Cov tswv yim tshiab los txhim kho cov txiaj ntsig kho mob rau mob ntshav qab zib raum

Keeb kwm keeb kwm: Ntshav qab zib raum kab mob (DKD), feem ntau ua rau lub raum tsis ua haujlwm thiab cov kab mob raum kawg thoob ntiaj teb, yuav loj hlob yuav luag ib nrab ntawm txhua tus neeg mob ntshav qab zib hom 2. Nrog rau qhov xwm txheej ntawm hom 2 mob ntshav qab zib mellitus nce ntxiv, kev tshawb pom ntxov thiab kev tswj hwm ntawm DKD yog qhov tseem ceeb hauv kev kho mob.

Lub cev tseem ceeb: Qhov kev tshuaj xyuas no muab cov kev hloov kho tshiab rau DKD hauv cov neeg mob ntshav qab zib hom 2, nrog rau kev tsom mus rau kev kho mob tshiab. Cov tswv yim ib txwm muaj rau kev tiv thaiv thiab kev kho mob ntawm DKD, piv txwv li, kev tswj glycemic thiab kev tswj ntshav siab, tsuas muaj qhov cuam tshuam me me ntawm kev txo qis glomerular pom tus nqi poob lossis nce mus raukab mob raum kawg. Thaum cov txiaj ntsig ntawm cov hlab plawv kev sim ntawm SGLT-2Kuv qhia qhov txiaj ntsig zoo ntawm SGLT-2i ntawm ntau lub raum kab mob ntsig txog qhov kawg, qhov cuam tshuam ntawm GLP-1 RA ntawm lub raum kab mob kawg uas tsis yog txo qis albuminuria tseem yuav tsim. Non-steroidal mineralocorticoid receptor antagonists kuj ua rau lub plawv thiab lub raum tiv thaiv cov teebmeem. Xaus: Nrog rau cov neeg sawv cev tshiab no thiab cov lus cog tseg ntawm cov neeg sawv cev ntxiv hauv kev txhim kho kev kho mob, cov kws kho mob yuav muaj peev xwm kho tau tus kheej ntawm kev kho DKD hauv cov neeg mob.mob ntshav qab zib hom 2. 

Ntsiab lus:Mob ntshav qab zib hom 2, Mob raum mob ntshav qab zib, Cov tshuaj tiv thaiv raum

Keeb kwm

Raws li International Diabetes Federation, 537 lab tus neeg laus (20-79 xyoo) tau nyob nrog ntshav qab zib mellitus thoob ntiaj teb xyoo 2021, thiab tus lej no yuav tsum nce mus rau ntau dua 780 lab los ntawm xyoo 2045 [1]. Ntawm cov no, kwv yees li 90-95% muaj ntshav qab zib hom 2 (T2D) [2, 3]. Ntawm cov neeg uas muaj T2D, yuav luag ib nrab yuav tsim kab mob raum mob ntshav qab zib (DKD), yav dhau los hu ua "diabetic nephropathy" [4, 5]. DKD yog qhov feem ntau ua rau lub raum tsis ua haujlwm thiab cov kab mob raum kawg (ESKD) ua rau muaj kev xav tau kev kho raum hloov (dialysis lossis hloov pauv) hauv ntiaj teb [6, 7]. Ntxiv mus, DKD yog ib qho ua rau muaj kab mob plawv thiab tag nrho kev tuag ntawm cov neeg mob ntshav qab zib [8, 9]. Muab qhov nce ntxiv ntawm T2D, kev tshawb pom ntxov thiab kev tswj xyuas kom zoo ntawm DKD yog qhov tseem ceeb hauv kev kho mob. Qhov kev tshuaj xyuas no muab kev hloov tshiab ntawm DKD pathophysiology, kev tshwm sim hauv chaw kho mob, thiab kev ua tiav tsis ntev los no hauv kev kho DKD.

