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Clinical Diagnostic Recommendations for DKD

Exclusion of Non-Diabetic Kidney Diseases

The guidelines from the American Diabetes Association (ADA) in 2022, the Kidney Disease Improving Global Outcomes (KDIGO) organization in 2020, and the Asia-Pacific Society of Nephrology (APSN) in 2020 all assert that Diabetic Kidney Disease (DKD) refers to the occurrence of proteinuria and/or renal function decline in diabetic patients, with the exclusion of kidney damage caused by other underlying reasons.

In actual clinical diagnoses of DKD patients, a subset frequently presents with coexisting non-diabetic kidney diseases (NDKD). This may include scenarios where diabetes or DKD coexists with conditions like IgA nephropathy, membranous nephropathy, lupus nephritis, hepatitis B-related nephritis, vasculitis-related kidney injury, and even renal amyloidosis.

A meta-analysis incorporating 48 studies, involving 4,876 cases of kidney biopsies in DKD patients, revealed a non-diabetic kidney disease (NDKD) occurrence rate of approximately 36.9%. The occurrence rate of diabetic nephropathy (DN) combined with non-diabetic kidney disease (NDKD) was about 19.7%. Consequently, the guidelines recommend that before diagnosing DKD in type 2 diabetes patients, a comprehensive assessment, incorporating medical history, clinical manifestations, relevant laboratory tests, especially serum immunology, and imaging examinations, should be conducted to rule out non-diabetic kidney diseases (NDKD). Only after excluding NDKD can a diagnosis of DKD be confirmed.

Measurement of Urinary Albumin/Creatinine Ratio (UACR) and eGFR

Internationally, guidelines from organizations such as the American Diabetes Association (ADA) in 2022, the Kidney Disease Outcomes Quality Initiative (KDOQI) in 2007, the 2021 Clinical Diagnosis and Treatment Guidelines for Diabetic Kidney Disease, and the 2021 edition of the Chinese Guidelines for the Prevention and Treatment of Diabetic Kidney Disease recommend the repetition of UACR and eGFR measurements three times within a 3–6 month period. A clinical diagnosis of Diabetic Kidney Disease (DKD) is considered when, during these repeated measurements, UACR increases (>30mg/g) and/or eGFR falls below 60mL/min/1.73m² on two or more occasions. However, it is important to note that factors such as intense physical activity, infection, fever, congestive heart failure, etc., can cause transient proteinuria.

Taking into account domestic and international guidelines, after excluding factors causing transient proteinuria, a diagnosis of DKD can be established if, during the 3–6 month period with three repeated measurements, UACR increases (>30mg/g) and/or eGFR is consistently below 60mL/min/1.73m² on two or more occasions.

In clinical practice, some DKD patients may not meet the diagnostic criteria based on urine tests, but their eGFR is below 60mL/min/1.73m². The 2021 Clinical Diagnosis and Treatment Guidelines for Diabetic Kidney Disease, the Chinese Guidelines for the Prevention and Treatment of Diabetic Kidney Disease (2021 edition), and the 2022 ADA guidelines suggest that after excluding factors such as infection, obstructive kidney disease, medications, malignant hypertension, and other causes of acute kidney injury, a diagnosis of normoalbuminuric diabetic kidney disease (NADKD) can be made if, during the 3–6 month period with three repeated measurements, urine tests are normal but eGFR remains below 60mL/min/1.73m² on two or more occasions.

In a 2021 meta-analysis of 31 studies (including 18 cross-sectional studies, 11 cohort studies, and 2 case-control studies), the overall prevalence of normoalbuminuric diabetic kidney disease (NADKD) in patients with type 2 diabetes and chronic kidney disease (CKD) was 45.6%. Within the DKD patient population, the prevalence of NADKD was 24.7%. A long-term follow-up study also found that regardless of proteinuria, diabetic patients with CKD stage 3 or later could experience varying degrees of further decline in kidney function after 10 years.

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Breakfast Choices for Individuals with Diabetic Kidney Disease

Managing daily life and dietary choices can be challenging for those dealing with diabetic kidney disease, a common chronic condition. Breakfast, often hailed as the most important meal of the day, holds particular significance for individuals living with both diabetes and kidney disease. This article explores dietary strategies for the breakfast of individuals with diabetic kidney disease, aiming to assist them in better managing their condition and enhancing their overall quality of life. Whether you are personally managing diabetes or a concerned family member, the information provided here can be valuable to you.

1.Egg Custard with Mixed Vegetables

Seafood Egg Custard (60g egg, 10g dried shrimp, 2g sesame oil)

Colorful Vegetable Mix (150g, including purple kale, bell peppers, and leafy greens)

Whole Wheat Bread (2 slices, 50g)

1 cup of milk (250ml)

This meal offers a diverse array of vegetables and high-quality protein from seafood and eggs, providing a well-rounded nutritional profile.

