Diabetic nephropathy (DN) is one of the microvascular complications of diabetes mellitus, also known as diabetic glomerulosclerosis, and is a renal complication specific to diabetes mellitus. Western medicine believes that the occurrence of this disease is related to abnormal glucose metabolism due to chronic hyperglycemia, renal hemodynamic changes, lipid metabolism disorders, vasoactive factors, growth factors and cytokines, oxidative stress, genetics and other factors, and its basic pathological changes are glomerular thylakoid stromal hyperplasia, glomerular capillary basement membrane (GBM) thickening and glomerulosclerosis. the prevalence of DN is 20% to 40%, and currently, the The prevalence of DN is 20% to 40%, and currently, DN has become the primary pathogenic factor leading to end-stage renal disease (ESRD). early stage of DN, the progression of the disease can be effectively stopped by strict control of blood glucose and blood pressure. Once the clinical stage of DN occurs, the kidney function will continue to decline until end-stage renal failure develops. The disease belongs to the categories of “edema”, “deficiency labor” and “guangs” in Chinese medicine.
Etiology and pathogenesis
1. The pathogenesis of DN is due to deficiency of the kidney, prolonged diabetes mellitus, depletion of qi and injury to yin, damage to the five viscera, as well as phlegm, heat, depression and stasis. At the beginning of the disease, there is a deficiency of both qi and yin, and gradually there is a deficiency of liver and kidney yin.
As the disease progresses, the symptoms include cloudy urine, frequent nocturia, edema of the lower limbs, face and even the whole body, and finally oliguria or anuria, nausea and vomiting, palpitation and shortness of breath, chest tightness and inability to lie down. The evolution of the disease mechanism and symptom characteristics are divided into three stages.
At the beginning of the disease, there is a deficiency of both qi and yin, and gradually there is a deficiency of yin in the liver and kidney, stagnation of the kidney channels, and leakage of essence. The kidney is the master of water and the division of opening and closing. With diabetes, the kidney yin is deficient and the yin loses qi, resulting in deficiency of kidney qi, lack of power to consolidate, and loss of opening and closing, resulting in frequent urination and puffiness if there is more opening and less closing, and less urination if there is less opening and more closing; or deficiency of liver and kidney yin, resulting in dryness of the eyes and blurred vision if the essence and blood cannot be carried up to the eyes.
In the progressive stage of disease, the spleen and kidney yang deficiency, water and dampness retention, overflowing skin, then face and feet edema, and even chest water, ascites; Yang deficiency can not warm the four ends, then fear of cold limbs cold.
In the late stage of the disease, the kidney body is exhausted, the kidney is not used, the toxins are stopped inside, the five organs are damaged, and the qi, blood, yin and yang are decayed. When the kidney yang declines, water-dampness floods and turbid toxin stops inside the body, the upper and lower levels of the body will be rejected and the evidence of change will rise. If the turbid toxin floods upward, the stomach loses harmony and descends, then nausea and vomiting, loss of appetite; if water drink overtakes the heart and shoots the lungs, then palpitations and shortness of breath, chest tightness and panting, and inability to lie down; if drowning toxin takes over the brain, then confusion and unconsciousness, or even coma; if the kidney element fails, turbid evil congests the three jiao, and the kidney gate is not opened, then little or no urine, and vomiting and vomiting, which leads to the blockage.
The disease is located in the kidney and can involve the five viscera and six internal organs; the disease is characterized by deficiency of the liver, spleen and kidneys, and deficiency of qi, blood, yin and yang in the five viscera; the symptoms are characterized by qi stagnation, blood stasis, phlegm, turbidity and toxicity, and dampness and heat.
Diagnosis
Clinical manifestations
In addition to the symptoms of diabetes mellitus, the early stage of the disease generally lacks the typical symptoms of kidney damage; in the clinical stage, patients with nephropathy may show symptoms such as edema, lumbago, weakness, dizziness and tinnitus; patients with nephrotic syndrome may be accompanied by high edema; patients with azotemia of renal insufficiency may show poor appetite, or even nausea and vomiting, or twitching of hands and feet; combined with heart failure may show chest tightness, breath-holding, or even wheezing and inability to lie down.
2. Signs There are no obvious signs in the early stage, and then blood pressure may gradually increase, or the face may become white, claw nail color, swelling of the limbs, thoracic fluid, ascites, etc.
Physical and chemical examination
Urine examination
Urine microalbumin Patients with early stage nephropathy show an increased urinary albumin excretion rate (UAER) of 20-200 μg/min.
