Expert Consensus on the Diagnosis and Management of Diabetic Kidney Disease
Diabetic kidney disease (DKD) has emerged as a significant public health concern in China, driven by the rapid economic growth and lifestyle changes that have led to an increasing prevalence of diabetes. The lack of standardized processes for the prevention and management of DKD prompted the Peking University Health Science Center to organize a group of experts in nephrology and endocrinology to develop a Chinese consensus statement on DKD. This consensus emphasizes evidence-based approaches and focuses on three key areas: risk factors for the incidence and progression of DKD, the diagnosis of DKD and indications for renal biopsy, and the overall management of DKD.
Risk Factors for the Incidence and Progression of DKD
The development and progression of DKD are influenced by a complex interplay of genetic, epigenetic, and environmental factors. Major modifiable risk factors include hyperglycemia, hypertension, dyslipidemia, and obesity. These factors are critical in both the onset and progression of DKD. Proteinuria and a decline in glomerular filtration rate (GFR) are also important predictors for the incidence and progression of DKD. Additionally, unhealthy dietary patterns and lifestyle choices contribute to the progression of the disease.
Diagnosis of DKD and Indications for Renal Biopsy
The diagnosis of DKD is typically made in patients with type 1 diabetes (T1D) or type 2 diabetes (T2D) who exhibit moderate albuminuria (urinary albumin creatinine ratio [UACR] 30–300 mg/g) or massive albuminuria (UACR ≥300 mg/g), or a reduction in estimated GFR (<60 mL/min/1.73 m²), along with the presence of diabetic retinopathy and the exclusion of other causes of chronic kidney disease (CKD). Renal biopsy is indicated in cases where urinary sediment shows active hematuria, sudden edema, massive proteinuria, or a rapid decline in renal function, especially in the absence of retinopathy. This helps to rule out non-diabetic renal disease (NDRD) or DKD with concomitant NDRD.
Management of DKD
The management of DKD involves a comprehensive approach that includes controlling risk factors such as hypertension, hyperglycemia, and dyslipidemia, modifying lifestyle, and providing patient education.
Glycemic Management in DKD
Optimized hypoglycemic therapy is recommended for DKD patients. Intensive therapy should not be over-emphasized in non-dialysis patients with DKD. It is reasonable to control Hemoglobin A1c (HbA1c) within 7% to 8%, and individualized hypoglycemic therapy should be advocated. Sodium-dependent glucose transporters 2 (SGLT-2) inhibitors show promising prospects in delaying the progression of DKD.
Blood Pressure Management in DKD
For non-dialysis adults with DKD, it is recommended to treat those with a blood pressure (BP) consistently >140 mmHg systolic or >90 mmHg diastolic with BP-lowering drugs to maintain a BP consistently <140 mmHg systolic and <90 mmHg diastolic. For non-dialysis DKD patients with proteinuria, it is suggested to maintain a BP consistently <130 mmHg systolic and <80 mmHg diastolic. ACE inhibitors or ARBs are recommended for adults with non-dialysis dependent DKD, especially those with hypertension and UACR ≥300 mg/g creatinine. The combination of ACE inhibitors, ARBs, or direct renin inhibitors is not recommended for non-dialysis patients with DKD.
Management of Other Cardiovascular Risk Factors
For non-dialysis dependent DKD patients, the use of statins or statins combined with ezetimibe is suggested. Serum uric acid should be controlled within the normal range, and dietary protein intake should be 0.8 g/kg per day for non-dialysis dependent patients with DKD.
Referral to a Nephrologist
Referral to nephrologists should be considered for diabetic patients with consistent proteinuria, an abrupt sustained fall in GFR, CKD-related complications requiring treatment, advanced kidney disease, or the absence of retinopathy combined with a rapid increase in proteinuria or nephrotic syndrome.
Future Clinical Research
Several areas require further research to improve the diagnosis and management of DKD. These include the identification of novel early biomarkers for DKD, genetic susceptibility for the incidence of DKD, new modifiable factors related to the rapid progression of renal function, optimal glycemic targets and monitoring frequency, the safety and efficacy of combined antihypertensive therapy, the impact of intensive BP control on the incidence of DKD, long-term lipid management, the potential of novel agents such as endothelin receptor antagonists and non-steroidal mineralocorticoid receptor antagonists, epidemiological characteristics of DKD in young-onset diabetes, differences in the natural history of DKD between different types of diabetes, and the effects of dietary protein intake on the development of DKD. Additionally, the initiation of uric acid-lowering therapy in non-symptomatic hyperuricemic and diabetic populations with different stages of CKD and cardiovascular risks needs further clarification.
Conclusion
The Chinese consensus statement on DKD provides a comprehensive framework for the diagnosis and management of DKD, emphasizing the importance of controlling modifiable risk factors, optimizing glycemic and blood pressure management, and addressing other cardiovascular risk factors. Future research is needed to further refine these recommendations and improve outcomes for patients with DKD.
doi.org/10.1097/CM9.0000000000001049
Was this helpful?
0 / 0