2.Broccoli with Chicken

Broccoli Salad (150g broccoli, a pinch of salt, a drizzle of sesame oil)

Chicken Breast Slices (50g chicken breast, 2ml light soy sauce, a touch of sesame oil)

1 cup of soy milk (300ml)

Half a Red Date and Sweet Potato Steamed Bun (30g small bun, 1 red date, 20g sweet potato flour, made from a mixture of wheat and sweet potato flour, fermented and steamed)

This meal includes a variety of vegetables, lean protein from chicken, and whole grains. Adjust the portion of chicken and broccoli for those with smaller appetites.

3.Seaweed Rice Roll with Yogurt

Seaweed Rice Roll (150g cooked rice, 1 sheet of seaweed, half a carrot, a little ham, 1 egg, a moderate amount of sesame oil, a pinch of black sesame seeds, half a cucumber, and a lettuce leaf)

1 cup of unsweetened yogurt

The seaweed rice roll combines the main carbohydrate source with various vegetables. Paired with yogurt, it becomes a convenient and nutritious breakfast option, especially suitable for individuals with diabetes on the go.

4.Oatmeal Porridge

Oats are renowned for their stomach-nourishing and lung-moistening properties, helping prevent post-meal high blood sugar. Oatmeal porridge, often referred to as the “longevity porridge,” is favored by many centenarians. Adding millet to the oats creates a fragrant and soft porridge with calming and sleep-enhancing effects, along with stomach nourishment and lung moisturization. Oats are high in dietary fiber, providing a satisfying feeling of fullness without causing spikes in blood sugar levels, making it an excellent choice for preventing post-meal high blood sugar.

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What are the effective treatment for diabetic kidney disease?

Diabetes is a chronic metabolic disorder characterized by insufficient or ineffective insulin, leading to elevated blood glucose levels. Normally, insulin, a hormone, facilitates the conversion of blood sugar into energy. However, in individuals with diabetes, this process is disrupted, resulting in high blood sugar.

Diabetes is divided into two main types: Type 1, often caused by the immune system attacking insulin-producing beta cells in the pancreas, and Type 2, involving insufficient insulin production or poor cellular response to it.

Elevated blood sugar can lead to various health issues, including cardiovascular diseases, kidney disease, and eye problems.

Therefore, the management of diabetes typically involves adjustments to diet, medication, and lifestyle. Timely diagnosis and effective control are crucial to slowing down or preventing the development of complications.

The treatment of diabetic kidney disease involves a multifaceted approach. The optimal approach to treating diabetes typically involves a comprehensive, personalized plan that combines medication and lifestyle adjustments.

Blood Glucose Control:

Tight control of blood glucose levels is crucial. This often involves a combination of medications (insulin or oral hypoglycemic agents) and lifestyle modifications, including a well-balanced diet and regular exercise.

Blood Pressure Management:

Controlling hypertension is vital to slowing the progression of diabetic kidney disease. Medications like angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) are commonly prescribed to help manage blood pressure and reduce proteinuria.

Medication Management:

Medications may be prescribed to address specific symptoms or complications associated with diabetic kidney disease, such as medications to control high cholesterol levels.

Dietary Changes:

A dietitian may recommend a diet low in sodium, saturated fats, and cholesterol. Protein intake may also be monitored, as excessive protein can strain the kidneys.

Weight Management:

Maintaining a healthy weight is important. Weight loss, if necessary, can help improve insulin sensitivity and reduce the risk of complications.

Regular Exercise:

Engaging in regular physical activity can help control blood glucose levels, manage weight, and contribute to overall cardiovascular health.

Smoking Cessation:

Quitting smoking is crucial, as smoking can exacerbate kidney disease and increase the risk of cardiovascular complications.

Regular Monitoring and Follow-up:

Regular check-ups and monitoring of blood pressure, blood glucose levels, and kidney function are essential. Adjustments to the treatment plan may be made based on these assessments.

Treatment of Complications:

Prompt treatment of complications, such as urinary tract infections or other infections, is important to prevent further kidney damage.

Kidney-Friendly Medications:

Some medications need adjustment or avoidance in individuals with kidney disease. It's important to consult with healthcare providers to ensure that prescribed medications are kidney-friendly.

Renal Replacement Therapy:

In advanced stages of diabetic kidney disease, when kidney function is severely impaired, renal replacement therapy such as dialysis or kidney transplantation may be considered.

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How diabetics can control their diet

Diabetes poses significant health risks, increasing the likelihood of heart diseases, kidney damage, and eye complications such as diabetic retinopathy. It can also result in nerve damage, causing pain or loss of sensation, contribute to foot problems, potentially leading to amputation, and make individuals more susceptible to skin infections and gum diseases.

Managing diet is crucial for diabetes control. Here are some guidelines:

Control Carbohydrate Intake: Choose complex carbohydrates with a low glycemic index, such as whole grains, brown rice, and oats. Distribute carbohydrate intake evenly throughout the day.

Increase Dietary Fiber: Include fiber-rich foods like vegetables, fruits, whole grains, and legumes to help stabilize blood sugar levels.

Choose Healthy Proteins: Opt for lean protein sources like fish, poultry, tofu, and legumes. Protein helps control hunger and slows down carbohydrate digestion.

Limit Saturated Fats and Cholesterol: Reduce intake of saturated fats and cholesterol found in fried foods, fatty meats, and full-fat dairy products.

