Volume 13 · Issue 10 · 2021

Diabetic nephropathy (DKD) is a common and important microvascular complication caused by diabetes, and has become the main cause of chronic kidney disease (CKD) and end-stage kidney disease (ESRD). Early renal damage in diabetes mellitus is mainly renal tubular damage, and renal tubular-related biomarkers can suggest the progression and prognosis of DKD. Novel hypoglycemic drugs attenuate renal tubular injury, protect the kidney and improve renal outcomes through hemodynamic and non-hemodynamic pathways.

The Guidelines for Clinical Application of Blood Glucose Monitoring in China (2021 Edition) is an update and revision of the Guidelines for Clinical Application of Blood Glucose Monitoring in China (2015 Edition), which introduces new technologies and new evidence in the field of blood glucose monitoring in recent years, aiming to highlight the advancement, standardization and practicality. In order to help the readers better understand and grasp the updating points and the basis of revision, this paper emphatically introduces the compiling background and updating key points of the new edition of the guide.

Type 2 diabetes (T2DM) has long been believed to be a lifelong condition. Clinical practice in recent years has shown that some T2DM patients can stop taking hypoglycemic drugs after taking certain intervention measures while their blood sugar is still at normal or close to normal levels. At present, most scholars use "remission" to describe the continuous improvement of metabolism in T2DM patients to near normal state. This paper introduces the concept and judgment criteria of T2DM mitigation, the strategies to achieve T2DM mitigation, the influences and predictors of T2DM mitigation, and expounds the possible mechanisms to induce T2DM mitigation. T2DM remission has important clinical significance. It not only protects patients from drug therapy for a period of time, but also reduces the risk of complications in patients. Research on the remission mechanism is also expected to derive new intervention targets, but there are still some problems in this field that need to be solved. Clinically, the management of patients with T2DM who have been relieved cannot be relaxed, and regular review is required. If the patient's blood glucose exceeds the control standard, the corresponding treatment should be initiated in time according to the guidelines.

Blood glucose monitoring is an important part of diabetes management. With the progress of science and technology, the methods of blood glucose monitoring are constantly developing in the direction of convenience, accuracy, minimally invasive and non-invasive, which brings great convenience to clinical work. In recent years, the clinical research achievements in the field of blood glucose monitoring are increasing at home and abroad. Therefore, the Diabetes Branch of Chinese Medical Association organized experts to revise and update the Guidelines for Clinical Application of Blood Glucose Monitoring in China (2015 Edition) according to new evidence-based medical evidence, aiming to further standardize blood glucose monitoring, guide medical staff to rationally apply various blood glucose monitoring methods and correctly interpret the monitoring results, so as to further improve the management level of diabetes.

Type 2 diabetes mellitus (T2DM) has some reversibility in the early stage. Short-term intensive insulin therapy can significantly improve islet β cell function and insulin sensitivity, and is an effective means to reverse T2DM. In order to better guide the clinical practice of short-term intensive insulin therapy to reverse T2DM, the expert group has systematically sorted out the existing clinical evidence and combined with practical experience to form this consensus recommendation. This consensus gives the definition of diabetes remission and hyperglycemia reversal, and recommends short-term intensive insulin reversal therapy for eligible newly diagnosed T2DM patients or T2DM patients whose original treatment plan cannot achieve blood glucose standard; During short-term intensive insulin reversal therapy, blood glucose normalization should be the goal; The course of intensive therapy is at least 2 weeks after blood glucose reaches the standard; After intensive treatment, the efficacy should be predicted in combination with the existing clinical evidence, and then an individualized follow-up management plan should be formulated.

To investigate the fluctuation of blood glucose in patients on hemodialysis who were diagnosed as type 2 diabetes mellitus (T2DM) with diabetic kidney disease (DKD) using a flash glucose monitoring system (FGM).

T2DM patients with DKD who underwent regular hemodialysis in Blood Purification Center of Tianjin Medical University Chu Hsien-I Memorial Hospital from June to December 2020 were randomly selected, and FGM and self-monitoring of blood glucose (SMBG) were performed. The 4-hour blood glucose before dialysis, 4-hour blood glucose during dialysis, 4-hour blood glucose after dialysis, the mean amplitude of glycemic excursions and the blood glucose variability were recorded. The consistency of FGM and SMBG values were evaluated by Parkes error grid. Paired t-test was adopted to compare the blood glucose values before and after dialysis, and independent sample t-test was used to compare the data between dialysis day and non-dialysis day.

