Diabetic nephropathy is one of the most important microvascular complications in China, which is increasing year by year. from 2009 to 2012, the number of diabetic nephropathy patients in China reached up to 30%-50% of the total number of patients in the community. Diabetic nephropathy starts insidiously and usually has no discomfort in the early stage. If it is not effectively controlled, once patients enter the stage of massive proteinuria, the disease can progress rapidly to the point of needing renal replacement therapy, and its kidney function can decline 14 times faster than other kidney lesions. There is a trend of gradual increase in the number of patients with chronic renal failure and need for hemodialysis due to diabetic nephropathy in China. In Beijing, for example, from 2009, diabetic nephropathy became the first cause of new patients entering hemodialysis, and its proportion can reach 24.4%, similar to that of western countries. Therefore, it is very important to prevent and delay the development of diabetic nephropathy to improve the quality of life and prognosis of diabetic patients. I. What is diabetic nephropathy? In 2014, the American Diabetes Association and the American Kidney Disease Foundation reached a consensus that diabetic nephropathy refers to chronic kidney disease caused by diabetes, mainly including glomerular filtration rate (GFR) below 60 ml/min/1.73 m2 or urinary albumin/creatinine ratio (ACR) above 30 mg/g for more than 3 months. Diabetic glomerulonephropathy refers specifically to glomerulopathy caused by diabetes mellitus as confirmed by renal biopsy. Identification of diabetic high-risk groups The prevention and treatment of diabetic nephropathy must start with the identification of diabetic high-risk groups. Diabetic high-risk groups include: 1, age ≥ 45 years; body mass index (BMI) ≥ 24; previous IGT (impaired glucose tolerance, i.e., between 7.8-11.1 mol/L after meals) or IFG (impaired fasting glucose, i.e., between 5.7-7.0 mol/L fasting glucose); or glycated hemoglobin HbAlc located between 5.7-6.5%. 2, with a family history of diabetes; 3, with reduced high-density lipoprotein cholesterol (HDL) (<0.93 mmol/L) and/or triglyceridemia (>2.2 mmol/L); 4, with hypertension (adult blood pressure ≥140/90 mmHg) and/or cardiovascular or cerebrovascular pathology; 5, pregnant women aged ≥30 years; with a history of gestational diabetes; having delivered a large infant (≥4kg); those with unexplained stalled labor; women with polycystic ovary syndrome; 6, those who do not participate in physical activity for years (e.g., sedentary people); 7, those who use some special medications, such as glucocorticoids, diuretics, etc. If you are at risk for any of the above it is recommended that you have regular diabetes screening. Once impaired glucose tolerance or impaired fasting glucose is found, you need to change your lifestyle and control your blood sugar to delay or avoid the occurrence of diabetes and diabetic nephropathy. Prevent diabetic nephropathy Patients who already have diabetes need to prevent diabetic nephropathy from occurring. First of all, you need to change your lifestyle. This includes adjusting diet, exercising reasonably, quitting alcohol, quitting smoking and controlling weight. The total daily calorie intake should be maintained close to the ideal weight (ideal weight = height – 105) (Kg). If the body type is fat, the calories can be reduced appropriately, and the thinner people can increase the calories appropriately to make their weight close to the ideal weight. Long-term exercise can improve insulin sensitivity, improve glucose tolerance, reduce body weight, improve lipid metabolism, improve endothelial function, control blood sugar and blood pressure, and slow down the development of diabetes and diabetic nephropathy. For simple diabetic patients in good condition, the frequency and intensity of exercise should meet certain requirements, which can be gradual from a short period of low intensity to at least 3 days per week with a total time of 150 minutes or more of moderate intensity aerobic exercise (heart rate of 50%-70% of the maximum value during exercise). Patients with other co-morbidities need to exercise as prescribed by their physicians. Smoking is a risk factor for proteinuria and kidney function progression in patients with diabetic nephropathy. Quitting or reducing smoking is an important way to prevent or control the progression of diabetic nephropathy in patients with diabetes. Blood glucose control is an important factor influencing whether nephropathy occurs in diabetic patients, and requires patients and endocrinologists to develop an appropriate glucose lowering program in public. Generally speaking, the goal of glycemic control is: glycosylated hemoglobin (HbAlc) does not exceed 7%. For middle-aged and elderly patients, the HbAlc control target should be relaxed to no more than 7%-9%. 4. Delay the progress of diabetic nephropathy In early diabetic nephropathy, the renal function is still normal, and the main goal is to reduce or delay the occurrence of large amounts of proteinuria. After the development of diabetic nephropathy, the amount of urine protein is closely related to the progression of nephropathy. In addition to lifestyle changes and good blood sugar control, studies have shown that angiotensin-converting enzyme inhibitors (ACEI)/angiotensin receptor antagonists (ARB) drugs can reduce the amount of urine protein and delay the progression of nephropathy (with or without hypertension). And the drugs are more effective in improving diabetic nephropathy and cardiovascular disease on a low-sodium diet, while they may be harmful on a high-sodium diet. Therefore, sodium intake should be limited to 2-2.5g per day (no more than 5g of sodium chloride). High protein intake (more than 20% of total calories) is associated with decreased renal function in diabetic patients. Therefore, patients with diabetic nephropathy should avoid a high protein diet and strictly control the daily protein intake to no more than 15% of total calories. microalbuminuria should be controlled at 0.8-1.0 g per kg of body weight. hypertension is also an important cause of aggravating kidney damage. if patients are combined with hypertension, they should be treated with antihypertensive drugs. the target of blood pressure control for patients with proteinuria is 130/80 mmHg. The treatment of advanced diabetic nephropathy is based on controlling blood glucose, controlling blood pressure, and reducing urinary protein. It also requires correction of lipid metabolism disorders, treatment of complications of renal insufficiency, and even dialysis treatment. Recent studies have proved that after controlling multiple risk factors (lowering glucose, lipids, blood pressure and paying attention to life interventions) the proportion of diabetic nephropathy progressing to renal failure decreases significantly and the survival rate increases significantly. At the same time continue a low protein diet, the amount of protein intake should be controlled to 0.6-0.8 g per kg body weight for those with overt proteinuria and renal impairment. as the protein intake is reduced, the quality should be high, and should be based on high quality protein with high biological potency, which can be obtained from poultry, fish, soy and high quality vegetable protein. For exercise, the aforementioned principles can still be followed. It should be noted that inappropriate exercise can induce ketosis due to insufficient insulin levels and hypoglycemia due to excessive energy consumption, thus the choice of exercise intensity, duration, frequency and program should be individualized, and it is recommended to develop a reasonable exercise program under the guidance of professionals. Blood sugar should still be controlled to meet the standard. For patients with combined renal insufficiency, whose red blood cell life span is shortened, glycosylated hemoglobin may be underestimated. For patients with renal function progressing to CKD stage 4 to 5, fructosamine or glycosylated serum albumin is more reliable to reflect the level of blood glucose control. In summary, prevention and treatment of diabetic nephropathy requires the use of an integrated approach and attention to all aspects of life. Establishing a reasonable and healthy lifestyle and cooperating with physicians to do a good job in lowering glucose and blood pressure can truly prevent and delay diabetic nephropathy.