Meal Timing: Divide daily meals into smaller, more frequent portions to prevent spikes in blood sugar levels.

Balanced Meal Composition: Ensure a balanced combination of various food groups in each meal to avoid excessive intake of any one nutrient.

Regular Meals: Eat meals on a regular schedule, avoiding prolonged periods without food or overeating.

Consider Cooking Methods: Choose cooking methods like steaming, baking, or grilling instead of frying to reduce added fats.

Limit Sugar Intake: Be mindful of added sugars in beverages and snacks. Opt for sugar-free or low-sugar alternatives.

Monitor Blood Sugar Levels: Regularly monitor blood glucose levels and make adjustments to the diet plan as needed.

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How to reverse diabetic kidney disease?

Diabetic nephropathy is considered irreversible and is a chronic complication of diabetes that cannot be cured. The survival period varies for each patient, with some living around 10 years and others up to 20 years.

This largely depends on the progression of diabetic nephropathy in each individual. Some diabetes patients may already have diabetic nephropathy or reach a stage of renal insufficiency.

However, with good control of blood sugar and blood pressure, along with regular medication, the kidney disease may stabilize and not progress further. In such cases, the life expectancy of these patients may reach around 20 years.

For diabetes patients with concurrent kidney diseases, such as renal insufficiency, poor control of blood pressure and blood sugar, inadequate treatment, and a continuous rise in creatinine levels leading to uremia, prompt dialysis treatment is required.

The life expectancy for these patients is relatively short, possibly around 10 years, with more severe cases facing a survival period of around 5 years.

Diabetic kidney disease (or diabetic nephropathy) is a complication of diabetes that affects the kidneys. While it may not always be completely reversible, there are steps you can take to manage and potentially slow down its progression:

Blood Sugar Control: Maintaining stable blood sugar levels is crucial in managing diabetic kidney disease. This often involves a combination of medication, insulin, and lifestyle changes. Follow your healthcare provider's recommendations for managing your diabetes.

Blood Pressure Control: High blood pressure can contribute to the progression of kidney disease. Medications, dietary changes (such as reducing sodium intake), and lifestyle modifications can help control blood pressure.

Healthy Diet: Adopting a kidney-friendly diet can be beneficial. This often includes reducing the intake of salt, phosphorus, and potassium. A dietitian can provide personalized advice based on your specific needs.

Regular Exercise: Engaging in regular physical activity can help control blood sugar levels and blood pressure. Consult with your healthcare provider before starting a new exercise program.

Medication Management: Take medications as prescribed by your healthcare provider. These may include medications to control diabetes, blood pressure, and other conditions that may be contributing to kidney disease.

Quit Smoking: If you smoke, quitting can have numerous health benefits, including a positive impact on kidney health.

Regular Check-ups: Regular monitoring and follow-up with your healthcare provider are crucial. They can assess your kidney function, adjust medications, and provide guidance on managing your condition.

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How effective is Finerenone?

New medicine for treating diabetic nephropathy – LUCIFINE finerenone tablets

LUCIFINE Finerenone Tablets Is a non-steroidal mineralocorticoid receptor antagonist (MRA) indicated to reduce the risk of sustained eGFR decline end stage kidney disease, cardiovascular death non-fatal myocardial infarction, and hospitalization for hear failure in adult patients with chronic kidney disease(CKD) associated with type 2 diabetes T2D)

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of a drug and may not reflect the rates observed in practice.

The safety of LUCIFINE was evaluated in 2 randomized, double-blind, placebo-controlled, multicenter pivotal phase 3 studies, FIDELIO-DKD and FIGARO-DKDin which a total of 6510 patients were treated with 10 or 20 mg once daily over a mean duration of 2.2 and 2.9 years, respectively.

Overall, serious adverse events occurred in 32% of patients receiving LUCIFINE and in 34% of patients receiving placebo in the FIDELIO-DKD study: the findings were similar in the FIGARODKD study. Permanent discontinuations due to adverse events also occurred in a similar proportion of patients in the two studies (6-7% of patients receiving LUCIFINE and in 5-6% of patients receiving placebo).

The most frequently reported (≥10%）adverse reaction in both studies was hyperkalemia [see Warnings and Precautions(5.1)]. Hospitalization due to Hyperkalemia for the LUCIFINE was 0.9% vs 0.2% in the placebo group across both studies. Hyperkalemia led to permanent discontinuation of treatment in 1.7% receiving LUCIFINE versus 0.6% of patients receiving placebo across both studies.

LUCIFINE is a CYP3A4 substrate. Concomitant use with a strong CYP3A4 inhibitor increases Finerenone exposure, which may increase the risk of LUCIFINE adverse reactions. Concomitant Use of LUCIFINE with strong CYP3A4 inhibitors is contraindicated see Contraindications (4) Avoid concomitant intake of grapefruit or grapefruit juice.

