The Chinese guidelines for renal replacement therapy for end-stage diabetic nephropathy are released, and 39 recommendations are summarized in one article!

Patients with end-stage diabetic nephropathy are very common, which includes two conditions: one is end-stage renal disease (ESRD) caused by diabetes, also known as diabetic nephropathy; the other is chronic kidney disease combined with diabetes, but diabetes is not the cause of ESRD, It is called ESRD with diabetes
.

However, their common characteristics are high incidence of cardiovascular and cerebrovascular events, poor peripheral vascular conditions, high risk of complications such as infection, large blood sugar fluctuations, and difficult management
.

The expert group summarizes the timing, selection of renal replacement therapy, peritoneal dialysis, hemodialysis, and kidney transplantation for end-stage diabetic nephropathy and puts forward relevant suggestions, hoping to attract the attention of nephrologists and continuously improve the treatment level of the disease
.

Timing of renal replacement therapy 1.
It is recommended that patients enter into dialysis.
Indications: when estimated glomerular filtration rate (eGFR) is less than 15 ml/min/1.
73 m2, pre-dialysis preparations can be made.
Start dialysis treatment, such as: ① unrelieved fatigue, nausea, vomiting, itching, etc.
; ② difficult to correct hyperkalemia; ③ uncontrollable metabolic acidosis; ④ uncontrollable water and sodium retention and resistant hypertension, Severe edema, especially associated with congestive heart failure or acute pulmonary edema; ⑤ Uremic pericarditis; ⑥ Uremic encephalopathy and progressive neuropathy; ⑦ Other symptoms, signs and auxiliary examination results that require dialysis; Clinical judgment
.

The choice of dialysis method 1.
It is recommended to choose hemodialysis, peritoneal dialysis or kidney transplantation according to the patient's own situation
.

The influencing factors include patient age, willingness, peripheral vascular condition, abdominal condition, operating ability, quality of life, socioeconomic benefit, and experience of dialysis center
.

 2.
It is recommended to perform kidney transplantation as much as possible for patients who meet the transplant conditions, and combined pancreas-kidney transplantation is possible when conditions permit
.

Compared with dialysis, patients with ESRD who receive kidney transplantation have a better prognosis
.

Peritoneal dialysis 1.
Peritoneal dialysis catheter placement and management in patients with end-stage diabetic kidney disease are recommended as in non-diabetic ESRD patients
.

 2.
Mode selection of peritoneal dialysis: The maintenance peritoneal dialysis mode commonly used in clinic can be used for diabetic peritoneal dialysis patients
.

The selection of the mode should follow the principle of individualization, taking into account the patient's body surface area, the type of peritoneal solute transport, the level of residual renal function, the adequacy of solute and water removal, life>
.

 3.
Selection of peritoneal dialysis dose: For initial dialysis patients who still have a certain residual renal function, incremental peritoneal dialysis is a feasible initial treatment strategy
.

For patients whose residual renal function is very low or has been completely lost, standard-dose dialysis should be used as the initial treatment plan, and attention should be paid to the impact of dialysis on blood sugar, and the use of hypoglycemic drugs should be adjusted accordingly
.

 4.
The dose of incremental peritoneal dialysis usually does not exceed 6L/d or the dialysis day is less than 7d/week.
Common dialysis prescriptions are shown in Table 1
.

5.
Selection of peritoneal dialysis fluid: traditional peritoneal dialysis fluids with different glucose concentrations were selected according to the patient's overall capacity and ultrafiltration level
.

The traditional glucose dialysate is not conducive to the control of blood sugar in diabetic peritoneal dialysis patients.
If conditions permit, icodextrin dialysate or amino acid dialysate can be used
.

 6.
Dialysis adequacy assessment of diabetic peritoneal dialysis patients is based on general peritoneal dialysis patients
.

The main focus is on the nutritional status of peritoneal dialysis patients and whether the solute clearance is sufficient: ①Peritoneal dialysis patients have good clinical status: ➣Good appetite, no nausea, vomiting, insomnia, obvious fatigue, restless legs and other toxin accumulation symptoms, can maintain a better life ability
.

➣ In a normal volume state, without volume-dependent hypertension, heart failure, pulmonary edema, serous effusion and interstitial water retention and peripheral edema, dry body weight is stable
.

➣Good nutritional status, serum albumin ≥35 g/L, normal subjective comprehensive nutritional assessment (SGA), no obvious anemia
.

➣ No obvious manifestations of metabolic acidosis and electrolyte disturbance
.

 ② Sufficient solute clearance in peritoneal dialysis patients: It is necessary to rely on comprehensive determination of urea clearance index, creatinine clearance rate and other indicators
.

Small molecule solute clearance should reach the minimum target value: continuous ambulatory peritoneal dialysis patients require weekly total urea clearance index ≥1.
7, weekly creatinine clearance rate ≥50 L/1.
73㎡
.

