a kidney biopsy is required for diabetic kidney disease and when a kidney biopsy should be done.
This guide combs the indications of kidney biopsy for diabetic nephropathy in China, including: DM with a history of less than 5 years, large proteinuria or renal insufficiency; large proteinuria or nephrotic syndrome in a short period of time; urine sediment indicates "active" renal small Globular hematuria; unexplained rapid decline in eGFR or more than 30% decline in eGFR within 3 months after ACEI/ARB treatment; massive proteinuria but no diabetic retinopathy; refractory hypertension.
Or have clinical symptoms, signs or laboratory tests of a systemic disease.
If pathological staging or condition evaluation of DKD is needed, kidney biopsy can be considered as appropriate for the above situations.
Before treatment, the diabetic kidney needs to be staged.
The combined evaluation method of eGFR and UACR is recommended for clinical staging of DKD.
It is recommended to use the Mogensen T1DKD staging method as appropriate for clinical staging of T2DKD.
However, it is still recommended that conditional units try their best to carry out kidney biopsy and pathological staging of DKD.
The specific clinical/pathological staging recommendations are shown in the table below for reference.
Table 1: Interpretation of the Chinese Guidelines for DKD Clinical/Pathological Stages and Key Points of Prevention and Treatment Diabetic Nephropathy (Part I) is over here.
Next week, we will prepare the same wonderful part next for everyone.
You can also directly log in to the "Doctor Station" to search.
"Interpretation of the Chinese Guidelines for Diabetic Nephropathy" by Professor Sun, listen to Professor Sun's personal explanation! Course viewing 1.
Log in to the medical doctor station (If the medical doctor station is not installed, click the QR code or read the original download) 2.
Find the "Courses" page 3.
Enter the name of the course you want to see in the search box 4.
Enter "Diabetic Kidney Disease" Interpretation of the Chinese Guide" to watch Scan the QR code to download the Doctor Station App Famous Doctor Class for you to watch for free to read the original text, watch it now↓↓↓↓
