糖尿病肾脏疾病非经典临床类型与病理变化综述

Non-Classical Clinical Types and Pathological Changes of Diabetic Kidney Disease:A Review

糖尿病肾脏疾病(diabetic kidney disease,DKD)是糖尿病的常见并发症,约1/3糖尿病患者可发展至DKD。典型DKD临床早期表现为微量蛋白尿,随着疾病进展可出现大量蛋白尿并伴随肾功能减退。一般认为DKD患者出现大量蛋白尿后病情逆转可能性降低,最终部分患者可发展为终末期肾病(end-stage renal disease,ESRD)。此外,DKD典型病理变化为肾小球基底膜增厚、系膜基质增多、K-W结节及晚期糖尿病肾小球硬化。然而,临床上某些DKD患者,特别是2型糖尿病(type 2 diabetes mellitus,T2DM)合并慢性肾脏病患者临床表现可呈多样性,疾病进展与转归不同,表现为非经典型DKD类型,如正常白蛋白尿型、蛋白尿缓解型、肾功能快速下降型。此外,肾活检还可见新月体形成这一特殊病理改变。但目前临床医师对此认识尚不足,故值得重视。本文结合国内外文献及本课题组既往研究结果,对非经典DKD临床表型与病理变化进行初步介绍,以期进一步加强临床医生对非经典DKD表型与病理变化的认识,提高我国DKD防治水平。

Diabetic kidney disease(DKD)is a common complication of diabetes mellitus and approximately 1/3 of diabetic patients may progress to DKD.A typical early clinical manifestation of DKD is microalbuminuria and patients may present with macroproteinuria accompanied by a decrease in renal function condition as the disease progresses.It is generally believed that the likelihood of a reversal of the disease is reduced after the development of macroproteinuria in patients with DKD,and that eventually some patients'condition may develop into end-stage renal disease(ESRD).Moreover,the thickening of the glomerular basement membrane,mesangial matrix expansion,Kimmelstiel-Wilson(KW)nodules,and glomerulosclerosis in end-stage diabetes mellitus are typical pathologic changes of DKD.However,some DKD patients,especially those with type 2 diabetes mellitus(T2DM)combined with chronic kidney disease,may have diverse clinical manifestations,showing variations in disease progression and regression,and manifesting as non-classical types of DKD,such as normoalbuminuric DKD,proteinuria-reduced DKD,and DKD with rapid decline in renal function.In addition,the formation of crescents,a special pathological change,is observed in renal biopsy.However,this issue is currently under-recognized by clinicians and therefore deserves more attention.In order to improve clinicians'understanding of the presentations and pathological changes of non-classical DKD and the level of DKD prevention and treatment in China,we present a preliminary introduction to the clinical phenotypes and pathological changes of nonclassical types of DKD in this paper by summarizing the findings of our prior studies as well as domestic and international literature.