24-hour urine protein quantification Early DN urine protein quantification <0.5g/d; clinical DN, urine protein quantification >0.5g/d.
Urine routine No obvious urine protein abnormality in early DN, intermittent proteinuria may occur later, and persistent proteinuria may be obvious in clinical stage.
Peripheral blood examination DN renal insufficiency may show decreased hemoglobin.
Blood biochemical examination Renal insufficiency can be seen in clinical DN and late DN stage, with elevated blood muscle sound and urea nitrogen.
Diagnosis
Staging criteria
The diagnosis of DN should be based on the history of diabetes mellitus, clinical manifestations, physical, chemical and pathological examinations, and renal function.
1.Early DN A history of diabetes mellitus (often more than 6-10 years) with persistent microalbuminuria (UAER of 20-200μg/min or 30-300mg/d) should be diagnosed as early DN.
2, Clinical DN A longer history of diabetes mellitus, positive urine protein, or even a large amount of proteinuria and nephrotic syndrome, should be considered clinical DN.
3.Diagnosis of DN needs to exclude other renal diseases and perform kidney pathology puncture if necessary. Histopathological examination can confirm the diagnosis if there is no obvious cell proliferation in the glomerulus, only diffuse widening of the thylakoid stroma and extensive thickening of the GBM (early stage requires electron microscopic pathological confirmation), especially when Kimmelstiel-Wilson nodules are present.
Staging criteria (see Appendix A)
Differential diagnosis DN has both diabetic and nephrotic manifestations, and the diagnosis is often clear when combined with laboratory and pathological examinations. Other renal diseases should be excluded before DN is diagnosed, and renal puncture pathology should be performed if necessary.
Membranoproliferative nephritis and membranous nephropathy Coexisting with diabetes mellitus in about 20% of cases, further renal tissue biopsy should be performed to differentiate when the following conditions are present: proteinuria in TlDM patients in the early stage (within 6 years); persistent proteinuria without retinopathy; rapid deterioration of renal function; microscopic hematuria with red blood cell tubular pattern.
Functional proteinuria Strenuous exercise, fever, primary hypertension, cardiac insufficiency, etc. can cause an increase in urinary protein, which can be diagnosed by detailed medical history, clinical manifestations and laboratory tests.
Treatment
Patients with DN should be given a high-quality, low-protein, vitamin-rich diet, and intake of vegetable proteins such as legumes should be limited. Patients with edema and hypertension should limit the intake of sodium. According to the patient’s condition, Chinese medicine diet should be given to balance yin and yang, regulate the internal organs, and help to eliminate evil. For example, for kidney yang deficiency, leek, dog meat, lamb bone, shrimp, cinnamon and other foods are recommended; for kidney yin deficiency, Chinese wolfberry, mulberry, turtle meat, wood ear, silver ear and other foods are recommended; for spleen deficiency, lentils, coix seeds, yam, lotus seeds and so on; for bladder dampness and heat, amaranth, fishy grass, mung beans, adzuki beans and so on are recommended. In addition, the patient can also choose food therapy formulas according to the patient’s condition, such as astragalus yam porridge (astragalus, yam) for spleen and kidney deficiency; coix seed porridge (coix seed, japonica rice) or astragalus winter melon soup (astragalus, winter melon) for edema. The early stage of the disease can be used taijiquan, five birds play, eight duanjin, crane pile, strong gong and other traditional exercise gong, moderate activity, should not be strenuous exercise; DN kidney failure should be bed rest, the amount of activity should not be too much, do not overwork, can be used qigong within the gong and other static gong method. In order to balance the body’s yin and yang, harmonize the qi and blood, smooth the meridians for the purpose of the recovery of the disease body has a certain auxiliary effect.
The basic characteristics of the disease are: deficiency of Qi (spleen qi deficiency, kidney qi deficiency) and Yin (liver and kidney yin deficiency); deficiency of phlegm, heat, stagnation and stasis; the internal organs involved are mainly the kidney, liver and spleen; the disease lasts for a long time, and there are many different evidence.
