Kev Txhais Lus Ntawm 2022 Tsab Ntawv ADA Cov Lus Qhia Txog Kev Ntsuas Thiab Kev Kho Mob Ntshav Qab Zib Nephropathy Pom Zoo Hloov Kho Cov Ntsiab Lus

Lub koom haum American Diabetes Association (ADA) Diabetes Medical Diagnosis and Treatment Standards, uas tau hloov kho txhua xyoo, yog ib qho ntawm cov lus qhia muaj txiaj ntsig zoo tshaj plaws rau kev kuaj mob thiab kev kho mob ntshav qab zib. Piv nrog rau 2021 version ntawm cov lus qhia, 2022 version ntawm cov lus qhia muaj ib tshooj cais ntawm "cov kab mob raum ntev (CKD) thiab kev tswj hwm kev pheej hmoo" rau hom 2 mob ntshav qab zib mellitus (T2DM) thiab tau hloov kho tseem ceeb. Tam sim no peb yuav piav qhia cov ntsiab lus tshiab.

1. Kev xaiv cov tshuaj hypoglycemic

Cov lus qhia tshiab tau pom zoo rau thawj daim ntawv thov ntawm sodium-glucose cotransporter 2 inhibitors (SGLT2i) lossis glucagon-zoo li peptide-1 receptor agonist (GLP-1RA) rau kev kho hypoglycemic hauv cov neeg mob T2DM thiab CKD, thiab raws li Nrog lossis tsis muaj metformin raws li xav tau. Thawj zaug, thawj zaug hypoglycemic xwm txheej ntawm SGLT2i lossis GLP-1RA hauv cov neeg mob T2DM nrog CKD yog siab dua li ntawm metformin, tshwj xeeb tshaj yog SGLT2i.

Nyem Yuav Cistanche rau mob raum

Tau ntau xyoo, metformin yog cov tshuaj pom zoo rau kev kho thawj zaug ntawm T2DM kev tswj ntshav qab zib. Nyob rau hauv xyoo tas los no, nrog kev nce ntxiv ntawm cov pov thawj raws li cov pov thawj, nws tau pom tias SGLT2i lossis GLP-1Kev kho RA tuaj yeem txo cov proteinuria, ncua kev ua haujlwm ntawm lub raum, thiab txo lub luag haujlwm ntawm cov kab mob plawv muaj qhov tseem ceeb. zoo dua piv nrog cov tshuaj hypoglycemic ib txwm muaj.

Yog li, rau cov neeg mob uas muaj T2DM thiab CKD [tshwj xeeb tshaj yog tso zis albumin / creatinine piv (UACR) Ntau dua lossis sib npaug li 300 mg / g lossis / thiab kwv yees glomerular filtration rate (eGFR) Tsawg dua lossis sib npaug li 60 ml / min / 1.73m2] , cov txheej txheem tshiab ntawm cov lus qhia, tsis hais txog ntshav qab zib Yog tias qhov xwm txheej tau tswj hwm, SGLT2i yuav tsum tau muab, uas tuaj yeem ncua kev loj hlob ntawm CKD thiab txo qhov kev pheej hmoo ntawm lub plawv tsis ua haujlwm. SGLT2i tuaj yeem ua tau zoo dua rau cov neeg mob uas muaj kev pheej hmoo siab ntawm CKD. Tsis tas li ntawd, randomized soj ntsuam sim tsis tau pom muaj kev pheej hmoo ntawm mob raum raug mob nrog SGLT2i siv.

Yog tias qhov kev pheej hmoo ntawm cov hlab plawv yog qhov tseem ceeb hauv cov neeg mob T2DM thiab CKD, nws raug nquahu kom siv GLP-1RA, uas tuaj yeem txo qhov kev pheej hmoo ntawm cov kab mob plawv thiab hypoglycemia, thiab txo cov proteinuria, uas tuaj yeem ua rau qeeb ntawm kev loj hlob ntawm cov hlab plawv. CKD. Qee GLP-1RAs yuav tsum tau hloov koob tshuaj thaum eGFR txo qis (tshwj tsis yog liraglutide, dulaglutide, thiab semaglutide).

