The 2021 edition of the Chinese Guidelines for the Prevention and Treatment of Diabetes and Kidney is released.

Diabetic kidney disease (DKD) refers to chronic kidney disease (CKD) caused by diabetes and is an important risk factor for cardiovascular disease and early death in diabetic patients

The 2021 edition of the "Guidelines for the Prevention and Treatment of Diabetic Kidney Disease in China" was released recently.

1.

The selection and dosage adjustment of DKD treatment drugs should be based on eGFR (estimated glomerular filtration rate)

2.

The first category: SGLT-2i

The second category: GLP-1RA

2) Hypoglycemic drugs that may be beneficial to the kidneys

The first category: Metformin

The second category: DPP-4i

3) Other hypoglycemic drugs

Including sulfonylureas, glinides, α-glycosidase inhibitors, thiazolidinediones, and insulin

2.

Second, for patients with T2DM who cannot use SGLT2i or whose blood glucose still does not meet the standard after use, it is recommended to use GLP-1RA with evidence of delaying the progression of DKD

Third, if 15≤eGFR<30, GLP-1RA can be used
.

Fourth, if eGFR<15, insulin, linagliptin, nateglinide, etc.
can be used
.

3.
Adjust the dose of hypoglycemic drugs according to eGFR

1) Metformin:

Drug insert: If eGFR<45, ban metformin (see figure below);

Clinical diagnosis and treatment guidelines: If eGFR<30, ban metformin
.

2)SGLT-2i:

Drug insert: If eGFR<45, it is not recommended to use SGLT-2i (see figure below)
.

Clinical diagnosis and treatment guidelines: If eGFR<30, disable SGLT-2i
.

3) DPP-4i:

Linagliptin is mainly eliminated through the hepato-intestinal system, and there is no need to adjust the dose when used in patients with CKD
.

DDP-4i is not used in combination with GLP-1RA
.

4) Sulfonylureas:

Preference is given to hypoglycemic agents with a short half-life, such as gliquidone
.

5) Glinides:

When eGFR<15, nateglinide can be used
.

Three, the choice of antihypertensive drugs

1.
Blood pressure goal

It is recommended that the blood pressure control goal for patients with DKD (especially with albuminuria) is <130/80 mmHg
.

2.
The drug of choice

It is recommended that patients with DKD and hypertension be the first choice for treatment with ACEI or ARB drugs
.

ACEI or ARB drugs can be safely used in patients with serum creatinine ≤ 265 μmol/L (3.
0 mg/dl)
.

3.
Special reminder

First, for diabetic patients without hypertension and normal urinary UACR and eGFR, there is currently no evidence that ACEI or ARB can prevent DKD and may increase cardiovascular risk
.

Second, it is generally believed that ACEI or ARB drugs should be discontinued if the increase in serum creatinine is greater than 30% within two months of medication
.

Fourth, the choice of lipid-lowering drugs

1.
Lipid-lowering goals

It is recommended that the LDL-C target value for DKD patients is <2.
6 mmol/L
.

2.
The drug of choice

The first choice is statin therapy
.

3.
Combination medication

If adverse reactions occur when using statins, reduce the amount of statins and use ezetimibe in combination, but it is not recommended to use ezetimibe alone
.

4.
Choose lipid-lowering drugs based on eGFR

Atorvastatin and its metabolites are mainly eliminated by the liver and (or) extrahepatic metabolism and then bile.
Therefore, there is no need to adjust the dose when using DKD patients
.

Ezetimibe is mainly combined with glucuronide in the small intestine and liver and is excreted by bile and kidneys.
However, patients with renal insufficiency do not need to adjust the dose
.

Microvascular Complications Group of Diabetes Branch of Chinese Medical Association.
Guidelines for Prevention and Treatment of Diabetic Nephropathy in China (2021 Edition)[J].
Chinese Journal of Diabetes, 2021.
13(8): 762-784.