Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada
Diabetes. 2020 Nov;69(11):2229-2237. doi: 10.2337/db20-0604.
The landscape of kidney disease in diabetes has shifted. The classical dogma of "diabetic nephropathy" progressing through stages of albuminuria, leading to decline in glomerular filtration rate and end-stage kidney disease (ESKD), has been replaced by a more nuanced understanding of the complex and heterogeneous nature of kidney disease in diabetes. Paralleling this evolution, standardized definitions have resulted in a growing appreciation that acute kidney injury (AKI) is increasing in its incidence rapidly and that people with diabetes are much more likely to develop AKI than people without diabetes. Here, I propose that AKI should be considered a complication of diabetes alongside other complications that similarly do not fit neatly into the historical microvascular/macrovascular paradigm. In this article, we take a look at the evidence indicating that diabetes is a major risk factor for AKI and we review the causes of this increased risk. We consider the long-term implications of AKI in diabetes and its potential contribution to the future development of chronic kidney disease, ESKD, and mortality. Finally, we look toward the future at strategies to better identify people at risk for AKI and to develop new approaches to improve AKI outcomes. Recognizing AKI as a bona fide complication of diabetes should open up new avenues for investigation that may ultimately improve the outlook for people living with diabetes and at risk for kidney disease.
糖尿病肾病的格局已经发生了变化。从蛋白尿进展到肾小球滤过率下降和终末期肾病（ESKD）的“糖尿病肾病”经典学说已经被更细致地理解糖尿病肾病的复杂性和异质性所取代。与此并行的是，标准化的定义使人们越来越认识到急性肾损伤（AKI）的发病率正在迅速上升，而且糖尿病患者比非糖尿病患者更容易发生 AKI。在这里，我提出 AKI 应该被视为糖尿病的一种并发症，就像其他同样不符合历史微血管/大血管范式的并发症一样。在本文中，我们将探讨一些证据，表明糖尿病是 AKI 的一个主要危险因素，并回顾导致这种风险增加的原因。我们考虑 AKI 在糖尿病中的长期影响及其对未来慢性肾脏病、ESKD 和死亡率发展的潜在贡献。最后，我们展望未来，探讨如何更好地识别发生 AKI 的高危人群，并开发改善 AKI 结局的新方法。将 AKI 确认为糖尿病的一种真正并发症，应该为进一步研究开辟新的途径，从而最终改善糖尿病患者和有肾脏疾病风险人群的预后。