2. Kom so kom txaus eGFR ntau ntawm SGLT2i rau cov neeg mob T2DM thiab CKD

For patients with T2DM combined with CKD or diabetic kidney disease (DKD), the new guideline recommends the use of SGLT2i when UACR≥300 mg/g and eGFR≥25 ml/min/1.73 m2, to delay the progression of CKD and reduce cardiovascular events; while the old guideline eGFR application The range is >30 ml / min / 1.73 m2.

Qhov kev hloov tshiab no yog raws li kev tshawb fawb soj ntsuam tshiab DAPA-CKD cov txiaj ntsig kev tshawb fawb. Cov kev tshawb fawb CREDENCE yav dhau los suav nrog cov neeg mob T2DM nrog 30 Tsawg dua lossis sib npaug rau eGFR Tsawg dua lossis sib npaug li 90 ml / min / 1.73m2 thiab UACR Ntau dua lossis sib npaug rau 300 mg / g, qhia tias SGLT2i tuaj yeem txo cov proteinuria, ncua CKD kev loj hlob, thiab txo cov kab mob plawv; thaum DAPA-CKD Cov kev tshawb fawb yog cov neeg mob T2DM nrog 25 Tsawg dua lossis sib npaug rau eGFR Tsawg dua lossis sib npaug li 75 ml / min / 1.73m2 thiab UACR Ntau dua lossis sib npaug li 300 mg / g, thiab cov txiaj ntsig ntawm kev ncua kev loj hlob ntawm CKD thiab txo cov kab mob plawv kuj tau txais. Muab qhov no, ADA tau txo qis qhov ntau ntawm eGFR hauv SGLT2i kho cov neeg mob ntshav qab zib nrog CKD lossis DKD.

SGLT2i yog ib chav kawm ntawm cov tshuaj hypoglycemic uas ua rau kom cov kua nplaum tawm ntawm lub raum. Raws li eGFR txo qis, qhov ua tau zoo hypoglycemic ntawm cov tshuaj no txo ​​qis. Rau kev kho mob hypoglycemic, feem ntau pom zoo hauv cov lus qhia tshuaj ntawm ntau yam SGLT2i tias SGLT2i daim ntawv thov cov pej xeem yog T2DM cov neeg mob nrog eGFR Ntau dua lossis sib npaug li 45 ml / min / 1.73m2.

Txawm li cas los xij, hauv kev tshawb fawb ntawm T2DM ua ke nrog CKD lossis DKD, nws tau pom tias cov neeg mob ntshav qab zib nrog eGFR.<45 ml/min/1.73m2 were treated with SGLT2i, which can reduce proteinuria, delay CKD progression, reduce cardiovascular events and eGFR≥45 ml/min/1.73 The m2 population is the same, indicating that its effects of reducing proteinuria and delaying the progress of renal function are independent of the hypoglycemic effect.

3. Pom zoo tsis-steroidal mineralocorticoid receptor antagonist finerenone rau cov neeg mob T2DM thiab CKD

Finerenone yog ib hom tshiab uas tsis yog-steroidal mineralocorticoid receptor antagonist (MRA). FIDELIO-DKD txoj kev tshawb fawb pom tau tias, piv nrog cov placebo, finerenone txo qis cov proteinuria hauv cov neeg mob T2DM thiab CKD, txo lub raum sib xyaw qhov kawg (HR 0.82, 95 feem pua ​​CI: {{6}). }.73~0.93, P{{{10}}}001) thiab cov kab mob plawv. Endpoint (HR 0.86, 95 feem pua ​​CI: 0.75 ~ 0.99, P=0.03).

Yog li ntawd, rau cov neeg mob T2DM nrog CKD, yog tias muaj kev pheej hmoo siab ntawm cov hlab plawv lossis CKD kev loj hlob lossis SGLT2i siv tsis tau, ADA pom zoo kom siv cov finerenone kom ncua kev loj hlob ntawm CKD thiab txo cov kab mob plawv.

4. Kev tswj cov ntshav siab kom zoo thiab txo cov ntshav siab hloov pauv tuaj yeem pab txo qis kev pheej hmoo ntawm CKD lossis ua rau qeeb ntawm kev mob raum.