It should be noted that insufficient dialysis should be considered in the presence of symptoms or signs, even if the small molecule solute clearance reaches the minimum target value
.

 7.
It is recommended to regularly assess the volume status of diabetic peritoneal dialysis patients, and control volume overload by strictly limiting water and salt intake, protecting residual renal function, rationally adjusting dialysis prescriptions, and correcting hyperglycemia
.

It is recommended to take the following measures to control the volume of diabetic peritoneal dialysis patients: ① Strictly limit the intake of water and salt, generally the intake of sodium chloride does not exceed 5 g/d (or sodium does not exceed 2 g/d)
.

The amount of water intake should be within the limits, and attention should be paid to the intake of hidden water in the diet; ② Protect residual renal function as much as possible; ③ Reasonable dialysis prescriptions; Correct
.

 8.
The prevention and treatment strategies of peritoneal dialysis-related infectious complications in diabetic peritoneal dialysis patients are recommended to refer to general peritoneal dialysis patients
.

 9.
It is suggested that the target target of serum potassium in diabetic peritoneal dialysis patients is 3.
5-5.
0 mmol/L
.

 10.
It is recommended that diabetic peritoneal dialysis patients with gastroparesis adopt a low-fat, low-fiber diet and eat less frequently
.

 11.
Blood glucose monitoring and targets for peritoneal dialysis patients: It is recommended that diabetic peritoneal dialysis patients detect glycosylated hemoglobin (HbA1c) at least once every 3 months; it is recommended to follow the principle of individualization, and generally control HbA1c at about 7%
.

Special attention should be paid to the risk of hypoglycemia.
For elderly patients at risk of hypoglycemia, HbA1c should be appropriately relaxed to 8.
5%
.

The following table (Table 2) shows the adjustment of the oral hypoglycemic drug cascade in dialysis patients
.

12.
Nutritional treatment of peritoneal dialysis patients: ① The protein intake is recommended to adopt an individualized protein diet plan.
The protein intake (DPI) of patients without residual renal function is 1.
0-1.
2 g·kg⁻¹·d⁻¹, with residual renal function The DPI of patients with renal function is 0.
8-1.
0 g·kg⁻¹·d⁻¹; ②The recommended caloric intake is 35 kcal·kg⁻¹·d⁻¹ (1kcal=4.
184 kJ)
.

Patients over the age of 60, those with less activity and good nutritional status can be reduced to 30-35 kcal·kg⁻¹·d⁻¹
.

When calculating energy intake, the calories absorbed by the body from the glucose contained in the dialysate during peritoneal dialysis should be subtracted
.

Hemodialysis 1.
Hemodialysis patients with end-stage diabetic nephropathy are recommended to individually select autologous arteriovenous fistulas, graft arteriovenous fistulas or dialysis catheters with tunnels and polyester sleeves as long-term vascular access
.

 2.
For patients who are expected to need hemodialysis within 3 to 6 months, autologous arteriovenous fistula angioplasty should be considered
.

If the patient needs to establish a graft arteriovenous fistula, it can be established 3 to 6 weeks before starting dialysis
.

For ready-to-wear grafts or dialysis catheters with tunnels and Dacron sleeves, this can be delayed until hours to days before dialysis is required
.

 3.
Hemodialysis mode: The maintenance hemodialysis mode commonly used in clinical practice can be used for diabetic hemodialysis patients
.

 4.
Frequency of hemodialysis: The recommended hemodialysis program is 3 times a week.
If 2 times a week is used, it is recommended to extend the time of a single dialysis session
.

 5.
The assessment of hemodialysis adequacy in patients with end-stage diabetic nephropathy refers to that of general patients
.

 6.
For patients with end-stage diabetic nephropathy complicated with diabetic retinal hemorrhage, the dialysis anticoagulation regimen needs to be adjusted
.

Patients with end-stage diabetic nephropathy are often complicated with diabetic retinal hemorrhage.
When diabetic retinal hemorrhage occurs, no anticoagulant or citrate anticoagulation is the first choice.
In principle, short-term and frequent dialysis is used for patients with intolerance
.

 7.
The prevention and treatment of hypotension in hemodialysis should focus on prevention, including active prevention, early detection, rapid treatment, and appropriate expansion of blood volume
.

 8.
The monitoring of vascular access complications in patients with end-stage diabetic nephropathy should be strengthened
.

 9.
It is recommended that patients with end-stage diabetic nephropathy on hemodialysis monitor serum potassium every 1 to 3 months
.

 10.
The principles of blood glucose monitoring, target target, general treatment and drug treatment in hemodialysis patients with end-stage diabetic nephropathy are the same as those in peritoneal dialysis patients
.

It is recommended to strengthen blood glucose monitoring on dialysis days and to adjust the hypoglycemic regimen of patients with end-stage diabetic kidney disease individually
.

 11.
For patients with blood glucose ≥27.
8 mmol/L at the beginning of hemodialysis, it is recommended to inject a small dose of ultra-short-acting insulin (2-4 U) subcutaneously, and monitor the blood glucose level within 2 hours
.

