Department of Clinical and Molecular Medicine, "La Sapienza" University, Rome, Italy.
Endocrine and Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy.
J Nephrol. 2020 Feb;33(1):9-35. doi: 10.1007/s40620-019-00650-x.
This joint document of the Italian Diabetes Society and the Italian Society of Nephrology reviews the natural history of diabetic kidney disease (DKD) in the light of the recent epidemiological literature and provides updated recommendations on anti-hyperglycemic treatment with non-insulin agents.
Recent epidemiological studies have disclosed a wide heterogeneity of DKD. In addition to the classical albuminuric phenotype, two new albuminuria-independent phenotypes have emerged, i.e., "nonalbuminuric renal impairment" and "progressive renal decline", suggesting that DKD progression toward end-stage kidney disease (ESKD) may occur through two distinct pathways, albuminuric and nonalbuminuric. Several biomarkers have been associated with decline of estimated glomerular filtration rate (eGFR) independent of albuminuria and other clinical variables, thus possibly improving ESKD prediction. However, the pathogenesis and anatomical correlates of these phenotypes are still unclear. Also the management of hyperglycemia in patients with type 2 diabetes and impaired renal function has profoundly changed during the last two decades. New anti-hyperglycemic drugs, which do not cause hypoglycemia and weight gain and, in some cases, seem to provide cardiorenal protection, have become available for treatment of these individuals. In addition, the lowest eGFR safety thresholds for some of the old agents, particularly metformin and insulin secretagogues, have been reconsidered.
The heterogeneity in the clinical presentation and course of DKD has important implications for the diagnosis, prognosis, and possibly treatment of this complication. The therapeutic options for patients with type 2 diabetes and impaired renal function have substantially increased, thus allowing a better management of these individuals.
本文是意大利糖尿病学会和意大利肾脏病学会的联合文件，根据最近的流行病学文献，回顾了糖尿病肾病（DKD）的自然史，并就非胰岛素类降糖药物的抗高血糖治疗提供了更新的建议。
最近的流行病学研究揭示了 DKD 的广泛异质性。除了经典的白蛋白尿表型外，还出现了两种新的白蛋白尿无关表型，即“非白蛋白尿性肾功能损害”和“进行性肾功能下降”，这表明 DKD 向终末期肾病（ESKD）的进展可能通过两种不同的途径，即白蛋白尿和非白蛋白尿。一些生物标志物与白蛋白尿和其他临床变量无关的估计肾小球滤过率（eGFR）下降相关，因此可能改善 ESKD 的预测。然而，这些表型的发病机制和解剖学相关性尚不清楚。此外，在过去的二十年中， 2 型糖尿病伴肾功能受损患者的高血糖管理发生了深刻变化。一些新型降糖药物不会引起低血糖和体重增加，在某些情况下似乎还能提供心脏肾脏保护，因此可用于这些患者的治疗。此外，一些旧药物（特别是二甲双胍和胰岛素促分泌剂）的最低 eGFR 安全阈值已被重新考虑。
DKD 的临床表现和病程的异质性对该并发症的诊断、预后，可能还有治疗具有重要意义。 2 型糖尿病伴肾功能受损患者的治疗选择大大增加，从而能够更好地管理这些患者。