Parkes error grid showed that 73.4% of the values fell into zone A, 26.4% fell into zone B, and 99.7% fell into zone A and zone B together. FGM accuracy was clinically accepted. The 4-hour blood glucose before dialysis was significantly higher than that at the corresponding time point on non-dialysis day; 4-hour blood glucose during dialysis was lower than that at the corresponding time point on non-dialysis day, and 4-hour blood glucose after dialysis was significantly higher than that at the corresponding time point on non-dialysis day. The difference was statistically significant (all P<0.05). Compared with non-dialysis days, the average blood glucose fluctuation increased on the day of dialysis (P<0.05).

FGM is an acceptable alternative for blood glucose monitoring in patients on hemodialysis who were diagnosed as T2DM with DKD. The mean amplitude of glycemic excursions increased remarkably on the day of dialysis.

To investigate the association between individual and combined cardiometabolic morbidities and chronic kidney disease (CKD) in middle-aged and elderly population in Henan.

The China Cardiometabolic Disease and Cancer Cohort (4C) Study—Henan Branch Center is a population-based, multicenter, prospective cohort study. Middle-aged and elderly population who with complete information on blood pressures, fasting plasma glucose (FPG), oral glucose tolerance test (OGTT) 2 h glucose, glycated hemoglobin A_1c (HbA_1c), total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), high-density lipoprotein-cholesterol (HDL-C), triglycerides (TG), and estimated glomerular filtration rate (eGFR) at baseline from 2011 to 2012, were invited to attend an in-person visit from 2014 to 2016. The t test, χ² test and nonparametric test were used for comparison between the baseline data of participants of different genders. Cox regression analysis was used to analyze the correlation between individual and combined cardiovascular metabolic diseases and CKD.

A total of 4 114 participants were enrolled, including 1 363 men and 2 751 women. The prevalence of CKD was 2.4% (98/4 114). Participants with only diabetes [hazard ratio (HR)=3.802, 95% confidence interval (CI) 0.999-14.471, P=0.050], only hypertension (HR=1.966, 95%CI 0.554-6.978, P=0.296), or only dyslipidemia (HR=2.954, 95%CI 0.918-9.503, P=0.069) did not exhibit significantly higher risk for CKD. When analyzed collectively, participants with diabetes complicated with hypertension (HR=4.792, 95%CI 1.418-16.193, P=0.012), diabetes complicated with dyslipidemia (HR=3.770, 95%CI 1.202-11.820, P=0.023), and hypertension complicated with dyslipidemia (HR=3.739, 95%CI 1.183-11.816, P=0.025) exhibited significantly higher risk for CKD. Moreover, participants with the combination of diabetes, hypertension and dyslipidemia exhibited the highest risk for CKD (HR=6.877, 95%CI 2.285-20.702, P<0.01).

Diabetes, hypertension and dyslipidemia showed additive associations with the risk of CKD events in middle-aged and elderly adults in Henan, China.

To investigate the hospitalization costs and influencing factors in patients with diabetic kidney disease (DKD).

A total of 14 851 patients who hospitalized with diabetes in the First Hospital Affiliated of Chongqing Medical University from 2005 to 2016 were enrolled retrospectively. The patients′ gender, age, primary diagnosis, second diagnosis, average daily hospitalization cost, total hospitalization cost and other information were recorded. Patients were divided into DKD group, diabetic retinopathy (DR) group and diabetic peripheral neuropathy (DPN) group according to the types of microvascular complications. Mann-Whitney U test, Kruskal-Wallis H test and χ² test were used to compare the hospitalization costs and length of stay among different groups, and multi-linear regression analysis were used to investigate the influencing factors of the hospitalization costs of patients with DKD.

Of the 14 851 patients with diabetes, 3 435 (23.13%) patients suffered DKD. The prevalence of DKD, DR and DPN in diabetic patients differs in age, sex and statistical year (P<0.05). Compared with other diabetic microvascular diseases (DR and DPN), patients with DKD had the longest hospital stay, with an average of 12 (8, 16) days, and had the highest average daily hospitalization costs coupled with total hospitalization costs, which were RMB (966.49±438.99) Yuan and RMB (12 852.88±12 820.50) Yuan, respectively (P<0.05). The age, number of microvascular complications and severity of DKD had a statistically significant difference on the total costs of hospitalization in DKD patients (P<0.05), among which age had the greatest impact on total hospitalization costs (standardized coefficient Beta value was 0.11).

Patients with DKD suffered heavy financial burden. Moreover, the age, number of microvascular complications and severity of DKD had a significant effect on their hospitalization costs, among which age had the greatest impact on total hospitalization costs.

To observe the changes of serum secretory frizzled-associated protein 5 (sFRP5) in patients with diabetic kidney disease (DKD) and investigate the correlative factors.

