2015年欧洲肾脏最佳临床实践关于糖尿病合并慢性肾脏病3b期或更高阶段临床管理指南

Cheng Ji,Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR45 mL/min),1,1 1,2,PURPOSE AND SCOPE OF THIS GUIDELINE,3,Why was this guideline produced? This clinical practice guideline was designed to facilitate informed decision-making on the management of adult individuals with diabetes mellitus and CKD stage 3b or higher (eGFR45 mL/min). It was not intended to define a standard of care, and should not be construed as such. It should not be interpreted as a prescription for an exclusive course of management.,4,Who is this guideline for? This guideline intends to support clinical decision making by any health care professional caring for patients with diabetes and CKD stage 3b or higher (eGFR45 mL/min), i.e. for general practitioners, internists, surgeons and other physicians dealing with this specific patient population in both an outpatient and an in-hospital setting. The guideline also aims to inform about the development of standards of care by policy-makers.,5,CHAPTER 1: ISSUES RELATED TO RENAL REPLACEMENT MODALITY SELECTION IN PATIENTS WITH DIABETES AND END-STAGE RENAL DISEASE,6,Should patients with diabetes and CKD stage 5 start with peritoneal dialysis or haemodialysis as a first modality?,Statements 1.1.1 We recommend giving priority to the patients general status and preference in selecting renal replacement therapy as there is an absence of evidence of superiority of one modality over another in patients with diabetes and CKD stage 5 (1C). 1.1.2 We recommend providing patients with unbiased information about the different available treatment options (1A). 1.1.3 In patients opting to start haemodialysis(HD), we suggest prefering high flux over low flux when this is available (2C). 1.1.4 We suggest diabetes has no influence on the choice between HD or haemodiafiltration (HDF) (2B).,7,Should patients with diabetes and CKD stage 5 start dialysis earlier, i.e. before becoming symptomatic, than patients without diabetes?,Statements 1.1.1 We recommend initiating dialysis in patients with diabetes on the same criteria as in patients without diabetes (1A).,1. Tatters al l J, Dekker F, Hei mburger O, et alWhen to start dialysis：updated guidance following publication of the Initiating Dialysis Early and Late(IDEAL)studyJ. Nephrol Dial Transplant,2011,26:2082-2086.,8,In patients with diabetes and CKD stage 5, should a native fistula, graft or tunnelled catheter be preferred as initial access?,Statements 1.3.1 We recommend that reasonable effort be made to avoid tunnelled catheters as primary access in patients with diabetes starting HD as renal replacement therapy (1C). 1.3.2 We recommend that the advantages, disadvantages and risks of each type of access be discussed with the patient.,9,10,Is there a benefit to undergoing renal transplantation for patients with diabetes and CKD stage 5?,1.4.1 We recommend providing education on the different options of transplantation and their expected outcomes for patients with diabetes and CKD stage 4 or 5 who are deemed suitable for transplantation (Table 5) (1D).,11,Is there a benet to undergoing renal transplantation for patients with diabetes and CKD stage 5?,Statements only for patients with type 1 diabetes and CKD stage 5 1.4.2 We suggest living donation kidney transplantation or simultaneous pancreas kidney transplantation to improve survival of suitable patients (2C). 1.4.3 We suggest against islet transplantation after kidney transplantation with the aim to improve survival (2C). 1.4.4 We suggest pancreas grafting to improve survival after kidney transplantation (2C).,12,Is there a benet to undergoing renal transplantation for patients with diabetes and CKD stage 5?,Statements only for patients with type 2 diabetes and CKD stage 5 1.4.5 We recommend against pancreas or simultaneous kidney pancreas transplantation (1D). 1.4.6 We recommend diabetes in itself should not be considered a contraindication to kidney transplantation in patients who otherwise comply with inclusion and exclusion criteria for transplantation (1C).,13,CHAPTER 2. ISSUES RELATED TO GLYCAEMIC CONTROL IN PATIENTS WITH DIABETES AND CKD STAGE 3B OR HIGHER (eGFR 45 mL/min),14,A. Should we aim to lower HbA1C by tighter glycaemic control in patients with diabetes and CKD stage 3b or higher (eGFR 45 mL/min)? B. Is an aggressive treatment strategy(in number of injections and controls and follow-up) superior to a more relaxed treatment strategy in patients with diabetes and CKD stage 3b or higher (eGFR 45 mL/min) and using insulin?,15,Statements 2.1.1 We recommend against tighter glycaemiccontrol if this results in severe hypoglycaemic episodes (1B). 2.1.2 We recommend vigilant attempts to tighten glycaemic control with the intention to lower HbA1C when values are 8.5% (1C). 2.1.3 We suggest vigilant attempts to tighten glycaemic control with the intention to lower HbA1C according to the flow chart in Figure 4 in all ot