Moderate and Weak CYP3A4 Inhibitors LUCIFINE is a CYP3A4 substrate. Concomitant use with a moderate or weak CYP3A4 inhibitor increases Finerenone exposure, which may increase the risk of LUCIFINE adverse reactions. Monitor serum potassium during drug initiation or dosage adjustment of either LUCIFINE or the moderate or weak CYP3A4 inhibitor, and adjust LUCIFINE dosage as appropriate [(see Dosing and Administration (2.3) and Drug interaction (7 .2)]. Strong and Moderate CYP3A4 inducers.

LUCIFINE is a CYP3A4 substrate. Concomitant use of LUCIFINE with a strong or moderate CYP3A4 inducer decreases Finerenone exposure. which may reduce the efficacy of LUCIFINE. Avoid concomitant use of LUCIFINE with strong or moderate CYP3A4 inducers.

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What is the cost of medications for treating diabetic kidney disease?

It’s widely known that the treatment for type 2 diabetes, RYBELSUS® (semaglutide) tablets, comes with a high cost of up to $995 for 30 tablets. Similarly, the medication for treating diabetic kidney disease, Kerendia finerenone tablets, can be as expensive as $670 for 30 tablets. The exorbitant prices of these medications undoubtedly add to the challenges faced by patients in their daily lives.

Is there an equally effective but more affordable medication available? The answer is LUCIFINE finerenone tablets produced by Lucius Pharmaceuticals. LUCIFINE finerenone tablets are a diabetes kidney disease treatment that has received approval from the Laotian Ministry of Health and is manufactured in Lucius Pharmaceuticals’ GMP factory in Laos, as approved by the U.S. FDA.

LUCIFINE finerenone tablets are not only a legitimately authorized medication but also come at a very affordable price, being only one-third the cost of Kerendia finerenone tablets while delivering the same efficacy.

DKD Care Center serves as the authoritative global distributor for LUCIFINE finerenone tablets, and we possess the necessary authorization certificates from Lucius Pharmaceuticals. The introduction of this new medication comes with significant discounts. If you have been suffering from diabetic kidney disease for an extended period, please don’t hesitate to contact us promptly.

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The medications used to treat diabetic kidney disease

Angiotensin Receptor Blockers (ARBs) or ACE Inhibitors

Both of these drug classes act on angiotensin II, where ARBs block its action, and ACE inhibitors reduce its production. Besides their blood pressure-lowering effects, both have the added benefits of reducing urine protein and providing kidney protection, making them the preferred antihypertensive medications for diabetic nephropathy. Even if blood pressure is not high, they should be used when proteinuria is present in diabetic nephropathy.

The dosage for reducing urine protein is generally higher than that for lowering blood pressure. As long as blood pressure is tolerable, doses can be used at 2 to 4 times the standard antihypertensive dosage. Since the effects of these two drug classes overlap, combining them doesn’t significantly increase efficacy but does markedly increase side effects. Therefore, guidelines recommend choosing only one of them and explicitly advise against their combined use.

SGLT-2 Inhibitors

SGLT-2 inhibitors are a relatively new class of antidiabetic drugs that have been introduced in recent years. Apart from their blood sugar-lowering effects, they also exhibit significant reduction in urine protein and demonstrate benefits such as slowing down kidney damage, protecting kidney function, preventing uremia, safeguarding cardiovascular health, and managing heart failure. Currently, they have been approved for use in patients with diabetes as well as in individuals with non-diabetic chronic kidney disease and non-diabetic heart failure.

Third-Generation Aldosterone Receptor Antagonists

The currently available medication in this class is finerenone. Apart from its blood pressure-lowering effects, it also demonstrates the ability to reduce urine protein and provide kidney protection. It has been approved for use in the treatment of diabetic nephropathy.

Increasing evidence suggests that elevated aldosterone levels, in conjunction with the action of angiotensin II, contribute to water and sodium retention, pro-inflammatory effects, fibrotic effects, and oxidative stress. This interaction can lead to myocardial infarction and heart failure in the heart and glomerulosclerosis and renal fibrosis in the kidneys, inducing kidney damage and loss of kidney function. Therefore, selectively blocking the overactivation of aldosterone receptors is a novel target in the treatment of diabetic nephropathy.

The results of the completed large-scale clinical studies FIDELIO-DKD, FIGARO-DKD, and FIDELITY indicate that, in patients with controlled blood sugar and blood pressure, and maximal use of angiotensin receptor blockers or ACE inhibitors, finerenone can still significantly reduce urine protein, decrease the risk of new-onset proteinuria, and significantly lower the risk of composite renal outcomes (renal function decline, uremia, and renal death) by 23%. It also significantly reduces the risk of composite cardiovascular outcomes (myocardial infarction, stroke, and cardiovascular death) by 14%. These findings confirm a clear renal and cardiovascular protective effect of finerenone.

In terms of safety, compared to the commonly used first-generation aldosterone receptor antagonist spironolactone and the second-generation aldosterone receptor antagonist eplerenone, finerenone has a more even distribution in the heart and kidneys, achieving a 1:1 distribution. This allows for dual benefits in both the kidneys and the heart. Additionally, it exhibits higher selectivity and affinity for aldosterone receptors, with less impact on androgen hormones and a lower risk of hyperkalemia. With a broad applicability and promising prospects, finerenone is poised to bring about a third significant advancement in the treatment of diabetic nephropathy.

