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Diagnosis and treatment of diabetic kidney disease

2017-01-11 17:05

Diabetic kidney disease (DKD), as one of the microvascular complications of diabetes, is an important cause of disability and death in diabetes mellitus. With the incidence of diabetes increased year by year, the proportion of DKD in end stage renal disease has been increasing year by year, and the prevention and treatment of DKD is of great significance. Department of nephropathy, 

Diagnosis and staging of diabetic kidney disease

If there is a large number of diabetic patients with albuminuria, microalbuminuria and diabetic retinopathy, the course of more than 5~10 years should be considered DKD.

DKD staging

Phase I: renal volume increased, glomerular filtration rate increased (GFR = 150 ml/ (min.1.73m2)), no clinical symptoms.

Phase II: normal urinary albumin phase: rapid microalbuminuria ACR < 30 ug/gCr, GFR 130~150ml/ (min.1.73m2); blood pressure more normal.

III phase: early DKD:ACR 30~300 ug/gCr, GFR normal ml/ (min.1.73m2); mild blood pressure.

IV: DKD: advent of proteinuria, ACR, 300ug/gCr, urinary protein >0.5g/24h, GFR ~20ml/ (min.1.73m2); high blood pressure, edema, hyperlipidemia.

Stage V: advanced DKD:GFR<20 ml/ (min.1.73m2), uremia.

* the urine protein was negative in the first three cases of urine routine examination, and could only be detected by rapid microalbuminuria.

DKD differential diagnosis

Diabetes combined with proteinuria is not equal to DKD. In the following cases, attention should be paid to the differential diagnosis:

No retinopathy; GRF decreased rapidly; the sharp increase in proteinuria or nephrotic syndrome; the expression of urinary sediment, a red and white blood cells; the other accompanying diseases (such as autoimmune disease symptoms or signs); the angiotensin converting enzyme inhibitor (ACEI), angiotensin II receptor antagonist (ARB) after initial treatment, GRF decreased rapidly; the nephrotic syndrome lasted for a long time, but with normal renal function. These conditions suggest that diabetes may be associated with other kidney diseases, suggesting that renal biopsy to assist in the diagnosis.

Diabetic kidney disease treatment

After the occurrence of DKD in diabetic patients, the rate of progression to renal failure is 14 times faster than that of common kidney disease. Therefore, it is very important to prevent and delay the occurrence and development of DKD to improve the quality of life of patients.

DKD prevention and control in 3 stages:

1 DKD prevention, do a good job of diabetes screening, once found to have impaired glucose tolerance or high fasting blood glucose should be actively treated to prevent the occurrence of diabetes and diabetic nephropathy.

2 DKD early treatment, early microalbuminuria, after active treatment, some patients can be reversed, active intervention can reduce and delay the occurrence of massive proteinuria.

3 to prevent the occurrence and delay of DKD renal dysfunction.

The treatment of DKD emphasizes the comprehensive treatment of controlling blood glucose, blood pressure, correcting the disorder of lipid metabolism, reducing proteinuria, protecting renal function and actively treating complications.

(a) DKD general treatment

Limited salt can reduce renal damage and excretion load, help blood pressure control. Quitting smoking can reduce the risk of disease progression 30%. Weight loss, weight loss in overweight patients may help stabilize renal function and reduce proteinuria. Low protein diet is effective in delaying the progress of DKD, suggested daily protein intake in patients with diabetes mellitus proteinuria control in 0.6~0.8g/kg weight, and combined with a-ketoacid therapy can effectively reduce proteinuria (45.5% reduction). To carry out comprehensive education management, appropriate exercise and alcohol, etc..

(two) control of high blood sugar

Strict control of blood glucose, can make type 1 and type 2 diabetic patients with microalbuminuria incidence decreased by 39%, 33%, so as soon as possible to control blood sugar, glycosylated hemoglobin < 6.5%.

In the early stages of diabetes, especially type 2 diabetes, blood sugar can be controlled by diet and exercise. Oral hypoglycemic agents and / or insulin therapy are often required.

(three) control of blood pressure

Elevated blood pressure is not only an important factor to accelerate the progression of DKD, but also a major risk factor for the prognosis of patients with cardiovascular disease. The ideal blood pressure level of diabetic patients is 130/80mmHg, when the urine protein 1g/24h, blood pressure should be controlled below 125/75mmHg. Strict control of hypertension can significantly reduce proteinuria, delay the progress of renal damage. Systolic blood pressure in patients with 140mmHg, the rate of decline in renal function of 13.5% per year, while systolic blood pressure of 140mmHg, the rate of decline in renal function was 1%.

Angiotensin converting enzyme inhibitor (ACEI), angiotensin II receptor antagonist (ARB) (CCB), calcium channel blockers, thiazide diuretics and beta blockers are recommended as first-line antihypertensive drugs. However, ACEI and ARB are the first choice in the control of hypertension, reduce proteinuria and delay the progress of renal function.

(four) correct lipid metabolism disorder

Hyperlipidemia is not only directly involved in insulin resistance and cardiovascular complications, low density lipoprotein cholesterol (LDL) can also aggravate the development of proteinuria and renal fibrosis. When DKD patients with nephrotic syndrome and renal insufficiency, and will progress to increase hyperlipidemia. LDL (130mg/dl), 3.38mmol/L three (TG) and 2.26mmol/L (200mg/dl) in patients with diabetes mellitus should be treated with lipid-lowering therapy. The treatment goal is LDL < 2.6mmol/L, TG < 1.7mmol/L (200mg/dl)).

(five) control of proteinuria

Proteinuria is a manifestation of DKD, but also a sign of worsening renal function and cardiovascular events. Patients with normal blood pressure and proteinuria or microalbuminuria should be treated with ACEI and ARB.

(six) renal replacement therapy

DKD patients with renal dysfunction, often accompanied by more serious complications, such as coronary heart disease, cerebrovascular and peripheral vascular disease, so the beginning of renal replacement therapy than non DKD early. Decreased glomerular filtration rate (GRF) is recommended

 

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