Diabetic nephropathy (DN) is the most common chronic microvascular complication of diabetes mellitus and also one of the leading causes of death in diabetic patients. To date, there is no specific treatment for diabetic nephropathy, and clinical emphasis is still placed on early intervention and comprehensive treatment, with specific means including.
1.Restrict protein intake
Excessive protein intake will increase the metabolites of protein in the blood (such as creatinine, urea nitrogen, etc.), increasing the burden on the patient’s kidneys, so patients with diabetic nephropathy should have a low-protein diet, and high-quality animal protein (such as eggs, dairy, lean meat, fish, etc.) is the main (accounting for
2/3), in order to ensure the supply of essential amino acids.
The specific plan is: when the kidney function is normal, the daily protein intake is 0.8~1.0 g/kg body weight; when the creatinine clearance rate decreases and the kidney function decreases, the protein restriction is more strict, and the daily protein intake is controlled at
When the creatinine clearance decreases and the renal function decreases, the daily protein intake should be limited to 0.6 g/kg, and the compound a-keto acid (trade name: Kai Tong) should be taken at the same time. Note: When on a low-protein diet, make sure to have enough calories (daily calories up to
30~35kal/kg) to avoid the increase in the decomposition of own protein and fat, which will aggravate the kidney burden and lead to malnutrition.
2. Strictly control blood sugar
The American Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) show that both type 2 diabetes and type 1 diabetes have good glycemic control.
Good glycemic control can reduce the occurrence and development of diabetic microvascular complications, reduce the incidence of type 1 diabetic nephropathy by half, reduce the incidence of type 2 diabetic nephropathy by
It also reduces the incidence of type 2 diabetic nephropathy by 1/3 and significantly reduces microalbuminuria.
The ideal target values for blood glucose control are: fasting blood glucose below 6.1 mmol/L, 2-hour postprandial blood glucose below 8.0 mmol/L, and glycated hemoglobin below 6.5%.
Patients with early diabetic nephropathy can use Glucophage or Novaluron, which are mainly metabolized in the liver and 95% of the metabolites are excreted from the feces through the bile, and less than 5% are excreted through the kidney.
Therefore, it will not increase the burden on the kidney and has less impact on the kidney. In addition, α-glucosidase inhibitors are almost not absorbed into the blood by the intestine, so they have little effect on the kidney and can be used.
For diabetic patients whose oral hypoglycemic drugs have failed or who have developed renal insufficiency, all oral hypoglycemic drugs should be stopped and insulin should be used to control blood sugar.
3.Strictly control blood pressure
Hypertension is an important risk factor for diabetic nephropathy. A large number of studies have proved that: strict control of blood pressure can reduce albumin excretion, delaying the deterioration of renal function. Therefore, the blood pressure control requirements for diabetic patients are more stringent than the general population. For ordinary diabetic patients, blood pressure should be controlled at
For ordinary diabetic patients, blood pressure should be controlled below 130/85 mmHg; for diabetic nephropathy patients with microalbuminuria, blood pressure should be controlled below 120/80 mmHg.
The preferred antihypertensive drugs for diabetic patients are angiotensin-converting enzyme inhibitors (ACEl, such as Lortin, etc.) or angiotensin II receptor antagonists (ARB, such as Dextran, etc.).
can not only reduce hypertension, but also have renoprotective effects, which can lower intracapillary glomerular pressure, reduce albumin excretion and delay the progression of diabetic nephropathy. However, care should be taken to check renal function and blood potassium regularly during the drug administration. When renal insufficiency, blood creatinine is greater than
3 mg/dL (or 265 mmol/L) should not be used.
When the patient’s blood pressure is high, a combination of ACEI (or ARB) and calcium antagonist (such as Bexin, Loxodone, etc.) can be used, and a low-dose diuretic can be added if the treatment is not effective.
It should be emphasized that patients with hypertension should be advised to eat a low-salt diet (3-6 grams of salt/day, especially in the presence of nephrotic syndrome), quit smoking, exercise appropriately, and control their body weight. Especially for obese type 2
Type 2 diabetes, even a mild weight loss is also very beneficial for blood pressure control.