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Medicine to treat diabetic nephropathy

The prevention and treatment of DKD mainly focuses on strict blood sugar and blood pressure control. Widely accepted drugs with renal protection include RAAS inhibitors, such as ACEI/ARB. However, despite the use of the above treatments, DKD disease progression cannot be completely avoided, and there is an urgent need to find new treatments.

Three new classes of antidiabetic drugs are believed to have renoprotective effects independent of hypoglycemic effects, including SGLT2 inhibitors, GLP-1 receptor agonists, and DPP-4 inhibitors. Multiple studies have shown that SGLT2 inhibitors can reduce urinary protein levels in DKD patients and delay the progression of T2DKD. In terms of new drugs under development for diabetic nephropathy, Serodus’ SER150 is in clinical phase 2/3 and is about to be launched. Most other drugs such as dapagliflozin, CSL346, and MEDI 3506 are in clinical phase 2.

LUCIFINE Finerenone Tablets Is a non-steroidal mineralocorticoid receptor antagonist (MRA) indicated to reduce the risk of sustained eGFR decline end stage kidney disease, cardiovascular death non-fatal myocardial infarction, and hospitalization for hear failure in adult patients with chronic kidney disease(CKD) associated with type 2 diabetes T2D)

Where can I buy medications for treating diabetic kidney disease?

You can purchase medications for treating diabetic kidney disease at various locations, including hospitals, pharmacies (both in-person and online), and through online healthcare platforms. However, it's important to note the following:

Hospitals: Hospitals often have pharmacies where you can purchase prescribed medications. Your doctor will provide you with a prescription, and you can fill it at the hospital pharmacy.

Pharmacies (In-person): Local pharmacies or drugstores in your community also carry medications for diabetic kidney disease. You will need a valid prescription from your healthcare provider to purchase these medications.

Online Pharmacies: Reputable online pharmacies may offer a convenient option for purchasing prescribed medications. Ensure that the online pharmacy is legitimate, follows safety regulations, and requires a valid prescription.

Online Healthcare Platforms: Some online healthcare platforms may provide virtual consultations with healthcare professionals who can prescribe medications. In some cases, these platforms may also have an affiliated online pharmacy where you can purchase prescribed medications.

Always prioritize purchasing medications from licensed and trustworthy sources to ensure their safety, efficacy, and proper handling. Additionally, only obtain medications with a valid prescription from a healthcare professional to ensure they are appropriate for your specific condition and health status.

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Treatment Approaches for Diabetic Kidney Disease

Comprehensive management is essential for patients with diabetic kidney disease. This includes adjustments to unhealthy lifestyles, control of risk factors (such as high blood sugar, hypertension, and lipid metabolism disorders), and diabetes education.

1. Lifestyle Modifications

Proper weight management.

Diabetes-specific diet.

Smoking cessation.

Regular physical activity.

2. Nutritional Management

For diabetic kidney disease patients not yet on dialysis, it is recommended to consume 0.8g of protein per kilogram of body weight daily. High-quality animal proteins are preferred as the primary source, and if necessary, supplementation with ketoacid analogs may be considered.

3. Blood Sugar Control

It is recommended for all diabetic kidney disease patients to undergo appropriate glycemic control.

SGLT-2 Inhibitors: Research has shown that SGLT-2 inhibitors have renal protective effects in addition to glycemic control. For T2DM patients with diabetic kidney disease, it is recommended to use SGLT2 inhibitors in patients with an eGFR ≥ 45 ml/min/1.73m^2 to reduce the risk of diabetic kidney disease progression and/or cardiovascular events.

GLP-1 Receptor Agonists: Research has indicated that GLP-1RA can reduce the risk of significant albuminuria in diabetic patients. It can be considered for patients with an eGFR ≥ 30 ml/min/1.73m^2.

LUCIFINE Finerenone Tablets：LUCIFINE Finerenone Tablets Is a non-steroidal mineralocorticoid receptor antagonist (MRA) indicated to reduce the risk of sustained eGFR decline end stage kidney disease, cardiovascular death non-fatal myocardial infarction, and hospitalization for hear failure in adult patients with chronic kidney disease(CKD) associated with type 2 diabetes T2D).

For patients with impaired kidney function, it is advisable to prioritize the use of antidiabetic medications with lower renal excretion. Severe kidney function impairment may warrant insulin therapy.

4. Blood Pressure Control

Effective blood pressure control can delay the onset and progression of diabetic kidney disease. It is recommended that blood pressure in non-pregnant diabetic patients older than 18 years of age should be maintained below 130/80 mmHg.

Other Medications: Aldosterone receptor antagonists can reduce urinary albumin, slow down eGFR decline, but carry a risk of elevated blood potassium levels. The benefit of preventing kidney endpoint events still requires further confirmation. Third-generation aldosterone receptor antagonists can lower the risk of cardiovascular events in diabetic kidney disease patients.

5. Correcting Lipid Abnormalities

The primary goal is to lower LDL-C, and the target level should be based on the patient’s ASCVD risk, with the aim of reducing LDL-C to the target value.