A total of 195 patients with type 2 diabetes mellitus (T2DM) who were admitted to the Department of Endocrinology of Henan People′s Hospital from January 2019 to June 2020 were selected, urine microalbumin/creatinine ratio (UACR) was measured in all subjects. T2DM patients were divided into three groups according to UACR: normal albuminuria group (65 cases, UACR<30 mg/g), microalbuminuria group (65 cases, 30 mg/g≤UACR≤300 mg/g) and large albuminuria group (65 cases, UACR>300 mg/g). Blood pressure, height and weight of all subjects were measured, and body mass index (BMI) was calculated. The fasting plasma glucose (FPG), fasting insulin (FIns), glycosylated hemoglobin A_1c (HbA_1c), total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), serum creatinine (SCr) and hypersensitive C-reactive protein (hs-CRP) were detected. Homeostatic model assessment of insulin resistance (HOMA-IR) was calculated. Detection the levels of serum sFRP5, interleukin-6 (IL-6), tumor necrosis-α (TNF-α) and transforming growth factor-β1 (TGF-β1). One-way analysis of variance (ANOVA) test and χ² test were used to compare the differences between indicators in the three groups. The correlation between serum sFRP5 levels and inflammatory factors and other factors was analyzed by Spearman correlation analysis. The influencing factors of serum sFRP5 were analyzed by multiple stepwise linear regression methods.

Serum levels of sFRP5 in microalbuminuria group and large albuminuria group were lower than those in normal albuminuria group (P<0.05), and large albuminuria group were lower than those in microalbuminuria group (P<0.05). Duration, FPG, HbA_1c, FIns, HOMA-IR, SBP, DBP, SCr, UACR, hs-CRP, IL-6, TNF-α and TGF-β1 in microalbuminuria group and large albuminuria group were higher than those in normal albuminuria group (all P<0.05). Those indexes in large albuminuria group were higher than microalbuminuria group (allP<0.05). Serum sFRP5 was negatively correlated with duration, FPG, FIns, HOMA-IR, HbA_1c, UACR, SCr, TC, hs-CRP, IL-6, TNF-α, TGF-β1(all P<0.05).UACR, TGF-β1, HOMA-IR were independent influencing factors of serum sFRP5 (allP<0.05).

Serum sFRP5 levels are significantly decreased in patients with DKD, which are closely related to blood glucose, blood lipid, insulin resistance and inflammatory factors. Serum sFRP5 may be involved in the occurrence and development of DKD through glycolipid metabolism, insulin resistance and inflammatory response.

In this study, blood oxygen level-dependent functional magnetic resonance imaging (BOLD-MRI) was used to observe the difference between renal oxygen consumption with or without diabetic nephropathy, and to explore a non-invasive, reliable, and sensitive examination method for the assessment and diagnosis of early diabetic kidney disease (DKD).

A total of 58 type 2 diabetes (T2DM) subjects who admitted in Beijing Tsinghua Changgung Hospital from July 2017 to December 2019 were selected, and 30 normal subjects were recruited. According to the urine albumin/creatinine ratio (UACR) and the assessment of glomerular filtration rate (eGFR), patients with T2DM were divided into two groups: normal renal function group (n=30): UACR<30 mg/g and eGFR ≥90 ml·min^-¹·(1.73 m^-²)^-¹; microalbuminuria group (n=28): UACR 30 to 300 mg/g and eGFR>60 ml·min^-¹·(1.73 m^-²)^-¹. The renal functional MRI (BOLD-MRI and arterial spin labeling-MRI) were performed to obtain quantitative values of the subjects′ renal cortex, and medulla oxygenation as well as blood perfusion. The results were analyzed by variance, χ² test, Pearson linear correlation analysis and receiver operating characteristic (ROC) curve. Furosemide was used in the normal controls to evaluate the reliability of BOLD-MRI scaning.

The renal cortex and medulla oxygenation values of three groups subjects were statistically different (P<0.01). Compared with control group, the medulla oxygenation R₂^* values were elevated in patients with microalbuminuria (P=0.011). The medulla oxygenation R₂^* values and eGFR were negatively correlated (r=-0.323, P=0.001). The area under the ROC curve of diagnosis of DKD by medulla oxygenation R₂^* value was 0.837.

The oxygen consumption of kidney cortex and medulla in T2DM patients was significantly increased. The renal medulla demonstrated a hypoxic injury in the diabetes patients without microalbuminuria and impaired renal function. Therefore, BOLD-MRI could be used to monitor the increase of renal medulla R₂^* value, which may be a risk indicator for early diabetic kidney disease.

To investigate the status of nutrient intakes and glycemic control in adults with type 1 diabetes (T1DM) in Guangdong Province. And to evaluate the effects of structured education on glycemic control and self-management in patients with T1DM.

Food frequency questionnaires (FFQ) were performed on the adult T1DM patients who enrolled in two sites in different regions of Guangdong T1DM translational medicine study (GTT) from June 2010 to June 2013 and had been followed up for 5 years continuously by December 2019. Data on nutrient intakes and clinical information was collected. Glycated hemoglobin A_1c (HbA_1c) was used to evaluate whether or not glycemic target was achieved. The differences between two sites and different diet pattern were compared using t-test, paired-samples t-test, analysis of variance (ANOVA) test, rank sum test or chi-square test, where suitable.

A total of 114 qualified questionnaires were included, and the qualified response rate was 95% (114/120). On average, 43.9% (50/114) of the patients reached the recommended intake levels of carbohydrates. More than half of the patients had excessive intake of protein and fat [52.6% (60/114) and 50.9% (58/114), respectively]. The intake of dietary fiber was 11.33 (7.23, 15.22) g, and the intake of some vitamins and minerals in all patients was significantly lower than the recommendation, and the proportion of patients meeting the recommended levels was pretty low. After 5 years of follow-up, the mean HbA_1c [(8.87±2.33)% vs. (7.12±1.06)%] and the proportion of patients with hyperglycemia [HbA_1c>9.5%, 32.40% (36/111)vs. 2.63% (3/114)] were significantly decreased, while the proportion of patients who achieved glycemic target [23.42% (26/111) vs. 51.75% (59/114)] and who adhered to self-glucose monitoring at least 4 times a day [27.03% (30/111) vs. 65.80% (75/114)] were significantly increased, when compared with the baseline results of GTT (P<0.01).

Current dietary quality of adults with T1DM in Guangdong Province was poor. Foods that are low in fat, high in fiber and vitamin and mineral-dense should be encouraged as important part of a healthy dietary pattern. As one of the self-management education systems, structured education may be associated with better self-management in T1DM.

This paper reports a special case of fulminant type 1 diabetes mellitus (FT1DM) caused by programmed death receptor 1 (PD-1) inhibitors. The patient was a 70-year-old woman who was treated with monoclonal antibody to carrelizu due to lymph node metastasis after gastric cancer surgery. After about 6 months of medication, he was admitted to hospital due to sudden coma, and his blood glucose was as high as 60.1 mmol/L. Considering diabetic ketoacidosis, glycosylated hemoglobin was further examined at 7.88%, and serum C-peptide was as low as 0.04 ng/ml on fasting and 2 h after meals. He was diagnosed as PD-1 inhibitor-related FT1DM. He was given fluid rehydration and insulin hypoglycemic therapy to correct water and electrolyte disorders. At present, the patient's clinical symptoms have improved, and he has long-term insulin hypoglycemic therapy, but his blood sugar fluctuates greatly.

This paper reports a case of fulminant type 1 diabetes mellitus (FT1DM) associated with insulin allergy and discusses its possible pathogenesis. This patient developed local skin allergy after protamin recombinant human insulin N and recombinant human insulin R, sharp decline of pancreatic islet β cell function, and recurrent spontaneous diabetic ketosis. In this paper, the diagnosis and treatment of this case of FT1DM associated with insulin allergy were reviewed, so as to improve clinicians' understanding of this disease, and to diagnose and treat it early to reduce the occurrence of related adverse outcomes.

Type 1 diabetes mellitus (T1DM) is the predominant type of childhood diabetes, accounting for approximately 80%. In fact, T1DM can occur at any age. Studies show that up to 50% of patients develop the disease in adulthood, and about half of them are misdiagnosed with type 2 diabetes. There is great heterogeneity in the clinical presentation of adult T1DM. Compared with childhood T1DM, adult T1DM has milder clinical manifestations (weaker ketosis tendency, higher fasting and postprandial C-peptide levels), slower islet autoimmune process, and the sensitivity and popularity of antibody detection technology. Correct clinical diagnosis of adult T1DM still poses certain challenges. This article will combine the research data on T1DM diagnosis in large-scale clinical studies at home and abroad, and discuss the difficulties and key points of diagnosis and classification between T1DM and adult T1DM.

Chronic kidney disease has become an important global public health problem, and its treatment goal is to delay the progression of the disease to end-stage kidney disease. As a common chronic complication of diabetes mellitus, diabetic nephropathy (DKD) is also one of the main causes of end-stage renal disease. Therefore, combined diabetes mellitus increases the difficulty of managing CKD. As a novel hypoglycemic drug, sodium-glucose cotransporter 2 inhibitor (SGLT2i) can not only reduce blood sugar, but also have obvious renal protective effects. It is recommended for preventing and delaying the occurrence and development of DKD. However, the mechanism of action of SGLT2i renal protection is not fully understood. Therefore, this paper summarizes the relevant clinical studies of SGLT2i renal protection in recent years, and summarizes the underlying mechanisms of SGLT2i renal protection.