Main evidence
Symptoms of Qi-Yin deficiency: cloudy urine, fatigue, shortness of breath, lazy speech, dry throat and mouth, dizziness and dreaminess, or frequent urination, heat in the hands and feet, palpitations, thin tongue, red or light red texture, little coating and dryness, sunken and weak pulse. ‘ Treatment: Benefit Qi and nourish Yin. Formula: Ginseng and Astragalus Dihuang Tang (Shen’s Zun Sheng Shu) plus or minus. Radix et Rhizoma Ginseng, Radix Astragali, Fu Ling, Di Huang, Yam, Cornus Officinalis, Dampi, Ze Di
Liver and kidney yin deficiency symptoms: cloudy urine, dizziness and tinnitus, irritability of the five hearts, soreness of the waist and knees, dryness of the eyes, short urine, red tongue with little coating, thin pulse. Treatment: Nourishing the liver and kidney. Remedy: Qiju Dihuang Wan (Medical grade) plus or minus. Fructus Lycii Chrysanthemum Radix Rehmanniae Rhizoma Cornu Cervi Pantotrichum Fu Ling Ze Di Dan Pi
Qi and blood deficiency symptoms: urinary turbidity, fatigue, shortness of breath and lazy speech, pale or yellowish face, dizziness, pale lips and nails, palpitations and insomnia, soreness of the waist and knees, weak tongue and pulse. Treatment: Tonifying Qi and nourishing Blood. Prescription: Angelica Sinensis Tonic Blood Soup (“Secret Collection of the Orchid Room”) combined with Jisheng Kidney Qi Pill (“Jisheng Formula”) plus or minus. Radix Astragali, Radix Angelicae Sinensis, Radix Cinnamomum Cassiae, Radix Rehmanniae Sinensis, Cornu Cervi Pantotrichum, Poria, Dampi, Zedoary
Spleen and kidney Yang deficiency symptoms: cloudy urine, fatigue and cold, soreness and coldness of the waist and knees, swelling of the extremities, especially the lower extremities, white face, clear and long urine or short urine, increased nocturnal urination, or diarrhea on the fifth night, light tongue and fat body with teeth marks, sunken and weak pulse. Treatment: Warming the kidney and strengthening the spleen. Radix et Rhizoma Pseudostellariae Rizhong Pill (Taiping Huimin Hodong Bureau Formula) combined with Zhenwu Tang (Treatise on Typhoid) plus or minus. Radix et Rhizoma Pseudoginseng, Radix Codonopsis Pilosulae, Poria, Radix Paeoniae Alba, Radix Glycyrrhiza Uralensis, in the main evidence, add Radix Bacopa Monnieri, Epimedium; add Fire Mamaku, Cistanches; add Nutmeg, Boneset.
Concurrent evidence
Symptoms: dizziness and headache, bitterness in the mouth and dizziness in the eyes, and strong and stringent pulse. Treatment: Calming the liver and quenching the wind. Prescription: Calming the liver and quenching the wind (Medicine Zhong Zhong Ginseng Xi Lu).
Blood stasis Symptoms: dark tongue, tortuous veins under the tongue, stasis spots and petechiae, sunken and stringent pulse. Treatment: Promote blood circulation and resolve blood stasis. Remedies: In addition to the main formula, it is advisable to add peach kernel, safflower, angelica, Chuanxiong and salvia.
Symptoms of damp-heat in the bladder: both frequent urination, urgency, burning, astringent pain, yellowish coating on the tongue and slippery pulse. Treatment: Clearing heat and relieving dampness. Remedies: Bazheng San plus or minus (Taiping Huimin He Ping Bureau Formula); recurrent episodes and delayed healing, incomparable Shan Yao Wan plus or minus (Taiping Huimin He Ping Bureau Formula); hematuria combined with Xiao Thistle Drink (Ji Sheng Formula).
Change of evidence
Symptoms: frequent nausea and vomiting, dizziness, edema around the body, or inability to urinate, pale and dark tongue, white and greasy coating, sunken and stringent or smooth pulse. Treatment: Lowering rebellion and resolving turbidity. Radix et Rhizoma Polygonatum (Treatise on Typhoid Fever) plus and minus. Radix et Rhizoma Ochraceae, Glycyrrhiza glabra, Radix et Rhizoma Ginger, Jujube, plus or minus: add Cornus officinalis, Huang Lian, if vomiting is severe.
Symptoms of drowning poison into the brain: confusion, dull gaze, or even coma, or sudden convulsions, epistaxis, epistaxis, pale purple tongue with teeth marks, white thick and greasy moss, sunken and slippery pulse. Treatment: Enlighten the body and awaken the mind, subdue the fright and extinguish the wind. Prescription: calamus and yujin soup (“Complete Book of Warm Diseases”) send An Gong Niuhuang Wan (“Article of Warm Diseases”) plus or minus. Add and subtract calamus and yujin fried gardenia and forsythia fresh bamboo leaves and bamboo leaves and lanterns chrysanthemum and dandan bark: add whole scorpion and centipede for convulsions of the limbs; add raw earth yellow and rhinoceros horn powder (buffalo horn powder substitute) for turbid poisonous injury to blood leading to epistaxis, epistaxis, epistaxis, etc.
