Ubara Yoshifumi, Sawa Naoki, Yamanouchi Masayuki, Kono Kei, Ohashi Kenichi
Nephrology Center, Toranomon Hospital, 2-2-2, Toranomon, Minato, Tokyo, Japan.
Department of Pathology, Toranomon Hospital, Minato, Tokyo, Japan.
Clin Exp Nephrol. 2025 Mar 24. doi: 10.1007/s10157-025-02661-4.
Many nephrologists considered that renal involvement in diabetes patients was seen as nodular glomerulosclerosis (i.e., Kimmelstiel-Wilson lesions). However, they diagnosed diabetic nephropathy or diabetic kidney disease (DKD) from clinical information on diabetes history, and reports of evaluation by kidney biopsy were scarce. Since the publication of the Tervaert classification of diabetic nephropathy in 2010, reports of kidney biopsy in these patients have increased. Analysis of biopsy specimens revealed not only the Tervaert classification (class I to IV) based on glomerular lesions, but also various other pathologies. Besides nodular lesions, findings included paratubular basement membrane insudative lesions (PTBMILs), polar vasculosis, and nephropathy associated with novel drugs (sodium-glucose transport protein 2 inhibitors and dipeptidyl peptidase-4 inhibitors). PTBMILs are unique to diabetic nephropathy. In patients with continuous hyperglycemia and excessive salt intake, elevated blood osmolality (calculated by serum Na × 2 + serum glucose/18 + serum urea nitrogen/2.8) leads to thirst and excessive drinking, which results in fluid overload and generalized edema. The increase in circulating blood volume is thought to induce PTBMILs because of the influx of serum components into the endothelium of glomerular vessels. This case series review presents diverse kidney biopsy findings in patients with diabetic nephropathy or diabetic kidney disease as well as the pathogenesis.
许多肾脏病学家认为，糖尿病患者的肾脏受累表现为结节性肾小球硬化（即Kimmelstiel-Wilson病变）。然而，他们根据糖尿病病史的临床信息诊断糖尿病肾病或糖尿病肾脏疾病（DKD），而肾脏活检评估报告却很稀少。自2010年Tervaert糖尿病肾病分类发表以来，这些患者的肾脏活检报告有所增加。对活检标本的分析不仅揭示了基于肾小球病变的Tervaert分类（I至IV级），还发现了各种其他病理情况。除了结节性病变外，还包括肾小管周围基底膜渗出性病变（PTBMILs）、极周血管病变以及与新型药物（钠-葡萄糖转运蛋白2抑制剂和二肽基肽酶-4抑制剂）相关的肾病。PTBMILs是糖尿病肾病所特有的。在持续高血糖和盐摄入过多的患者中，血液渗透压升高（通过血清钠×2 +血清葡萄糖/18 +血清尿素氮/2.8计算）会导致口渴和过度饮水，进而导致液体超负荷和全身性水肿。循环血容量增加被认为会因血清成分流入肾小球血管内皮而诱发PTBMILs。本病例系列综述展示了糖尿病肾病或糖尿病肾脏疾病患者多样的肾脏活检结果及其发病机制。