The preferred clinical approach is to use statins as lipid-lowering drugs. Moderate-intensity statins are typically initiated, and the dose may be adjusted as needed based on individual lipid-lowering effectiveness and tolerability.

If cholesterol levels do not meet the desired targets, other lipid-lowering medications, such as ezetimibe, can be used in combination. For extremely high-risk patients, if LDL-C levels remain above target even after the combination of statins and ezetimibe for 4-6 weeks, adding proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors can provide safe and effective lipid control, further reducing cardiovascular risk.

For ASCVD high-risk or extremely high-risk patients who, after standard lipid-lowering treatment for 3 months, still have difficulty achieving the desired LDL-C levels, it can be considered to lower LDL-C by 50% from baseline as an alternative target.

Once LDL-C reaches the target, if triglycerides (TG) remain elevated, additional TG-lowering medications, such as fibrates, can be added to the statin therapy. If fasting TG levels are above 5.7 mmol/L, measures to prevent acute pancreatitis should be taken, including the use of TG-lowering medications. Blood lipid monitoring should be conducted annually, and lipid levels should be regularly monitored during drug therapy.

6. Dialysis Treatment and Transplantation

When eGFR falls below 30 ml/min/1.73m², it is advisable to consult a kidney specialist to assess the need for renal replacement therapy.

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Diagnosis of Diabetic Kidney Disease

1. Diagnostic Criteria

The clinical diagnosis of diabetic kidney disease is based on the continuous presence of an elevated urinary albumin-to-creatinine ratio (UACR, preferably through random urine testing) and/or a decline in estimated glomerular filtration rate (eGFR), while simultaneously excluding other causes of chronic kidney disease (CKD).

2. Assessment of Disease Severity

Following confirmation of the diagnosis, the severity of CKD should be further assessed based on eGFR. The Kidney Disease Improving Global Outcomes (KDIGO) guideline recommends using a combined staging of CKD and albuminuria to assess the progression risk and follow-up frequency for diabetic kidney disease. For example, a diabetic patient with an eGFR of 70 ml/min/1.73m^2 and a UACR of 80 mg/g would be classified as having diabetic kidney disease G2A2, with a moderate progression risk, requiring annual follow-up.

3. Consider Referral to a Nephrologist in the Following Situations

(1)Active urinary sediment abnormalities (hematuria, proteinuria with hematuria, or cast nephropathy).

(2)Rapid decline in eGFR within a short period.

(3)Absence of diabetic retinopathy (DR), especially in cases of type 1 diabetes (T1DM).

(4)Rapid increase in UACR within a short period or the emergence of nephrotic syndrome.

It’s important to note that the presence of DR is not a mandatory condition for diagnosing diabetic kidney disease. While kidney biopsy is the gold standard for a pathological diagnosis of diabetic kidney disease, it is not routinely recommended for diabetic patients unless there are difficulties in determining the cause. In such cases, a kidney biopsy may be considered, but it is not typically performed as a routine procedure.

Screening for Diabetic Kidney Disease

After a diagnosis of diabetes, screening for diabetic kidney disease is essential. The Diabetes Kidney Disease Prevention and Treatment Guidelines recommend that screening for kidney disease should be conducted at the time of diagnosis for type 2 diabetes and at least once a year thereafter.

Screening should include urine tests for routine urinalysis, urinary albumin-to-creatinine ratio (UACR), and blood creatinine (to calculate eGFR – estimated glomerular filtration rate). This screening method is crucial for detecting early kidney damage, distinguishing it from other common non-diabetic kidney diseases, and can help save healthcare costs in the long run.

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What tests are needed to diagnose diabetic kidney disease?

Diabetic kidney disease, also known as diabetic nephropathy, is a complication of diabetes that occurs when high blood sugar levels over an extended period damage the kidneys. Diabetes, especially if poorly controlled, can lead to damage of the small blood vessels in the kidneys, affecting their ability to filter waste and excess fluids from the blood effectively. To diagnose diabetic kidney disease, several tests are typically conducted:

Urinalysis: This involves testing urine for the presence of protein, sugar, ketones, and other substances. In the early stages of diabetic kidney disease, there may be the presence of microalbuminuria or other abnormalities.

Urine Albumin/Creatinine Ratio: This is a more sensitive measure to assess the excretion of albumin in urine. Elevated levels may indicate microalbuminuria, an early sign of kidney damage.

Blood Creatinine Test: An increase in blood creatinine levels can be an indicator of impaired kidney function. In diabetic kidney disease, a decline in glomerular filtration rate (GFR) can lead to elevated blood creatinine.

Glomerular Filtration Rate (GFR) Measurement: GFR is calculated by measuring the rate at which the kidneys filter creatinine from the blood. A decreased GFR can suggest diabetic kidney disease.

Renal Ultrasound: This imaging test assesses the size, shape, and structure of the kidneys, detecting abnormalities such as stones, cysts, or other issues.

Kidney Biopsy (may be considered in some cases): A kidney biopsy involves taking a small sample of kidney tissue to determine the type and severity of the damage, guiding treatment decisions.

