Abstract
BACKGROUND: Tubulointerstitial lesions (TILs) play a crucial role in the progression of diabetic kidney disease (DKD). Current clinical prediction methods rely heavily on invasive biopsies and fall short of providing a comprehensive, multidimensional assessment. METHODS: This multicenter study, conducted from 2010 to 2024, involved patients with biopsy-confirmed DKD. We employed logistic regression and the Least Absolute Shrinkage and Selection Operator (LASSO) with 10-fold cross-validation to identify key predictive indicators. A machine learning-based nomogram was developed and model performance is evaluated by discrimination, calibration, and decision curve analysis (DCA). RESULTS: A total of 337 were divided into training (n = 180), internal validation (n = 78), and external validation (n = 79) cohorts. Multivariate analysis confirmed SCr (OR = 1.02, 95% confidence interval [CI]:1.01-1.03), HDL (OR = 0.68, 95% CI: 0.52-0.85), and severe glomerular hyperplasia (OR = 9.79, 95% CI: 1.41-80.89) as independent predictors. The AUC for the training, internal validation, and external validation cohorts were 0.93, 0.86, and 0.94, respectively, indicating high calibration accuracy (p > 0.05). DCA demonstrated a 75% higher net clinical benefit compared to traditional models at risk thresholds exceeding 18. CONCLUSIONS: In order to avoid repeated renal biopsy puncture, by integrating kidney function, metabolic markers, and pathological features, the model provides more accurate diagnosis and treatment suggestions for predicting the risk of TILs and further deterioration of renal function. This facilitates the early identification of high-risk patients and supports targeted interventions, marking a paradigm shift toward precision nephrology in the management of DKD.