de Sá João Roberto, Rangel Erika Bevilaqua, Canani Luis Henrique, Bauer Andrea Carla, Escott Gustavo Monteiro, Zelmanovitz Themis, Bertoluci Marcello Casaccia, Silveiro Sandra Pinho
Endocrinology Division, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil.
Nephrology Division, UNIFESP, São Paulo, Brazil.
Diabetol Metab Syndr. 2022 Jun 11;14(1):81. doi: 10.1186/s13098-022-00843-8.
Diabetic kidney disease is the leading cause of end-stage renal disease and is associated with increased morbidity and mortality. This review is an authorized literal translation of part of the Brazilian Diabetes Society (SBD) Guidelines 2021-2022. This evidence-based guideline provides guidance on the correct management of Diabetic Kidney Disease (DKD) in clinical practice.
The methodology was published elsewhere in previous SBD guidelines and was approved by the internal institutional Steering Committee for publication. Briefly, the Brazilian Diabetes Society indicated 14 experts to constitute the Central Committee, designed to regulate methodology, review the manuscripts, and make judgments on degrees of recommendations and levels of evidence. SBD Renal Disease Department drafted the manuscript selecting key clinical questions to make a narrative review using MEDLINE via PubMed, with the best evidence available including high-quality clinical trials, metanalysis, and large observational studies related to DKD diagnosis and treatment, by using the MeSH terms [diabetes], [type 2 diabetes], [type 1 diabetes] and [chronic kidney disease].
The extensive review of the literature made by the 14 members of the Central Committee defined 24 recommendations. Three levels of evidence were considered: A. Data from more than 1 randomized clinical trial or 1 metanalysis of randomized clinical trials with low heterogeneity (I < 40%). B. Data from metanalysis, including large observational studies, a single randomized clinical trial, or a pre-specified subgroup analysis. C: Data from small or non-randomized studies, exploratory analyses, or consensus of expert opinion. The degree of recommendation was obtained based on a poll sent to the panelists, using the following criteria: Grade I: when more than 90% of agreement; Grade IIa 75-89% of agreement; IIb 50-74% of agreement, and III, when most of the panelist recommends against a defined treatment.
To prevent or at least postpone the advanced stages of DKD with the associated cardiovascular complications, intensive glycemic and blood pressure control are required, as well as the use of renin-angiotensin-aldosterone system blocker agents such as ARB, ACEI, and MRA. Recently, SGLT2 inhibitors and GLP1 receptor agonists have been added to the therapeutic arsenal, with well-proven benefits regarding kidney protection and patients' survival.
糖尿病肾病是终末期肾病的主要病因，与发病率和死亡率的增加相关。本综述是巴西糖尿病协会（SBD）2021 - 2022年指南部分内容的授权直译。本循证指南为临床实践中糖尿病肾病（DKD）的正确管理提供指导。
该方法已在以往的SBD指南其他地方发表，并经机构内部指导委员会批准发表。简要来说，巴西糖尿病协会指定14名专家组成中央委员会，旨在规范方法、审查稿件，并对推荐等级和证据水平做出判断。SBD肾脏疾病部起草稿件，通过PubMed使用MEDLINE选择关键临床问题进行叙述性综述，纳入关于DKD诊断和治疗的最佳可用证据，包括高质量临床试验、荟萃分析以及大型观察性研究，使用医学主题词[糖尿病]、[2型糖尿病]、[1型糖尿病]和[慢性肾病]。
中央委员会的14名成员对文献进行的广泛综述确定了24条推荐意见。考虑了三个证据级别：A. 来自超过1项随机临床试验或1项低异质性（I < 40%）随机临床试验荟萃分析的数据。B. 来自荟萃分析的数据，包括大型观察性研究、单项随机临床试验或预先指定的亚组分析。C：来自小型或非随机研究、探索性分析或专家意见共识的数据。推荐等级是根据向小组成员发送的民意调查得出的，使用以下标准：I级：当超过90%的人达成一致时；IIa级：75 - 89%的人达成一致；IIb级：50 - 74%的人达成一致，III级：当大多数小组成员反对某种既定治疗时。
为预防或至少推迟DKD的晚期阶段及其相关心血管并发症，需要强化血糖和血压控制，以及使用肾素 - 血管紧张素 - 醛固酮系统阻滞剂，如ARB、ACEI和MRA。最近，SGLT2抑制剂和GLP1受体激动剂已被纳入治疗手段，在肾脏保护和患者生存方面有充分证实的益处。
