Diabetes nephropathy

　　The etiology and pathogenesis of diabetic nephropathy are not clear. It is currently believed that multiple factors are involved, and the disease is caused by the combined action of certain genetic backgrounds and some risk factors.

　　1. Genetic factors

　　The proportion of male patients with diabetic nephropathy is higher than that of female patients; studies from the United States have found that in the same living environment, African Americans and Mexican Americans are more prone to diabetic nephropathy than whites; in the same ethnic group, certain families are prone to diabetic nephropathy, all of which suggest the existence of genetic factors. In type 1 diabetes, 40% to 50% of patients develop微量白蛋白尿, and in type 2 diabetes, only 20% to 30% develop diabetic nephropathy during the observation period, all suggesting that genetic factors may play an important role.

　　2. Abnormalities in renal hemodynamics

　　Abnormalities in renal hemodynamics can be observed in the early stage of diabetic nephropathy, manifested as high glomerular perfusion and filtration, increased renal blood flow, and glomerular filtration rate (GFR), and the degree of increase after increased protein intake is more significant.

　　3. Metabolic abnormalities caused by high blood sugar

　　High blood sugar mainly causes kidney damage through changes in renal hemodynamics and metabolic abnormalities.

　　4. Hypertension

　　Almost all cases of diabetic nephropathy are accompanied by hypertension. In type 1 diabetic nephropathy, hypertension occurs simultaneously with微量白蛋白尿, while in type 2, it often appears before the onset of diabetic nephropathy. The control of blood pressure is closely related to the progression of diabetic nephropathy.

　　5. Metabolic abnormalities of vasoactive substances

　　During the occurrence and development of diabetic nephropathy, there can be various metabolic abnormalities of vasoactive substances. This includes metabolic abnormalities of RAS, endothelin, prostaglandin family, and growth factors, among others.

　　Diabetic nephropathy is more common in elderly diabetic patients. If the patient's blood sugar is not stable or poorly controlled for a long time, they often have many complications. This disease is often complicated with renal insufficiency, azotemia, and other diseases.

　　Diabetic nephropathy is one of the systemic microvascular complications of diabetes, and therefore, when diabetic nephropathy occurs, it is often accompanied by microvascular diseases in other organs or systems, such as diabetic retinopathy and peripheral neuropathy. Type 1 diabetes patients usually develop diabetic nephropathy around 10-15 years after onset, while type 2 diabetes patients develop diabetic nephropathy at a shorter time, which is related to older age and the presence of many other underlying diseases.

　　1. Proteinuria

　　Early diabetic nephropathy does not present with clinical proteinuria, and only radioactive immunological methods can detect trace proteinuria. The only manifestation of early clinical diabetic nephropathy is proteinuria, which gradually develops from intermittent to persistent.

　　2. Edema

　　Early diabetic nephropathy generally does not present with edema, but a small number of patients may have mild edema before the plasma protein level decreases. If there is a large amount of proteinuria, low plasma protein, and severe edema, it is usually a manifestation of the disease progressing to the late stage.

　　3. Hypertension

　　In type 1 diabetic patients without kidney disease, the prevalence of hypertension is not increased compared to normal people. In type 2 diabetes, there are more patients with hypertension, but if proteinuria occurs, the proportion of hypertension also increases. In patients with nephrotic syndrome, patients are accompanied by hypertension, most of which is moderate, and a few are severe.

　　4. Renal failure

　　The progression of diabetic nephropathy varies greatly. Some patients may have mild proteinuria for many years, but renal function remains normal. Some patients have little urine protein, which can rapidly develop into nephrotic syndrome, with gradual deterioration of renal function, and eventually lead to uremia.

　　5. Anemia

　　Patients with mild azotemia may have mild anemia.

　　Early prevention of diabetic nephropathy is very important, and common preventive measures include the following points:

　　1. All diabetic patients with a course of disease over 5 years should regularly check renal function, urine protein qualitative, 24-hour urine protein quantification, and pay attention to blood pressure measurement and fundus examination.

　　2. If possible, urine微量albumin and β2-microglobulin should be measured to detect diabetic nephropathy early. If urinary微量albumin increases, it should be measured 3 to 6 times within 3 months to determine whether it is persistent微量albuminuria.

　　3. If it is confirmed that there is an increase in trace albumin and other factors causing its increase, such as urinary tract infection, exercise, or primary hypertension, one should be highly vigilant. And try to control blood sugar as close to normal as possible. If blood pressure is >18.7/12kPa, it should be actively reduced to maintain normal blood pressure. At the same time, it should be emphasized that a low-salt, low-protein diet should be followed.

