With the improvement of living standards, material life is extremely rich and often sedentary, more and more people are suffering from the disease of wealth—diabetes, about 20-40% of diabetic patients will develop for diabetic nephropathy.
Nowadays, people with diabetes are getting younger and younger, and some young people in their 20s and 30s are prematurely exposed to the threat of diabetes As a result, the age of onset of diabetic nephropathy continues to advance, increasing the physical, mental and economic burden.
What is diabetic nephropathy? is it serious? Can it be cured? Kidney failure? Today, an expert in diabetic nephropathy, Dr. Zhou Yue, will tell us in detail.
1.
What is diabetic nephropathy
Diabetic nephropathy refers to chronic kidney disease caused by diabetes, usually in patients with proteinuria or Decreased glomerular filtration rate, 1 of 2, or both.
It is not diabetes + proteinuria or renal impairment, it must be diabetic nephropathy, or it may be diabetes combined with other types of kidney disease, such as diabetes Combined with IgA nephropathy, diabetes with membranous nephropathy, etc.
The typical clinical presentation of diabetic nephropathy is: Many years of diabetes followed by proteinuria and decreased renal function span>, and often with diabetic retinopathy. Proteinuria begins with microalbuminuria → gradually develops into marked proteinuria without hematuria, and renal function begins with increased glomerular filtration rate → decreased. (We will explain in detail what this means later.)
For the typical course of diabetic nephropathy, doctors can usually diagnose and treat directly based on experience. < span>Kidney puncture, renal puncture confirms the diagnosis before treatment.
Any of the following features is highly suspected not to be diabetic nephropathy
- Fundus examination revealed no diabetic retinopathy
- Red blood cell casts, malformed red blood cells, or white blood cell casts in the urine sediment
- Irregularly rapid increases in albuminuria, or glomerular filtration The rate of sudden and rapid decline, for example, in less than 1-2 years, the proteinuria continued to increase by more than 5-10 times, and the glomerular filtration rate decreased by more than 5ml/min/1.73m per year2
- If there is a physical examination report, it is found that urine protein is elevated prior to diabetes
- There is another systemic disease associated with kidney disease, for example, systemic lupus erythematosus
- Type 1 diabetes mellitus 5 Significantly increased proteinuria (greater than 300 mg/day) within the year
2.
Is diabetic nephropathy serious?
diabetic nephropathy is also mild or severe, and the severity of the disease can be assessed from three dimensions : Urinary protein, renal function and pathology.
If a patient has more protein in urine, poorer renal function, and more severe pathology, the more severe the disease is. The heavier, the greater the risk of uremia.
I’ll start with pathology: typical diabetic nephropathy, pathological manifestations are, Basement membrane thickening, mesangial hyperplasia, tuberous sclerosis, and glomerulosclerosis. Pathological grades I and IIa are relatively mild, grade IV is severe, and grades IIb and III are intermediate.
In terms of renal function: CKD stage 1-2 is early, and renal function is OK; stage 3b-4 is late, and renal function is very poor; stage 3a is in the middle. Stage 5 For the most serious, uremia stage. (If you don’t know your CKD stage, you can click the picture below to calculate)
Explain a little here, early Diabetic nephropathy may have abnormally elevated glomerular filtration rate. Many people may be a little confused. Isn’t the higher the glomerular filtration rate, the better?
This is because the diabetic milieu activates the RAAS system and many other downstream mediators, causing renal hypertrophy and increased glomerular blood flow, which together lead to abnormally elevated glomerular filtration rates, such as the following one According to the test results of a patient with early diabetic nephropathy, the glomerular filtration rate is too high, so it is not necessarily that the lower the serum creatinine, the better, and the higher the glomerular filtration rate, the better. Individual analysis of individual circumstances.
Tests for patients with early diabetic nephropathy▽
follow ProteinuriaSeverity classification: The severity of proteinuria in patients with diabetic nephropathy varies, more than 3.5g/day, or less, with only microalbumin Pee.
Microalbuminuria is defined as urinary albumin excretion between 30- Between 300mg/day, such as checking ACR (urine albumin to creatinine ratio), the result shows that it is between 30-300mg/g; significantly increased urinary protein means that the urinary albumin excretion is greater than 300mg/day, such as checking urine The albumin-to-creatinine ratio was greater than 300 mg/g, and the 24-hour urine protein quantification was greater than 500 mg/day.
3.
Is diabetic nephropathy curable?
Let’s take a look at the natural development of diabetic nephropathy. Without intervention, let it develop.
Persistent blood sugar elevation is poorly controlled, and after 5-10 years of development in diabetic patients, microalbuminuria may occur; after another 10 years , and gradually developed into marked proteinuria. After about 20-30 years of development, it can develop into renal failure or major cardiovascular disease and death.
Then we can predict that if a young man in his 30s develops diabetes, if he is not properly managed, he will develop cardiovascular disease in his 50s and 60s. The risk of serious diseases such as disease or kidney failure is greater.
