Diabetic kidney disease (DKD) patient When the kidneys choose hypoglycemic drugs, they should not only consider how to effectively lower blood sugar, but also pay attention to the protection of the kidneys. Therefore, DKD patients need to be more cautious in the choice of hypoglycemic drugs to avoid increasing the burden on the kidneys. Professor Wang Cheng from the Fifth Affiliated Hospital of Sun Yat-Sen University Focused on the comprehensive management of DKD patients to help more DKD patients effectively lower blood sugar, Safe kidney protection.
Professor Wang Cheng
Written by Wang Cheng, The Fifth Affiliated Hospital of Sun Yat-sen University< /strong>
November 14 is the United Nations Diabetes Day. By 2021, the number of adults with diabetes in the world has reached 537 million, The number of diabetic patients in China has exceeded 120 million, and 20% to 40% of diabetic patients have DKD.
DKD is the most common chronic Microvascular complications, which are also one of the leading causes of death in patients with diabetes, have become the leading cause of end-stage renal disease.
DKD is a chronic kidney disease caused by diabetes, mainly manifested as urinary albumin/creatinine ratio ≥30 mg/g and/or estimated glomerular filtration rate (eGFR) <60 ml/(min·1.73 m²) for more than 3 months, while excluding other chronic kidney diseases.
Pathological examination of kidney biopsy is an important basis for diagnosis, When the etiology is difficult to identify, pathological examination of renal biopsy is possible.
Recommended course of disease< strong>Patients with type 1 diabetes for more than 5 years and patients with type 2 diabetes at the time of diagnosis should perform urine albumin/creatinine ratio detection and eGFR evaluation to detect DKD early.
At least 1 yearly thereafter Second-rate.
DKD should be diagnosed immediatelyeGFR staging and urine albumin grading.
KDIGO recommends combining chronic kidney disease staging and albuminuria stage to assess the risk of DKD progression and frequency of reexamination.
The treatment of DKD is integrated comprehensive management Through the comprehensive management of DKD patients, including adverse lifestyle adjustments, risk factors (hyperglycemia, hypertension, lipid metabolism disorders, etc.) control, and diabetes education, the risk of renal adverse events and death in diabetic patients can be reduced.
Change bad lifestyle
Such as reasonable weight control, diabetes diet, smoking cessation and proper exercise. It is recommended that patients perform 5 times a week, 30 minutes of exercise that matches the cardiopulmonary function.
Excessive protein intake will increase protein metabolites (creatinine, urea nitrogen, etc.) in the blood, increase the burden on the patient’s kidneys, and increase urinary protein excretion. High-quality animal protein (milk, eggs, lean meat, fish, etc.) Protein (higher in “non-essential amino acids”).
For DKD patients who have not started dialysis, protein intake is recommended The dosage is 0.8 g/(kg·d), when the creatinine clearance rate decreases and the renal function declines, the protein restriction is more stringent, and the daily protein intake is controlled at 0.6 g/kg .
Dialysis patients can appropriately increase to 1.0~1.2 g/(kg·d).
The protein source should be mainly high-quality animal protein, and compound α-keto acid preparations can be supplemented if necessary. When carrying out low-protein diet treatment, it is necessary to ensure that there are enough calories (30-35 kal/kg per day), in order to Avoid increasing the decomposition of your own protein and fat, which will increase the burden on the kidneys and cause malnutrition.
In addition, DKD patients also need< strong>Low-salt diet (salt 3-6 g/d), especially when accompanied by nephrotic syndrome, for patients with hyperkalemia, it is necessary to limit Potassium intake.
Control blood sugar
Reasonable hypoglycemic therapy is recommended for all DKD patients. Long-term hyperglycemia is an important factor leading to microvascular damage in diabetes. When formulating blood glucose control goals for DKD patients, individualized control goals should be formulated according to age, duration of diabetes, life expectancy, comorbidities, complications, risk of hypoglycemia, etc.
The ideal blood sugar control target value is:The fasting blood glucose is lower than 6.1 mmol/L, the 2-hour postprandial blood glucose is lower than 8.0 mmol/L, and the glycosylated hemoglobin is lower than 6.5%. Elderly patients can relax the control standard appropriately.
Patients with renal insufficiency can preferentially choose hypoglycemic drugs that are less excreted from the kidneys, and patients with severe renal insufficiency should be treated with insulin.
Control blood pressure
< p>Reasonable antihypertensive treatment can delayDKDOccurrence and progression. Elevated blood pressure is not only an important factor for the occurrence and development of DKD, but also a major risk factor for the prognosis of patients with cardiovascular disease.
For patients with DKD, especially albuminuria, blood pressure It should be controlled below 130/80 mmHg, but the diastolic blood pressure should not be lower than 70 mmHg, and the diastolic blood pressure of elderly patients should not be lower than 60 mmHg.
Angiotensin-converting enzyme inhibition is the preferred antihypertensive drug for diabetic patients ACEI or angiotensin Ⅱ receptor antagonist (ARB), the dosage can be twice the usual antihypertensive dosage.
ACEI/ARB can not only reduce high blood pressure, but also protect the kidneys It can reduce the pressure in glomerular capillaries, reduce albumin excretion, and delay the progress of DKD. However, attention should be paid to regular checks of renal function and serum potassium during medication.
When renal insufficiency, serum creatinine is greater than 3 mg/dl (or 265 μmol/L ) cannot be used. ACEI/ARB are contraindicated in patients with bilateral renal artery stenosis.
When the patient’s blood pressure is high, it is often necessary to take combined medication, such as ACEI/ARB and Long-acting calcium ion antagonists such as nifedipine controlled-release tablets are used in combination, and small doses of diuretics (hydrochlorothiazide, spironolactone, etc.) can also be added when the curative effect is not good.
The primary goal is to reduce low-density lipoprotein cholesterol (LDL-C), and LDL-C should be reduced to the target value according to the risk of atherosclerotic cardiovascular disease in patients. Statin lipid-lowering drugs are the first choice for the treatment plan, and moderate-intensity statins should be used at the beginning, and the dose should be adjusted appropriately according to the individual lipid-lowering efficacy and tolerance.
The recommended goal of blood lipid therapy for DKD patients is: LDL-C in very high-risk patients with a history of atherosclerotic cardiovascular disease or eGFR<60 ml/(min·1.73 m²) The level is less than 1.8 mmol/L, and it should be less than 2.6 mmol/L in other patients.
Factors to avoid kidney damage
Infections, especially urinary tract infections, can accelerate the progression of DKD. Therefore, Once there is evidence of infection, active anti-infective treatment should be given. Try to avoid the use of drugs that are harmful to the kidneys, such as aminoglycoside antibiotics (streptomycin, gentamicin, etc.), antipyretic and analgesic drugs, and minimize the use of various contrast agents, such as intravenous pyelography. Patients should be rehydrated as soon as possible when they are dehydrated for various reasons.
［1］Chinese Medical Association Diabetes Branch, Guidelines for the Prevention and Treatment of Type 2 Diabetes in China (2020 Edition)[J].Chinese Journal of Diabetes, 2021,13(4):315-409. span>
［2］2021 “Guidelines for Prevention and Treatment of Diabetic Kidney Disease in China”, Chinese Journal of Diabetes, 2021,13(8): 762-784.
［3］American Diabetes Association. Standards of Medical Care in Diabetes2022［J］． Diabetes Care, 2022, 45 (Suppl 1): S1-S264