Pathophysiology

Ntau yam kev mob ntshav qab zib hom 2 suav nrog hyperglycemia thiab cuam tshuam nrog kev cuam tshuam ntawm metabolic, hloov pauv glomerular hemodynamic, thiab proinflammatory thiab profibrotic yam ua rau lub raum puas hauv DKD [10–13]. Cov kev no feem ntau ua rau glomerular hyperfiltration nrog rau glomerular hypertrophy, thiab cov pov thawj qhia tias qhov no tuaj yeem ua rau sclerosis ntxiv, tshwj xeeb nrog comorbid hypertension [11]. Kev rog rog thiab kab mob siab, feem ntau ntawm cov neeg uas muaj T2D, kuj ua rau glomerular hyperfiltration ntau dua [14]. Arteriolar hyalinosis nrog rau tubulointerstitial infammation thiab fibrosis kuj tseem ceeb ntawm DKD (Fig. 1 thiab 2) [11]. Kev nce permeability rau albumin, cim los ntawm qib siab ntawm albuminuria, tshwm sim los ntawm kev raug mob glomerular [15]. Albuminuria feem ntau txhim kho ua ntej tsis pom, tab sis eGFR poob kuj tseem tuaj yeem tshwm sim yam tsis muaj qhov tshwm sim ntawm albuminuria hauv DKD [16–18]. Hauv cov neeg uas muaj kev poob qis hauv eGFR yam tsis muaj albuminuria, cov ntaub so ntswg hauv lub raum feem ntau qhia pom cov kab mob loj heev thiab cov kab mob interstitial fibrosis [18]. Table 1 muab cov lus piav qhia txog kev tshawb pom ntawm glomerular lesion biopsies ntau hauv DKD.

Clinical manifestations

DKD feem ntau ua rau lub raum tsis ua haujlwm lossis ua rau cov kab mob plawv uas ua rau tuag taus li ntawm ib nrab ntawm cov neeg cuam tshuam [11, 20]. Yog li ntawd, kev paub ntxov ntxov, kev tshawb nrhiav, thiab kev cuam tshuam yog qhov tseem ceeb los txhim kho cov txiaj ntsig kho mob.

Cov cuab yeej kuaj mob thiab kev kuaj sim rau DKD

Kev nce siab ntxiv hauv cov zis albumin rau creatinine piv (UACR, Ntau dua lossis sib npaug rau 30mg / g [Ntau dua lossis sib npaug rau 3 mg / mmol]), thiab / lossis tsis tu ncua hauv eGFR (<60 mL/min/1.73m2 ) in a person with diabetes indicates DKD [21]. To qualify as DKD, however, these lesions must be due only to diabetes-related factors [21]. Te American Diabetes Association (ADA) Standards of Medical Care recommends that people with T2D be screened for DKD at their initial diagnosis and annually thereafter [21]. As shown in Fig. 3, there are three categories of albuminuria [22]:

• Theem A1, ib txwm mus me ntsis nce albuminuria:<30 mg/g (<3 mg/mmol) UACR in urine sample

• Qib A2, nce qib albuminuria, microalbuminuria: 30–300 mg/g (3–30 mg/mmol) UACR; tshwm sim Ntau dua lossis sib npaug li 2 zaug, 3-6 lub hlis sib nrug [21]. Tis qib qis albuminuria yog ib qho kev kwv yees tsis tshua muaj txiaj ntsig ntawm kev kis kab mob ntau dua li macroalbuminuria [23]

• Stage A3, severely increased albuminuria, macroalgae minutia: >300 mg/g (>30 mg/mmol) UACR; tshwm sim nplhaib Ntau dua los yog sib npaug rau 2 zaug, 3-6 lub hlis sib nrug [21]

The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is the most commonly used formula to estimate GFR from serum creatinine. Recently, the American Society of Nephrology and the National Kidney Foundation have made recommendations to use race-agnostic methods excluding race in the equation to diagnose and classify chronic kidney disease as a path toward equitable healthcare [24, 25]. A major development is a new CKD-EPI 2021 eGFR equation. This new equation does not include a term for race, with the intent to increase awareness of chronic kidney disease as well as to encourage more timely detection and therapeutic interventions, for all groups of people. The addition of the serum cystatin-C to the CKD-EPI 2021 eGFR equation improves accuracy and precision [25]. Although the serum cystatin-C test is available in some regions of the world, it is not widely used yet due to costs and lack of assay standardization [26–29]. Albuminuria and decreased eGFR, in both general and high-risk populations, are also associated with increased risks for cardiovascular events and mortality, as well as all-cause mortality [30, 31]. Therefore, as a holistic approach to assessing kidney and cardiovascular risks, these tests should be checked at least twice a year in people with diabetes and UACR >30 mg/g (>3 mg / mmol) thiab / lossis eGFR<60 mL/min/1.73 m2 [21].