These tests are typically ordered by a healthcare professional based on the patient's symptoms, results of urine tests, and suspicion of diabetic kidney disease. Once diagnosed, appropriate treatment measures can be implemented, and ongoing monitoring is crucial to ensure effective management of the kidney disease.

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Development of diabetic kidney disease

The progression of diabetic nephropathy can be categorized into five stages, ranging from mild to severe, each requiring varying diabetes treatments.

Stage 1: Hyperfiltration and Kidney Enlargement Phase

In this initial stage, associated with elevated blood glucose levels, kidney changes can be reversed through strict blood sugar control and insulin therapy over weeks to months.

Treatment focus:

Maintain a healthy lifestyle and manage factors contributing to atherosclerosis, such as high blood sugar, blood pressure, lipids, uric acid, blood viscosity, overweight, and smoking.

For diabetic patients with normal kidney function, aim for a daily protein intake of 0.8 grams per kilogram of body weight. Consider the impact on kidney function when selecting medications for blood pressure, lipids, and blood sugar.

Stage 2: Intermittent Microalbuminuria Phase

Characterized by kidney enlargement and increased filtration rate, this stage lacks clinical symptoms, with urinary protein excretion increasing after exercise.

Treatment focus:

Continue lifestyle interventions. Adjust daily protein intake to 0.6-0.8 grams per kilogram after a decrease in filtration rate. Prefer insulin over sulfonylurea drugs for blood sugar control.

Stage 3: Early Diabetic Kidney Disease Phase

Persistent microalbuminuria (30-300 mg in 24 hours) marks this stage, emphasizing the importance of low-protein diets, blood sugar control, and blood pressure management.

Treatment focus:

Implement a low-protein diet. Initiate insulin therapy early. Control blood pressure (≤130/80 mmHg) with renin-angiotensin system inhibitors. Monitor for kidney-harming factors.

Stage 4: Clinical Diabetic Kidney Disease Phase

Significant proteinuria (>500 mg in 24 hours) characterizes this stage, with an emphasis on aggressive blood sugar control and dietary management.

Treatment focus:

Opt for high-quality animal protein with a daily intake ≤0.6 grams per kilogram. Choose antidiabetic medications with less kidney excretion. Use antiplatelet medications. Strictly control blood pressure and lipids.

Stage 5: Kidney Failure Phase

Representing uremia, this stage requires either kidney dialysis or transplantation.

Treatment focus:

Follow a low-salt, low-protein, low-fat diet. Limit fluid intake as appropriate. Treat complications through specialized care. Dialysis and transplantation:

Recommended when glomerular filtration rate falls below 15 ml/min. Consider initiation slightly earlier than non-diabetic kidney disease patients.

Dialysis may be considered when blood creatinine levels reach 530-710 μmol/L and creatinine clearance is 10-15 ml/min. For effective kidney protection, early prevention is key, involving proactive blood sugar management, close monitoring, and lifestyle improvements. Early initiation of intensive insulin therapy can significantly reduce the risk of complications in diabetic nephropathy.

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What are the signs of diabetic kidney disease?

Diabetic kidney disease (DKD) is a complication of diabetes that affects the kidneys. Diabetic kidney disease poses serious health risks for individuals with diabetes. This condition, resulting from prolonged high blood sugar levels, can lead to kidney damage and, ultimately, kidney failure. The consequences include an increased risk of cardiovascular disease, high blood pressure, and fluid retention. Proteinuria, the presence of protein in the urine, is a common sign, and as the disease progresses, symptoms such as fatigue, swelling, and changes in urination may occur. Some signs and symptoms that may indicate the presence of diabetic kidney disease include:

Changes in Urination: Increased frequency of urination, especially at night (nocturia), or decreased urine output.

Fluid Retention: Swelling in the ankles, legs, or around the eyes due to the body's inability to remove excess fluid.

Fatigue: Feeling unusually tired or weak, which can be a result of anemia or other factors related to kidney function.

High Blood Pressure: Diabetes and high blood pressure often go hand in hand, and both can contribute to kidney damage.

Proteinuria: Presence of protein in the urine, which can be detected through a urine test. Healthy kidneys usually keep protein in the body, but damaged kidneys may allow it to leak into the urine.

Changes in Blood Creatinine and Glomerular Filtration Rate (GFR): Blood tests that measure creatinine levels and estimate GFR can indicate how well the kidneys are functioning. An increase in creatinine or a decrease in GFR may suggest kidney problems.

Edema: Swelling, particularly in the lower extremities, can occur due to the retention of salt and water when the kidneys are not functioning properly.

Poor Appetite and Nausea: Loss of appetite, nausea, and vomiting can be associated with advanced stages of kidney disease.

Itching and Skin Rash: Buildup of waste products in the blood can lead to skin-related issues such as itching and rashes.

Difficulty Concentrating: Impaired kidney function can lead to cognitive difficulties, trouble concentrating, and memory issues.

You need to check if you have any of these signs.

It's important to note that early stages of diabetic kidney disease may not present noticeable symptoms. Regular monitoring of blood pressure, blood sugar levels, and kidney function through blood and urine tests is crucial for individuals with diabetes to detect and manage kidney disease early.

