Should we enlarge the indication for kidney biopsy in patients with diabetes? The pro part

NDT Plus Pub Date : 2023-10-26 DOI:10.1093/ckj/sfad266
Loreto Gesualdo, Marco Fiorentino, Francesca Conserva, Paola Pontrelli
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Abstract

Abstract Diabetic nephropathy (DN) and non-diabetic renal diseases (NDRD) represent intricate challenges in diagnosis and treatment within the context of the global diabetes epidemic. As the prevalence of diabetes continues to escalate, effective management of renal complications becomes paramount. Recent advancements in comprehending the multifaceted nature of renal damage, fueled by insights from histopathological investigations, offer unprecedented prospects for refining diagnostic strategies and customizing therapeutic interventions. Renal biopsies have risen as indispensable tools for unraveling the diverse phenotypes of renal damage in diabetes. The pioneering Mazzucco's study identified three classes of renal damage in T2DM patients: classical diabetic glomerulosclerosis (DN), vascular and ischemic glomerular changes (NDRD), and other glomerulonephritides in the presence (DN+NDRD, mixed forms) or absence of DN (NDRD). The prevalence of these classes varies widely in published studies, influenced by factors such as ethnicity, geography, and selection criteria for renal biopsy. Moreover, the international RPS consensus classification system has stratified the classical diabetic nephropathy into progressive categories of renal impairment, a breakthrough that aids in prognostication. Histopathological scrutiny, particularly the intricate correlation between glomerular and tubulointerstitial lesions, contributes profoundly to enhancing our grasp of the phenotype's heterogeneity. This amplified comprehension holds the potential to steer personalized treatment strategies. Cutting-edge interventions, encompassing sodium-glucose cotransporter 2 (SGLT2) inhibitors, mineralocorticoid receptor antagonists (MRAs), and anti-endothelin receptor agents, are broadening the arsenal against renal injury in diabetes. When combined with the profound insights garnered from histopathological, omics, imaging and clinical data these therapeutic avenues promise a transformative shift towards precision-driven care paradigms. Collaborative efforts uniting researchers, clinicians, and patients are indispensable for propelling our knowledge of diabetic renal damage and ameliorating patient outcomes. The fusion of histopathological, omics and imaging findings into clinical decision-making harbors the potential to customize interventions and optimize care for individuals grappling with diabetes-associated renal complications. Furthermore, groundbreaking initiatives like the iBeat Study within the BEAT-DKD project (https://www.beat-dkd.eu/), elucidating distinct phenotypes of renal damage within diabetes, underscore the imperative necessity of integrating histopathological data into the broader framework of diabetic renal management.
我们是否应该扩大糖尿病患者肾活检的适应症?有利的部分
糖尿病肾病(DN)和非糖尿病肾病(NDRD)在全球糖尿病流行的背景下代表了诊断和治疗方面的复杂挑战。随着糖尿病患病率的不断上升,肾脏并发症的有效管理变得至关重要。在组织病理学研究的推动下,最近在理解肾损害的多面性方面取得了进展,为改进诊断策略和定制治疗干预提供了前所未有的前景。肾脏活组织检查已成为揭示糖尿病肾损伤不同表型的不可或缺的工具。Mazzucco的开创性研究确定了T2DM患者的三种肾损害类型:经典糖尿病肾小球硬化(DN),血管和缺血性肾小球改变(NDRD),以及存在(DN+NDRD,混合形式)或不存在DN (NDRD)的其他肾小球肽。在已发表的研究中,这些类型的患病率差异很大,受种族、地理和肾活检选择标准等因素的影响。此外,国际RPS共识分类系统已将经典糖尿病肾病分层为肾脏损害的进行性分类,这是有助于预后的突破。组织病理学检查,特别是肾小球和小管间质病变之间复杂的相关性,有助于增强我们对表型异质性的掌握。这种扩大的理解具有指导个性化治疗策略的潜力。包括钠-葡萄糖共转运蛋白2 (SGLT2)抑制剂、矿皮质激素受体拮抗剂(MRAs)和抗内皮素受体药物在内的尖端干预措施,正在扩大针对糖尿病肾损伤的武库。当结合从组织病理学、组学、影像学和临床数据中获得的深刻见解时,这些治疗途径有望向精确驱动的护理范式转变。研究人员、临床医生和患者的共同努力对于提高我们对糖尿病肾损害的认识和改善患者的预后是必不可少的。将组织病理学、组学和影像学结果融合到临床决策中,有可能为糖尿病相关肾脏并发症患者定制干预措施和优化护理。此外,像BEAT-DKD项目(https://www.beat-dkd.eu/)中的iBeat研究这样的突破性举措,阐明了糖尿病中肾损害的不同表型,强调了将组织病理学数据整合到糖尿病肾脏管理的更广泛框架中的必要性。
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