Daim ntawv qhia xyoo 2022 tau hais qhia tias kev ua tiav kev tswj ntshav siab ruaj khov thiab txo cov ntshav siab hloov pauv tuaj yeem txo qhov kev pheej hmoo ntawm DKD thiab txo qis kev mob ntshav qab zib nyuaj nrog CKD. Txuas ntxiv kom pom zoo siv ACEI lossis ARB, thiab tib lub sijhawm, nws raug nquahu kom saib xyuas cov ntshav potassium kom txo tau qhov kev pheej hmoo ntawm hyperkalemia. Nws yuav tsum tau muab sau tseg tias ACEI thiab ARB yuav tsum tau siv ntawm qhov siab tshaj plaws ntawm cov koob tshuaj, thiab cov koob tshuaj qis tsis tuaj yeem muab cov txiaj ntsig kho mob raum. Qhov siab tshaj plaws ntawm cov koob tshuaj ACEI thiab ARB tuaj yeem txo qis kev tuag thiab ua kom qeeb ntawm CKD. Daim ntawv thov ntawm ACEI thiab ARB tsis tas yuav txwv ntau dhau los ntawm kev nce hauv cov ntshav creatinine. Thaum qhov nce hauv cov ntshav creatinine nyob rau hauv 30 feem pua ​​​​thiab tsis muaj kev cuam tshuam hyperkalemia, RAS thaiv kev kho yuav tsum tau txuas ntxiv.

eGFR ntawm cov neeg mob ntshav qab zib tau tso npe rau hauv cov kev tshawb fawb ACEI lossis ARB tam sim no yog tag nrho ntau dua lossis sib npaug li 30 ml / min / 1.73m2; Txawm li cas los xij, cov kev tshawb fawb tsis ntev los no tau pom tias cov neeg mob uas muaj eGFR Tsawg dua lossis sib npaug li 30 ml / min / 1.73m2 txuas ntxiv siv ACEI / ARB piv nrog cov neeg uas tsis siv Cov neeg tuag tsawg dua, qhia tias cov neeg mob eGFR Tsawg dua lossis sib npaug. 30 ml / min / 1.73m2 tuaj yeem tau txais txiaj ntsig los ntawm kev siv ACEI thiab ARB txuas ntxiv.

5. Txhawm rau ncua kev loj hlob ntawm CKD, nws raug pom zoo tias cov neeg mob T2DM nrog UACR Ntau dua lossis sib npaug li 300 mg / g txo UACR Ntau dua lossis sib npaug li 30 feem pua.

Tau ntev, qhov chaw kho mob kawg los soj ntsuam seb qee yam kev kho mob puas muaj txiaj ntsig rau lub raum yog qhov kawg ntawm lub raum tsis ua haujlwm, thiab ob npaug ntawm qib creatinine hauv cov ntshav thiab txo qis ntawm eGFR ntau dua 40 feem pua ​​​​yog suav tias yog cov txiaj ntsig zoo rau qhov kawg ntawm qhov chaw kho mob. . Ntau cov kev tshawb fawb nyob rau xyoo tas los no tau pom tias hauv cov neeg mob CKD nrog UACR Ntau dua lossis sib npaug li 300 mg / g yog tias cov proteinuria txo qis dua 30 feem pua, nws tuaj yeem ncua qhov kev loj hlob ntawm CKD thiab txo qhov kawg ntawm lub raum tsis ua haujlwm.

After discussion by a scientific working group jointly supported by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA), a decrease in urinary albumin >30 feem pua ​​​​ntawm cov hauv paus ntsiab lus tau lees paub tias yog tus neeg sawv cev siv tau rau lub raum txiaj ntsig. Yog li ntawd, cov qauv tshiab ntawm ADA cov lus qhia pom zoo kom ncua kev nce qib ntawm CKD thiab txo UACR Ntau dua lossis sib npaug li 30 feem pua.

Hauv cov ntsiab lus, 2022 version ntawm ADA cov lus qhia tau nthuav dav ntxiv rau kev ua haujlwm kho mob thiab kev ua haujlwm, thiab kev ntsuas kev kho mob tau txiav txim siab raws li CKD staging, uas yooj yim rau kev siv tshuaj kho mob. Tshwj xeeb, nws raug pom zoo tias SGLT2i, finerenone, thiab RAS thaiv ntawm qhov siab tshaj plaws ntawm cov koob tshuaj tuaj yeem ua tiav cov txiaj ntsig kho mob ntau dua hauv CKD.

Yog xav paub ntxiv:ali.ma@wecistanche.com