Woo Keng Thye, Chan Choong Meng, Lim Cynthia, Choo Jason, Chin Yoke Mooi, Teng Esther Wei Ling, Mok Irene, Kwek Jia Liang, Tan Chieh Suai, Tan Hui Zhuan, Loh Alwin H L, Choong Hui Lin, Tan Han Kim, Lee Grace S L, Lee Evan, Wong Kok Seng, Tan Puay Hoon, Foo Marjorie
Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore.
Division of Pathology, Singapore General Hospital, Singapore, Singapore.
Kidney Dis (Basel). 2020 Jul;6(4):284-298. doi: 10.1159/000505624. Epub 2020 May 6.
This study on the prevalence of diabetic nephropathy (DN) and coexistence of non-diabetic renal disease (NDRD) in a cohort of 255 non-insulin-dependent diabetes mellitus (NIDDM) patients aims to determine the value of performing renal biopsies in these patients and elucidate the factors which could affect their progression to end-stage renal disease (ESRD).
Among 255 NIDDM patients, 93 had DN alone, 69 had NDRD alone, and the remaining 93 had DN plus NDRD (mixed group). The indications for renal biopsy were based on clinical suspicion of superimposed NDRD, including heavy or rapidly increasing proteinuria, renal impairment even though diabetes is of relatively short duration, rapidly declining renal function, and presence of hematuria with dysmorphic red blood cells suggesting presence of glomerulonephritis.
The following were predictors of ESRD: high systolic BP at biopsy, longer duration of diabetes, heavy proteinuria, and presence of diabetic retinopathy. Comparing patients in the NDRD group with the DN group and the mixed group, the NDRD group had lower serum creatinine and higher eGFR with lower urinary proteinuria and higher serum albumin at presentation and on follow-up. Kimmelstiel-Wilson nodules were associated with a poorer prognosis leading to a higher occurrence of ESRD among patients with DN.
Renal biopsy is of value in indicating the prognosis of NIDDM patients with DN based on the diabetic lesions. For NIDDM patients with atypical course and suspicion of associated NDRD, a renal biopsy would enable us to diagnose the underlying NDRD and offer appropriate therapy. Most nephrologists would consider renal biopsy for an NIDDM patient based on clinical indications like atypical clinical course and suspicion of an associated NDRD, but they would not perform a routine renal biopsy like for a CKD patient, unless it is for a research indication.
本研究针对255例非胰岛素依赖型糖尿病（NIDDM）患者队列中糖尿病肾病（DN）的患病率及非糖尿病肾病（NDRD）的共存情况，旨在确定对这些患者进行肾活检的价值，并阐明可能影响其进展至终末期肾病（ESRD）的因素。
在255例NIDDM患者中，93例仅患有DN，69例仅患有NDRD，其余93例患有DN加NDRD（混合组）。肾活检的指征基于临床怀疑存在叠加的NDRD，包括大量或快速增加的蛋白尿、即使糖尿病病程相对较短仍存在肾功能损害、肾功能快速下降，以及存在畸形红细胞血尿提示存在肾小球肾炎。
以下是ESRD的预测因素：活检时收缩压高、糖尿病病程长、大量蛋白尿以及存在糖尿病视网膜病变。将NDRD组患者与DN组和混合组患者进行比较，NDRD组在就诊时和随访时血清肌酐较低，估算肾小球滤过率（eGFR）较高，尿蛋白较低，血清白蛋白较高。Kimmelstiel-Wilson结节与预后较差相关，导致DN患者中ESRD的发生率较高。
基于糖尿病病变，肾活检对于指示NIDDM合并DN患者的预后具有价值。对于病程不典型且怀疑合并NDRD的NIDDM患者，肾活检能够使我们诊断潜在的NDRD并提供适当的治疗。大多数肾病学家会根据非典型临床病程和怀疑合并NDRD等临床指征考虑对NIDDM患者进行肾活检，但他们不会像对慢性肾脏病（CKD）患者那样进行常规肾活检，除非是出于研究目的。