However, we just talked about the natural course of the disease. With the advancement of modern medical technology, as long as patients recognize the seriousness of the disease, early prevention and control , with the regular follow-up review by a good doctor, and taking medicine on time, it is entirely possible to achieve a stable condition and not develop in a bad direction.
Through strict control of blood sugar, blood pressure, and blood lipids, a considerable number of patients with a small amount of albuminuria may completely subside and reverse the cure. Or keep it steady. In some patients with significantly increased proteinuria, it is also hoped that the treatment will reduce to the safe range of a small amount of proteinuria, or completely normal.
4.
How to avoid kidney failure
For people with diabetes, prevention of kidney failure and prevention of cardiovascular disease are equally important.
Many diabetic patients do not pay attention to disease management, and it is not that they do not develop renal failure, but they do not have the “opportunity” to develop Kidney failure, before kidney failure, results in premature disability or death from cardiovascular disease.
Therefore, for diabetic kidney patients, we should not only care about the kidneys, but also the heart. How should we care?
Looking carefully at the picture below, we will start with Life, Indicators, Drugs Diabetic kidney disease can be managed well in many aspects:
life aspects
Quit Smoking: Smoking increases the risk of coronary heart disease by 54%, stroke by 44%, myocardial infarction by 52%, smoking It can also damage the structure and function of the glomeruli, so we must resolutely quit smoking.
Low-salt diet, proper control of protein intake, generally recommended protein intake for diabetic kidney patients is 0.8g/kg/day;
span>
Exercise: Exercise 3-5 times a week, half an hour each time, with a total of at least 150 minutes of exercise, such as brisk walking, jogging, etc.
metrics p>
Glucose
Hyperglycemic environment It is the core factor that damages the kidneys and heart, so it is very important to meet the blood sugar target.
As for how much blood sugar is up to standard, different patients have individualized guidance. We have strict requirements for some patients; some can be relaxed. The following picture shows the approximate range of strict, general and loose blood sugar control:
Usually we recommend that most patients: glycosylated hemoglobin <7%, To achieve this goal, the blood sugar before meals is generally controlled between 4.4-7.2mmol/l; Blood sugar <10.
For very young patients with long life expectancy, early stage kidney disease, few complications, and high health awareness: It is recommended that the glycosylated hemoglobin be within 6.5%. To achieve this goal, fasting and postprandial requirements will be stricter.
For elderly and frail patients with short life expectancy and multiple comorbidities: Recommended glycated hemoglobin within 8% To achieve this goal, fasting and postprandial requirements are more relaxed.
blood pressure
130/80mmHg is generally recommended. For some young patients with more proteinuria, blood pressure may be lower, such as within 125/80mmHg.
Lipids:
For patients who have not yet developed cardiovascular disease, it is recommended to control low-density lipoprotein cholesterol (LDL-C) below 2.6mmol/l
Patients who have already developed cardiovascular disease are recommended to have stricter control of low-density lipoprotein cholesterol (LDL-C): below 1.8mmol/l
Proteinuria
Normal if possible, or ACR less than 300mg/g, or 24-hour urine protein quantification less than 500mg/day
drug management
due to RAS blockers and SGLT2i has been provenIt can significantly delay the progression of diabetic nephropathy, as well as prevent and improve cardiovascular disease. If the patient has no contraindications (such as high potassium, dehydration, etc.), most patients with diabetic nephropathy are recommended to use these two drugs to control urinary protein and delay the decline of renal function.
(to learn more about these two drugs, click → SGLT2i, the arrival of the era of new drugs for diabetic nephropathy, lowering blood sugar and protein, protecting the heart and improving care Kidney!; RAS blocker, a “life-saving drug” to avoid uremia, we owe it a “thank you”!)
In terms of blood sugar, The first-line drug is metformin, and other antidiabetic drugs can be combined if necessary.
5.
Strategically defied
< strong>tactically focused
due to diabetic nephropathy There is usually no discomfort in the early stages, so it is not easy to be taken seriously.
Diabetes patients must pay attention to regular annual examinations of urine and kidney function, so as to detect the clues of kidney disease as soon as possible. During the period of massive proteinuria, the rate of progression of kidney disease will be significantly accelerated.
Frozen three feet, not a day’s cold. When there are no symptoms, let everyone manage the indicators well. Many people have insufficient awareness and lack of motivation, but once it becomes serious, they will regret it later, which will bring a huge burden to individuals, families and society.
For patients who have been found to have diabetes, don’t be discouraged, and cooperate with doctors to improve their lifestyles and use drugs rationally. Strive to control urine protein, blood pressure, blood lipids and other indicators within a safe range as soon as possible, maintain stable renal function and prevent cardiovascular disease! Come on
References:
Diabetic kidney disease: Manifestations, evaluation, and diagnosis.UTD
Treatment of diabetic kidney disease.UTD
Diabetic kidney disease: Manifestations, evaluation, and diagnosis.UTD
Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition). Chinese Journal of Diabetes
KDIGO 2020 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease