1、ChengJiClinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher(eGFR45 mL/min)1112PURPOSE AND SCOPE OF THIS GUIDELINE3Whywasthisguidelineproduced?#lThisclinicalpracticeguidelinewasdesignedtofacilitateinformeddecision-makingonthemanagementofadu
2、ltindividualswithdiabetesmellitusandCKDstage3borhigher(eGFR45mL/min).lItwasnotintendedtodefineastandardofcare,andshouldnotbeconstruedassuch.Itshouldnotbeinterpretedasaprescriptionforanexclusivecourseofmanagement.4Whoisthisguidelinefor?#Thisguidelineintendstosupportclinicaldecisionmakingbyanyhealthca
3、reprofessionalcaringforpatientswithdiabetesandCKDstage3borhigher(eGFR45mL/min),i.e.forgeneralpractitioners,internists,surgeonsandotherphysiciansdealingwiththisspecificpatientpopulationinbothanoutpatientandanin-hospitalsetting.Theguidelinealsoaimstoinformaboutthedevelopmentofstandardsofcarebypolicy-m
4、akers.5CHAPTER 1:#ISSUES RELATED TO RENAL REPLACEMENT MODALITY SELECTION IN PATIENTS WITH DIABETES AND END-STAGE RENAL DISEASE6ShouldpatientswithdiabetesandCKDstage5startwithperitonealdialysisorhaemodialysisasafirstmodality?#Statements 1.1.1 We recommend giving priority to the patients general statu
5、s 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
6、.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).7ShouldpatientswithdiabetesandCKDstage5startdialysisearlier,i.e.beforebecomingsy
7、mptomatic,thanpatientswithoutdiabetes?#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 Di
8、alysis Early and Late(IDEAL)studyJ.Nephrol Dial Transplant,2011,26:#2082-2086.8InpatientswithdiabetesandCKDstage5,shouldanativefistula,graftortunnelledcatheterbepreferredasinitialaccess?#Statements 1.3.1 We recommend that reasonable effort be made to avoid tunnelled catheters as primary access in pa
9、tients 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.910IsthereabenefittoundergoingrenaltransplantationforpatientswithdiabetesandCKDstage5?#1.4.1 We recommend providing ed
10、ucation 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).11IsthereabenefittoundergoingrenaltransplantationforpatientswithdiabetesandCKDstage5?#Statements only for patients
11、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
12、.4.4 We suggest pancreas grafting to improve survival after kidney transplantation(2C).12IsthereabenefittoundergoingrenaltransplantationforpatientswithdiabetesandCKDstage5?#Statements only for patients with type 2 diabetes and CKD stage 5 1.4.5 We recommend against pancreas or simultaneous kidney pa
13、ncreas 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 DIAB
14、ETES AND CKD STAGE 3B OR HIGHER(eGFR 45 mL/min)14A.ShouldweaimtolowerHbA1CbytighterglycaemiccontrolinpatientswithdiabetesandCKDstage3borhigher(eGFR45mL/min)?#B.Isanaggressivetreatmentstrategy(innumberofinjectionsandcontrolsandfollow-up)superiortoamorerelaxedtreatmentstrategyinpatientswithdiabetesand
15、CKDstage3borhigher(eGFR8.5%(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 other conditions(2D).2.1.4 We recommend intense self-monitoring only to avoid hypoglycaemia in patients at high risk for hy
16、poglycaemia(2D).中国成人2型糖尿病HbA1C控制目标的专家共识建议对T2DM合并CKD患者的HbA1C可适当放宽控制在79。#161718AretherebetteralternativesthanHbA1ctoestimateglycaemiccontrolinpatientswithdiabetesandCKDstage3borhigher(eGFR45mL/min/1.73m2)?#Statements 2.2.1 We recommend the use of HbA1C as a routine reference to assess longer term glycaemic control in patients with CKD stage 3b or higher(eGFR45 mL/min/1.73 m2)(1C).在晚期CKD患者,使用糖化血清蛋白反映血糖控制水平可能更可靠。#2型糖尿病合并慢性肾脏病患者口服降糖药用药原则中国专家共识19A.Isanyoraldrugsuperiortoanotherintermsofmortality/complications/glycae
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