Ntxiv nrog rau kev saib xyuas rau lub raum puas thiab ua haujlwm, cov neeg muaj T2D yuav tsum tau kuaj lawv cov glycated hemoglobin (HbA1c) txhua 3-6 lub hlis los saib xyuas lawv cov ntshav qabzib [32]. ADA pom zoo tias cov neeg uas muaj T2D ua haujlwm nrog lawv tus kws kho mob los teeb tsa lub hom phiaj ntawm tus kheej rau kev tswj glycemic kom tsis txhob muaj ntshav qab zib, tab sis nrog lub hom phiaj dav dav ntawm HbA1c.<7% (53 mmol/mol) [32].

Table 1 Txheej txheem cej luam ntawm cov chav kawm thiab kev tshawb pom biopsy pom hauv glomerular lesions txuam nrog mob ntshav qab zib raum (DKD)

1. Tswj glycemic tswj - lub hom phiaj HbA1C Tsawg dua lossis sib npaug li 7% (53 mmol / mol) [32]

2. Tswj ntshav siab-ADA pom zoo kom ntshav siab qis dua 140/90 mmHg rau cov neeg mob ntshav qab zib, nrog lub hom phiaj qis dua (piv txwv li, 130/80 mmHg) muaj txiaj ntsig zoo rau cov neeg mob macroalbuminuria [21]. KDIGO pom zoo kom kho rau lub hom phiaj systolic ntshav siab ntawm<120 mmHg, as tolerated, in people with chronic kidney disease with or without diabetes, but not those having had a kidney transplant or on dialysis [34]. Measures to control blood pressure should include the use of either: i. Angiotensin-converting enzyme inhibitors (ACEi) or ii. Angiotensin II receptor blockers (ARB) [22] 

3. Tswj cov roj (cholesterol) - qhov zoo tshaj plaws, low-density lipoprotein (LDL) ntawm<100 mg/dL (2.59 mmol/L), total cholesterol of <150 mg/dL (3.88 mmol/L) i. Statins—used to treat high cholesterol [35, 36] 

4. Kev hloov hauv kev ua neej - txo qhov hnyav, ua kom lub cev muaj zog, thiab kev haus luam yeeb [8, 27]

Ntxiv rau qhov muaj txiaj ntsig zoo uas cov tshuaj txo cov ntshav siab tau nce ntxiv ntawm DKD [37], lwm hom tshuaj kuj tseem siv los tswj DKD hauv cov neeg muaj T2D. Table 2 teev cov chav kawm, piv txwv, thiab hom kev ua ntawm cov tshuaj no. Kev tswj kom zoo ntawm cov ntshav qabzib yog thawj kauj ruam hauv kev tiv thaiv qhov pib ntawm DKD. Ob leeg sodium-glucose thauj protein 2 inhibitors (SGLT2i) thiab glucagon-zoo li peptide-1 receptor agonists (GLP-1 RA) tau pom muaj txiaj ntsig zoo ntawm DKD, xws li txo qis hauv albuminuria lossis qis dua kev pheej hmoo ntawm cov tshiab. - pib albuminuria, ntau dhau ntawm glycemic tswj [44, 51]. Cov lus 3, 4, thiab 5 muab cov ntsiab lus ntawm cov kev sim tshuaj tsis ntev los no ntawm cov neeg ua haujlwm (SGLT-2i, GLP-1 RA, thiab tsis yog ste roidal mineralocorticoid receptor antagonists, MRAs) qhia kev cog lus hauv kev tswj hwm DKD.

Fig. 4 Cov tswv yim kho mob los tiv thaiv kev loj hlob / kev loj hlob ntawm cov kab mob raum ntev hauv cov neeg mob ntshav qab zib. Daim duab no tau tsim los ntawm Kab Mob Raum Txhim Kho Kev Txhim Kho Ntiaj Teb (KDIGO) [27] thiab luam tawm nrog kev tso cai los ntawm KDIGO. Cov ntawv luv: SGLT2, sodium-glucose thauj protein 2; RAS, renin-angiotensin system; CKD, mob raum mob.

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