　　If kidney damage occurs in diabetic patients clinically, diabetic nephropathy should be considered. High-risk factors for the occurrence of diabetic nephropathy include family history of kidney disease, significant hypertension, insulin resistance, significantly high GFR, or severe hypertension. Then, what tests should be done to diagnose diabetic nephropathy?

　　1. Urine sugar qualitative test is a simple method for screening diabetes, but it can appear false-negative or false-positive in diabetic nephropathy, so blood glucose determination is the main basis for diagnosis.

　　2. The urinary albumin excretion rate (UAE) is 20～200μg/min, which is an important index for diagnosing early diabetic nephropathy. When UAE continues to be greater than 200μg/min or routine urine protein test is positive (urinary protein quantification greater than 0.5g/24h), it is diagnosed as diabetic nephropathy. The urine sediment generally does not show significant changes, and a large number of leukocytes suggest urinary tract infection; a large number of red blood cells suggest possible hematuria due to other causes.

　　3. In the late stage of diabetic nephropathy, the endogenous creatinine clearance rate decreases and blood urea nitrogen and creatinine increase.

　　4. The renal dynamic glomerular filtration rate (GFR) of nuclide increases, and the ultrasound shows an enlarged kidney volume, which is consistent with early diabetic nephropathy. In uremia, the GFR significantly decreases, but the kidney volume often does not show significant shrinkage.

　　5. Perform screening for other complications of diabetes, such as fundus examination, and fluorescence fundus angiography if necessary, which can be seen as microaneurysms and other diabetic fundus lesions.

　　High-protein diet will aggravate glomerular hyperperfusion and hyperfiltration, so it is advocated that the diet of diabetic nephropathy patients should be based on the intake of high-quality protein. Protein intake should be mainly animal protein with high biological value, and protein intake should be restricted early, and for patients with a large amount of proteinuria and renal failure, it can be reduced to 0.6g/(kg·d). In addition to focusing on the intake of high-quality protein, symptoms can also be relieved through dietary therapy.

　　1. Egu and White Sesame Seed Porridge

　　Take 30 grams of Egu (Chinese yam), 10 white sesame seeds, 30 grams of glutinous rice. Shell the white sesame seeds, add them to the glutinous rice and Egu in a pot with an appropriate amount of water, and cook them into porridge. This formula can be used to treat symptoms such as turbid urine and the excretion of a large amount of protein in urine.

　　2. Astragalus Porridge

　　Take 30-60 grams of raw Huangqi (Astragalus), 60 grams of sticky rice, 10 grams of dried tangerine peel powder. First, decoct the Huangqi for 15 minutes and remove the residue, then add the sticky rice and cook it into porridge. After the porridge is cooked, add the dried tangerine peel powder. This formula can improve kidney function, eliminate proteinuria, and enhance physical fitness.

　　3. Black Soybean Stewed Pork

　　Take 50 grams of Hei Dou (black soybean), 100 grams of lean meat. First, put the pork in water, boil it, then remove the soup, and it can be eaten.

　　Some scholars divide diabetic nephropathy into three stages: early, middle, and late.

　　1. Early Stage

　　Early symptoms are manifested as both spleen and kidney deficiency, which is suitable for invigorating the spleen and Qi, and for tonifying the kidney and astringing essence. The formula used is Liushitong Decoction with modifications, including Shudihuang, Shengdihuang, Shanyao, Fuling, Zexie, Mudanpi, Maidong, Wuweizi, Shaoyaoziren, Zhizi, Zhishouwu, Danggui, Danshen, etc.

　　2. Middle Stage

　　Symptoms in the middle stage are manifested as both spleen and kidney yang deficiency, which is suitable for warming and tonifying the spleen and kidney, and for promoting diuresis and purging turbidity. The formula selected is Zhenwu Decoction with modifications, including Chuanbeizi, Guizhi, Baizhu, Fuling, Qianxiezi, Yangxiaohuo, Dongkuizi, Shuizhi, Shengjiang, Yimucao, Baishao, etc.

　　3. Advanced Stage

　　Advanced symptoms are often manifested as both yin and yang deficiency. The treatment options include Jisheng Shenqi Pill, Linggui Zhugan Decoction, and Dahuang Fuzi Xixin Decoction.