The latest version of diabetic nephropathy expert consensus grab prerelease read! (With full text)

The latest version of diabetic nephropathy expert consensus grab prerelease read! (With full text)


Diabetic nephropathy is one of the most important microvascular complications of diabetes mellitus, which is the primary cause of end-stage renal disease (ESRD).

Foreign research data show that more than 20 years duration of diabetic nephropathy in patients with a rate of 40.8 / 1000 person-years, the need for dialysis or transplantation and other renal replacement therapy. The prevalence of diabetic nephropathy in China also showed a rapid growth trend. From 2009 to 2012, the prevalence of diabetic nephropathy in Chinese patients with type 2 diabetes was 30% to 50% in community patients and 40% in hospitalized patients. Early onset, prophylaxis and delay the development of diabetic nephropathy to improve the survival rate of diabetic patients and improve their lives (http://www.agile-news.com/) .Diabetic nephropathy onset occult, once entered a large number of proteinuria period, progress to the ESRD rate of about 14 times that of other kidney disease, Quality is of great significance. This consensus for the regulation of diabetic nephropathy diagnosis and treatment provided the basis.


First, the definition and diagnosis of diabetic nephropathy

Diabetic nephropathy is caused by diabetes, kidney damage, is caused by diabetes, chronic kidney disease, including glomerular filtration rate (GFR) less than 60 ml · min-1.73 m-2 or urinary albumin / creatinine ratio (ACR) of more than 30 mg / g for more than 3 months. Diabetic glomerulopathy (diabetic glomerulopathy) specifically refers to the renal biopsy confirmed by the glomerular disease caused by diabetes.



(A) of the clinical diagnosis of diabetic nephropathy basis

1. Urinary albumin: microalbuminuria is the early clinical manifestations of diabetic nephropathy, but also the main basis for diagnosis of diabetic nephropathy.
2. Diabetic retinopathy: diabetic retinopathy often precedes diabetic nephropathy, most diabetic nephropathy patients with diabetic retinopathy, but dialysis in patients with diabetic nephropathy, the incidence of diabetic retinopathy is reduced, diabetic retinopathy by NKF / KDOQI As a guide to the diagnosis of type 2 diabetic patients with diabetic nephropathy.

(B) the screening of diabetic nephropathy and renal function evaluation

Renal function is an important manifestation of diabetic nephropathy, reflecting the main indicators of renal function is GFR, according to GFR and other evidence of renal damage can be chronic kidney disease (CKD) staging (Table 2).





Second, the prevention and treatment of diabetic nephropathy

Prevention and treatment of diabetic nephropathy is divided into three stages.
The first stage of the prevention of diabetic nephropathy, diabetes screening for key populations and found impaired glucose tolerance or impaired fasting glucose in patients with changes in lifestyle, blood glucose control and other measures to prevent the occurrence of diabetes and diabetic nephropathy.
The second stage is early treatment of diabetic nephropathy, there microalbuminuria in diabetic patients, to diabetic nephropathy treatment, reduce or delay the occurrence of a large number of proteinuria.
The third stage is to prevent or delay the occurrence or progress of renal insufficiency, treatment of complications, renal dysfunction occurs consider renal replacement therapy. Diabetic nephropathy treatment to control blood sugar, control blood pressure, reduce urinary protein mainly, but also lifestyle intervention, correct lipid metabolism disorders, treatment of renal dysfunction complications, dialysis treatment.

(A) Lifestyle guidance

Changes in lifestyle, including diet therapy, exercise, alcohol, smoking cessation, weight control, is conducive to slow the progress of diabetic nephropathy, renal protection.
1. Medical Nutrition Therapy
2. movement
3. Quit smoking

(B) control of blood sugar

DCCT and its follow-up Diabetes Intervention and Complications Epidemiologic Studies (EDIC), British Type 2 Diabetes Mellitus Prospective Study (UKPDS) and the American Veterans Collaboration Study (VAC) validated the association between type 1 diabetes mellitus and type 2 diabetes mellitus , Strict control of blood sugar can reduce the incidence of diabetic nephropathy or delay the progression of its course.

1. Blood glucose control goals: Diabetic nephropathy in patients with blood glucose control should follow the principle of individuality. Glycemic control objectives: glycosylated hemoglobin (HbA1c) not more than 7%. For the elderly patients, HbAlc control objectives appropriate to relax to no more than 7% to 9%. HbAlc may be underestimated because the life span of red blood cells in patients with CKD is shortened. In patients with CKD stage 4 to 5, fructosamine or glycated serum albumin reflects a more reliable glycemic control level.

2. Selection of anti-hyperglycemic drugs: including biguanides, sulfonylureas, glinides, thiazolidinediones, alpha-glucosidase inhibitors, dipeptidyl peptidase IV (DPP-4) inhibitors, Like peptide-1 (GLP-1) analogs and insulin. Some of the drugs in the kidney metabolism or excretion in diabetic nephropathy, especially in patients with renal insufficiency, reduced renal excretion or reduction of its active metabolite clearance can cause adverse reactions such as hypoglycemia, these drugs in the GFR below 60 Ml · min-1 · 1.73 m-2 when the reduction or withdrawal of discretion.


(C) control of blood pressure

Elevated blood pressure is not only an important factor to accelerate the progress of diabetic nephropathy, but also determine the prognosis of patients with cardiovascular disease the main risk factors. In patients with type 2 diabetic nephropathy, the effect of blood pressure on renal function is more pronounced. Patients with a systolic blood pressure exceeding 140 mmHg (1 mmHg = 0.133 kPa) have a rate of renal decline of 13.5% per year, whereas systolic blood pressure <140 mmHg The rate of decline in renal function was 1%. UKPDS studies have shown that intensive blood pressure control in diabetic patients in the early stages of diabetes not only significantly reduces the risk of diabetic macroangiopathy but also significantly reduces the risk of microvascular disease. A large number of clinical observations also confirmed that strict control of hypertension can significantly reduce urinary protein in patients with diabetic nephropathy, delay the progress of renal dysfunction. Intensive blood pressure control can also reduce the risk of cardiovascular end-point events by 20% to 30%.

(D) to correct lipid metabolism disorders

Hyperlipidemia is not only directly involved in diabetic insulin resistance and cardiovascular complications, low-density lipoprotein cholesterol (LDL-C) can also act on the glomerular mesangial cells on the LDL receptor, leading to mesangial cells and Podocyte injury, increased proteinuria and glomerular and tubulointerstitial fibrosis progression. Diabetic patients with nephrotic syndrome and renal dysfunction, will further aggravate hyperlipidemia. Therefore, positive correction of diabetic nephropathy in patients with lipid metabolism disorders, but also of diabetic nephropathy is of great significance.

(E) renal replacement therapy

Patients with diabetic nephropathy with GFR less than 15 ml · min-1 · 1.73 m-2 were eligible for renal replacement therapy, including hemodialysis, peritoneal dialysis, and kidney transplantation, if conditions warranted.

(6) other therapeutic drugs application, development and prospect

1. Microcirculation dilator
2. Exploration of Traditional Chinese Medicine Combined with Traditional Chinese and Western Medicine in Treating Diabetic Nephropathy
3. Development of drugs for the pathogenesis of diabetic nephropathy