Symptoms: inability to lie down with shortness of breath, cold fear and cold limbs, profuse sweating, palpitations and palpitations, swelling of the limbs, especially the lower limbs, coughing and vomiting of thin white sputum, light fat tongue, white slippery coating, sluggish and weak pulse or thin and short without root or knotted generation. Treatment: Warming the Yang and inducing diuresis, dipping the lung and calming asthma. Formula: Scape Drabble and Jujube Diarrhea Lung Soup (Jin Kui Yao) combined with Ling Gui Zhu Gan Tang (Jin Kui Yao) plus and minus. Add and subtract Draba Dajiao Fu Ling Gui Zhi Bai Zhu Licorice and Radix et Rhizoma Ginger: If the swelling is very swollen, add Five Peel Drink (Hua Shi Zhong Zang Jing); if the extremities are cold and sweating profusely, reuse Light Pill and add Ginseng.
Other treatments
Chinese patent medicine Sheng Wei Wei Wei Drink, used for Qi and Yin deficiency, palpitation and shortness of breath, weak pulse and spontaneous sweating, etc. Radix et Rhizoma Polygoni, used for deficiency of spleen and stomach, cold pain in the abdomen, vomiting and diarrhea. Jisheng Kidney Qi Pill, used for kidney deficiency and edema due to deficiency of kidney yang and internal stagnation of water-dampness, soreness and heaviness of the waist and knees, etc.
Chinese medicine reserved enema DN late stage of spleen and kidney failure, retention of turbid toxins, upward violation of the spleen and stomach, serious gastrointestinal symptoms, can be treated with Chinese medicine enema. For example, raw rhubarb, light slices of spleen, salvia, dandelion, calcined oyster, etc., decocted in water and concentrated to 100-200 ml, retaining enema in high position, 1 to 2 times a day, applicable to the actual evidence of Guange.
Acupuncture DN patients performing acupuncture treatment should be strictly sterilized, and it is advisable to prohibit acupuncture with caution.
Qi and Yin deficiency: Kidney Yu, Spleen Yu, Foot Sanli, Sanyinjiao, Zhimou, Taixi, Fuyao, Qubone, acupuncture with the tonic method, and between lines with the laxative method.
Liver and kidney yin deficiency: Liver Yu, Kidney Yu, Qi Men, Wei Zhong, acupuncture with tonic method.
Yin and Yang deficiency: Spleen Yu, Kidney Yu, Life Gate, Sanyinjiao, Qihai, Guan Yuan, acupuncture with tonic method.
Spleen and kidney yang deficiency: Spleen Yu, Kidney Yu, Life Gate, Sanyinjiao, Feet Three Miles, Tai Xi, Zhongji, Guan Yuan, acupuncture with tonic method.
Principles of Western medicine treatment
Control of blood glucose The patient’s blood glucose level must be strictly controlled to effectively prevent the occurrence and progression of DN.
Control blood pressure Using pharmacological and non-pharmacological therapies, blood pressure should be controlled below 130/80 mmHg.
Restrict protein intake It is advisable to give a high quality low protein diet. Appropriate restriction of protein intake [0.8g/(kg?d)] can reduce the early increased glomerular filtration rate (GFR); clinical stage: patients with DN, GFR starts to decline and needs to be more strictly controlled [0.6g/(kg/d)] to slow down and control the progression of the disease.
Renal replacement therapy in end-stage renal failure hemodialysis, abdominal dialysis, kidney or combined pancreas-kidney transplantation. Control of blood glucose Patients’ blood glucose levels must be strictly controlled to effectively prevent the onset and progression of DN.
Blood pressure control Using pharmacological and non-pharmacological therapies, blood pressure should be controlled below 130/80 mmHg.
Restrict protein intake It is advisable to give a high quality low protein diet. Appropriate restriction of protein intake [0.8g/(kg?d)] can reduce the early increased glomerular filtration rate (GFR); clinical stage: patients with DN, GFR starts to decline and needs to be more strictly controlled [0.6g/(kg/d)] to slow down and control the progression of the disease.
Renal replacement therapy in end-stage renal failure hemodialysis, abdominal dialysis, kidney or combined pancreas-kidney transplantation.