4. Strict control of blood lipids
Diabetic patients are often combined with disorders of lipid metabolism, which can trigger cardiovascular disease and aggravate kidney damage, so active treatment is required. The goal of lipid control is: total cholesterol (TC) <4.5
mmol/L, low-density lipoprotein-cholesterol (LDL-C) <2.6 mmol/L, high-density lipoprotein-cholesterol (HDL-C) >1.1
mmol/L, and triglycerides (TG) <1.5 mmol/L, of which total cholesterol and LDL-C are the most important. Lipid-regulating therapy includes dietary and pharmacological treatment. In terms of diet, foods rich in cholesterol and saturated fatty acids (e.g. egg yolk, animal fat, etc.) should be consumed sparingly. In terms of drug selection, statins (such as simvastatin, pravastatin, fluvastatin, etc.) are preferred if the increase in serum cholesterol is the main cause; if the increase in serum triglycerides is the main cause, fibrates (such as fenofibrate, etc.) are preferred.
5.Improve microcirculation
Diabetic patients often have high blood viscosity, there are microcirculatory disorders, affecting kidney function. For this situation, the clinical use of prostaglandin, Yi Kai (pancreatic kinase release enzyme) and other drugs.
6.Supplementation of erythropoietin
The kidney is not only an excretory organ, but also an important endocrine organ that can secrete a variety of hormones including erythropoietin. When patients with diabetic nephropathy progress to the stage of renal insufficiency, they may have different degrees of anemia, at this time, they can be given subcutaneous injection of erythropoietin and supplemented with iron and folic acid.
7.Application of gastrointestinal adsorbent
When diabetic nephropathy patients have renal insufficiency, patients can be given oral gastrointestinal adsorbent, such as packaged aldehyde oxidized starch 5-10 grams, 3 times/day.
8.Control urinary tract infection
Recurrent infections will accelerate the deterioration of diabetic nephropathy, therefore, once there is evidence of infection, active anti-infection treatment should be given.
9.Avoid the factors of kidney damage
Try not to use drugs that are damaging to the kidney, such as aminoglycoside antibiotics (streptomycin, gentamicin, etc.); minimize the use of various contrast agents, such as intravenous pyelogram. Patients should be hydrated as early as possible when they are dehydrated for various reasons.
10.Dialysis and transplantation treatment
If the diabetic nephropathy progresses to the stage of chronic renal failure, if the serum creatinine reaches 530 mmol/L (6 mg/dL) and the creatinine clearance rate is less than 15-20
mL/min, dialysis treatment should be started.
Patients with diabetic nephropathy should start dialysis earlier than chronic renal failure of other etiologies, because if dialysis is too late, other organ complications of diabetes (especially cardiovascular and cerebrovascular complications and fundus bleeding) may have occurred, and the patient’s quality of life and survival rate will be affected.
The advantages of hemodialysis are good dialysis effect, easy removal of body water, no protein loss, and not easy infection; the disadvantages are high failure rate of arteriovenous fistula due to diabetic arteriosclerosis, easy application of heparin anticoagulation leading to retinal hemorrhage and vision loss, obvious fluctuation of blood pressure before and after dialysis, and rapid decrease of blood osmolarity during dialysis which can The blood pressure fluctuates significantly before and after dialysis, and the rapid decrease in blood osmolarity during dialysis can lead to “dialysis imbalance” (acute cerebral edema in uremic patients due to dialysis treatment resulting in increased intracranial pressure and corresponding clinical symptoms), and the cost of dialysis is relatively high.
The advantages of peritoneal dialysis are that it is easy to perform, it can be done at home, and the cost of dialysis is low; the disadvantages are that the effect of dialysis is reduced due to the sclerosis of the diabetic peritoneal vessels and the small dialysis area, and the daily loss of protein with peritoneal dialysis is about 10
For patients with end-stage diabetic nephropathy, kidney transplantation or combined kidney-pancreas transplantation can be the most effective treatment method. However, kidney transplantation cannot fundamentally solve the main factors causing diabetic nephropathy, diabetes still exists, so the effect of kidney transplantation in diabetic patients is not as good as that in non-diabetic patients. In order to reduce the impact of diabetic complications on patients and kidney transplantation, early kidney transplantation is advocated.
Finally, once diabetic nephropathy is detected, most of it is not early, and treatment can only play the role of delaying the progress of the disease, which is difficult to completely cure. Therefore, the best approach is prevention.