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Do you know the symptoms of diabetic nephropathy?

Diabetic kidney disease (DKD) is one of the most common chronic complications of diabetes and a primary cause of end-stage renal disease. In the early stages, DKD often presents without noticeable symptoms, but as the condition progresses, the following main symptoms may occur:

Proteinuria: This is the earliest and most common symptom of DKD, involving the excessive excretion of protein in the urine. The degree of proteinuria can be assessed using the urine albumin-to-creatinine ratio (UACR), with a UACR >30mg/g indicating proteinuria.

High Blood Pressure: The prevalence of hypertension is significantly higher in individuals with DKD compared to the general population. Controlling blood pressure is crucial for preventing the exacerbation of kidney damage in DKD patients.

Edema: Impaired kidney function can lead to fluid retention in the body, resulting in swelling, commonly observed in the lower limbs, eyelids, and face.

Anemia: Since the kidneys play a key role in red blood cell production, kidney dysfunction can lead to anemia.

Uremia: In the advanced stages of DKD, renal failure can occur, leading to uremic symptoms such as nausea, vomiting, loss of appetite, fatigue, drowsiness, and difficulty breathing.

If you have diabetes, regular urine tests are recommended for early detection of DKD. Seeking prompt medical attention is advised if foamy urine or other potential symptoms of DKD are observed.

Here are some measures that can help prevent or slow the progression of DKD:

Blood Sugar Control: Maintaining good blood sugar control is crucial for preventing DKD.

Blood Pressure Control: Actively managing blood pressure is crucial, as hypertension can worsen kidney damage.

Lipid Control: Proper control of lipid levels is also important in mitigating kidney damage.

Quit Smoking: Smoking can worsen kidney damage.

Maintain Healthy Weight: Obesity increases the risk of developing DKD.

Regular Exercise: Exercise can help control blood sugar, blood pressure, and lipid levels, thus protecting the kidneys.

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What are the early symptoms of diabetic nephropathy?

Diabetic kidney disease is one of the most common chronic complications of diabetes and a major cause of end-stage renal disease. Due to its insidious onset, there is a considerable asymptomatic period, making early detection and treatment crucial.

The early symptoms of diabetic kidney disease are often not apparent and may include the following:

Microalbuminuria: Presence of a small amount of albumin in the urine, which may not be visibly foamy.

Decreased Vision: Diabetic kidney disease is often associated with diabetic retinopathy, leading to decreased vision as an early manifestation.

High Blood Pressure: Poor blood pressure control is common in individuals with diabetic kidney disease and can exacerbate kidney damage.

Fatigue: Kidney dysfunction can disrupt overall metabolic processes, resulting in fatigue.

Edema: Impaired kidney function can lead to fluid retention, presenting as swelling.

If you have diabetes, regular urine tests are recommended to detect diabetic kidney disease early. Seeking prompt medical attention is advised if foamy urine or other potential symptoms of diabetic kidney disease are observed.

Here are some measures that can help prevent or slow the progression of diabetic kidney disease:

Blood Sugar Control: Maintaining good blood sugar control is key to preventing diabetic kidney disease. Blood Pressure Control: Actively managing blood pressure is crucial, as hypertension can worsen kidney damage. Lipid Control: Proper control of lipid levels is also important in mitigating kidney damage. Quit Smoking: Smoking can worsen kidney damage. Maintain Healthy Weight: Obesity increases the risk of developing diabetic kidney disease. Regular Exercise: Exercise can help control blood sugar, blood pressure, and lipid levels, thus protecting the kidneys.

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What is the first symptom of diabetic kidney disease?

The initial symptom of diabetic kidney disease is often microalbuminuria, which is the presence of a small amount of albumin (a type of protein) in the urine. This may manifest in the early stages of the disease, highlighting the importance of early detection and treatment to prevent further kidney damage. If you have diabetes and observe changes in your urine, it's crucial to consult with a healthcare professional promptly for evaluation and guidance. In addition to microalbuminuria, other symptoms of diabetic kidney disease may include: Fluid Retention: The kidneys may have difficulty removing excess fluid from the body, leading to swelling in the ankles, legs, or around the eyes. Increased Blood Pressure: Diabetic kidney disease can contribute to elevated blood pressure, and high blood pressure, in turn, can worsen kidney damage. Decreased Glomerular Filtration Rate (GFR): As the kidneys' ability to filter blood declines, the GFR may decrease, indicating impaired kidney function. Fatigue and Weakness: Kidney dysfunction can result in anemia, leading to feelings of tiredness and weakness. Changes in Urination: This can include increased frequency, especially at night (nocturia), and difficulty or discomfort during urination. It's important to note that in the early stages, diabetic kidney disease may not present noticeable symptoms. Regular monitoring of blood pressure, blood glucose levels, and urine albumin levels, as well as routine check-ups with a healthcare professional, are essential for individuals with diabetes to detect and manage kidney issues early on. symptom of diabetic kidney disease, diabetic kidney disease, kidney damage, diabetes, Fluid Retention, Blood Pressure, GFR, Fatigue, Weakness, Urination