The target blood glucose level was 5.
6 to 13.
8 mmol/L
.

When blood glucose is ≥33.
3mmol/L, blood gas analysis, serum potassium measurement, and blood ketone body detection should be performed urgently to rule out ketoacidosis
.

When hyperglycemia occurs frequently, it should be diagnosed and treated by a diabetes specialist, and the patient's long-term hypoglycemic program should be adjusted
.

 12.
For diabetic patients receiving insulin treatment, when blood glucose before hemodialysis is less than 7 mmol/L, it is recommended to take 20-30 g of carbohydrates with low glycemic index orally at the initial stage of hemodialysis to prevent further blood glucose drop
.

 13.
For diabetic patients receiving insulin treatment, when blood glucose before hemodialysis is less than 3.
33 mmol/L or symptoms of hypoglycemia occur, if oral administration is possible, 5-10 g of glucose or 15-20 g of carbohydrate foods should be taken orally immediately; if oral administration is not possible For drug administration, 20 ml of 50% glucose solution was injected through the hemodialysis circuit within 60 s
.

Blood glucose monitoring was repeated every 15 minutes, and the above treatment was repeated once blood glucose was <3.
33 mmol/L
.

For diabetic patients who are prone to hypoglycemia during dialysis, preprandial insulin can be suspended once or the dose of preprandial insulin can be appropriately reduced before hemodialysis
.

When hypoglycemia occurs frequently, it should be diagnosed and treated by a diabetes specialist, and the patient's long-term hypoglycemic program should be adjusted
.

 14.
Nutritional treatment for hemodialysis patients: ①Protein intake: The recommended protein intake for hemodialysis patients is 1.
0-1.
2 g·kg⁻¹·d⁻¹, and more than 50% of the recommended protein intake is high biological value protein.
Supplementation of compound α-keto acid preparation 0.
12 g·kg⁻¹·d⁻¹ can improve the nutritional status of patients; ②Energy intake: The recommended caloric intake for maintenance hemodialysis patients is 35 kcal·kg⁻¹·d⁻¹ (1kcal= 4.
184 kJ), and it can be reduced to 30-35 kcal·kg⁻¹·d⁻¹ for patients over 60 years old, those with less activity and good nutritional status
.

Develop an individualized caloric balance plan based on patient age, gender, physical activity level, body composition, target weight, co-morbidities, and level of inflammation
.

Kidney transplantation 1.
Patients with end-stage diabetic nephropathy should pay attention to cardiac evaluation, peripheral vascular evaluation and infection evaluation in the evaluation before kidney transplantation
.

 2.
Perioperative blood sugar management for end-stage diabetic nephropathy in renal transplantation: It is recommended that most diabetic patients should target 7.
8-10.
0 mmol/L for perioperative blood sugar control
.

 3.
It is recommended that patients with end-stage diabetic nephropathy should undergo pancreas-kidney transplantation when conditions permit, which can be combined with pancreas-kidney transplantation or pancreas transplantation after kidney transplantation
.

 4.
The use of glucocorticoids and immunosuppressive drugs after kidney transplantation for end-stage diabetic nephropathy can cause deterioration of blood sugar control 5.
Nutritional therapy for patients with kidney transplantation: ① Protein intake: The changes in eGFR of patients after kidney transplantation should be considered Appropriate adjustment of protein intake, and supplementation of compound alpha keto acid preparation 0.
12 g kg⁻¹ d⁻¹; ② Energy intake: according to age, gender, physical activity level, body composition, mass status target, eGFR changes, Combined with disease or inflammation, consume 25-35 kcal·kg⁻¹·d⁻¹ energy to maintain normal nutritional status
.

Treatment and prevention of cardiovascular complications 1.
Coronary heart disease: continuous measurement of troponin is recommended, combined with dynamic changes in electrocardiogram and symptoms of acute coronary syndrome
.

 2.
Stroke: When stroke occurs in patients with end-stage diabetic nephropathy, the application of antiplatelet drugs, anticoagulants and thrombolytic drugs needs to weigh the pros and cons
.

 3.
The risk of dyslipidemia in patients with end-stage diabetic kidney disease may be higher than that in non-diabetic patients, but the management principles are the same
.

Other precautions 1.
It is recommended that when patients with end-stage diabetic kidney disease have symptoms such as depression, anxiety, personality disorders, drug addiction, and cognitive dysfunction, they should be transferred to a psychiatrist with knowledge of diabetes for treatment
.

 2.
A structured self-management education program for patients with end-stage diabetic kidney disease
.

References: 1.
Expert Group of Nephrology Branch of Chinese Medical Association.
Chinese guidelines for renal replacement therapy for end-stage diabetic nephropathy [J].
Chinese Journal of Nephrology, 2022, 38(1): 62-75.
DOI: 10.
3760/ cma.
j.
cn441217-20210322-00012.