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亚洲人群2型糖尿病患者肾脏异常改变与增生性糖尿病视网膜病变和糖尿病性黄斑水肿的相关性

Hsieh, Y.T., Tsai, M.J., Tu, S.T., Hsieh, M.C.

期刊名称:JAMA Ophthalmology

卷期:2018年第136卷第1期

姚颖 沈阳兴齐眼药股份有限公司医学经理

    糖尿病(DM)已成为影响全人类公共健康的主要疾病。国际DM联合会2013年发布的数据显示,全球已有3.82亿DM患者,2035年将会达到5.92亿。其中,发展中国家DM患者数量已超过发达国家;80.0%的DM患者生活在欠发达国家和地区。亚洲迅速成为全世界DM集中区。预测的2030年DM患者最多的10个国家中,有5个在亚洲,分别是中国、印度、巴基斯坦、印度尼西亚以及孟加拉共和国。我国1980年时的DM患病率还不足1.0%,但2010年我国DM小组的研究结果显示,20岁以上人群中,DM发病率为9.7%;DM发病率有地区、城乡差别以及随年龄增长而增加订起势嘲。以此推算,我国DM患者已超过9200万,超过印度成为全球DM患者人口最多的国家。

    糖尿病视网膜病变(DR)为DM常见的微血管并发症,是工作年龄人群第一位的致盲性疾病。因此了解糖尿病性视网膜病变(DR)的发病相关因素,对糖尿病性视网膜病变(DR)的筛查、预防及治疗有很大作用,关于糖尿病视网膜病变(DR)与糖尿病全身的并发症的关系有很多研究,但是,对于糖尿病慢性肾病对糖尿病性视网膜病变(DR)的发展或进展的影响的相关研究还很少,本文献做了相关研究,对糖尿病视网膜病变与糖尿病全身的并发症的相关关系提供了进一步的循证证据。


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摘要

摘要:重要性:慢性肾病和糖尿病性视网膜病变(DR)的共病是众所周知的。然而,据我们所知,没有群组研究显示慢性肾病对糖尿病性视网膜病变(DR)的发展或进展的影响。

目的: 探讨在2型糖尿病中慢性肾脏疾病与糖尿病性视网膜病变(DR)的发展及糖尿病黄斑水肿(DME)的发展之间的关系。

设计、设置和参与者: 在台湾2个医疗中心进行的8年前瞻性群组研究包括21352型糖尿病患者。暴露数: 基准线和后续随访平均肾功能,包括血清肌酐水平、估算的肾小球滤过率(eGFR)和尿白蛋白/肌酐比值(ACR)

主要结果和措施:用免散瞳眼底摄影检测糖尿病性视网膜病变和糖尿病黄斑水肿(DME)。用Cox回归分析肾剖面图,评估新发性糖尿病性视网膜病变(DR)、增殖型糖尿病性视网膜病变(DR)和糖尿病黄斑水肿(DME)的风险率(HRs)

结果:研究对象的平均年龄为63.4(平均标准偏差SD11.9),女性为1025(48%)。血清肌酐水平较高( 2.358HR,增加1 mg/dL[转化为微摩尔/每升,乘以76.25];95%置信区间,1.901-2.924;P < 0.001),估算的肾小球滤过率小于60 mL/min/1.73m2 (40-60: HR, 2.235;95%置信区间,1.351-4.035;P = .002;30 - 45:HR,2.625;95%置信区间,1.436-4.798;P = .002;< 30:HR,5.488;95%置信区间,2.739-10.993;P < .001)和尿的尿白蛋白的肌酐比值(ACR)超过30mg/g(31-300:HR,3.202;95%置信区间,2.029-5.053;P < .001; > 300:HR,6.652;95%置信区间,3.922 - -11.285;P < .001),在基准线均与增殖型糖尿病性视网膜病变(DR)的发展有关。基线尿白蛋白/肌酐比值ACR (30 mg/g) (31-300: HR, 3.202;95%置信区间,1.078 - -2.267;P = .02;> 300:HR,2.707;95%置信区间,1.640 - -4.470;-2.707;P < 0.001)与糖尿病黄斑水肿(DME)的发展有关。调整基线值后,平均随访肾剖面图,包括高血清肌酐水平(HR, 2.369 / mg/dL;95%置信区间,1.704-3.293;P < 0.001),估算的肾小球滤过率小于30 mL/min/1.73m2 (HR, 4.215;95%置信区间,1.265 -14.039;P = .02),尿的尿白蛋白的肌酐比值(ACR)超过30 mg/g (31-300: HR, 2.344;95%置信区间,1.200 -4.503;P = . 01;300>:HR,4.193;95%置信区间,1.638-10.735;P = .003)在随访期间仍与新发PDR相关。

结论和相关性:基线的异常肾脏资料,包括高血清肌酐水平,低估算的肾小球滤过率,和高尿尿白蛋白/肌酐比值(ACR),都与2型糖尿病患者的PDR发展相关。高基线尿尿白蛋白/肌酐比值(ACR)与糖尿病黄斑水肿(DME)有关。在调整基线值后,不正常的平均随访肾资料仍与新发PDR相关。对慢性肾脏疾病的积极治疗可能在防止糖尿病性视网膜病变(DR)的恶化方面起到作用。

Importance:The comorbidity of chronic kidney disease and diabetic retinopathy (DR) is well known. However, to our knowledge, no cohort study has demonstrated the effect of chronic kidney disease on the development or progression of DR.Objective:To investigate the association of chronic kidney disease with the development of DR and diabetic macular edema (DME) in type 2 diabetes.Design, Setting, and Participants:This 8-year prospective cohort study that was conducted in 2 medical centers in Taiwan included 2135 patients with type 2 diabetes.Exposures:The baseline and mean follow-up renal profiles including serum creatinine level, estimated glomerular filtration rate (eGFR), and urinary albumin/creatinine ratio (ACR).Main Outcomes and Measures:Diabetic retinopathy and DME were detected with nonmydriatic fundus photography. Cox regression analyses was used to evaluate the hazard ratios (HRs) for the renal profiles of new-onset DR, proliferative DR, and DME.Results:The mean (SD) age of the study participants was 63.4 (11.9) years and 1025 (48%) were women. A higher serum creatinine level (HR of 2.358 for an increase of 1 mg/dL [to convert to micromoles per liter, multiply by 76.25]; 95% CI, 1.901-2.924; P  <  .001), an estimated glomerular filtration rate of less than 60 mL/min/1.73m2 (40-60: HR, 2.235; 95% CI, 1.351-4.035; P  =  .002; 30-45: HR, 2.625; 95% CI, 1.436-4.798; P  =  .002; <30: HR, 5.488; 95% CI, 2.739-10.993; P  <  .001), and a urinary albumin to creatinine ratio (ACR) of more than 30 mg/g (31-300: HR, 3.202; 95% CI, 2.029-5.053; P  <  .001; >300: HR, 6.652; 95% CI, 3.922-11.285; P  <  .001) at baseline were all associated with the development of proliferative DR. A baseline urinary ACR of more than 30 mg/g (31-300: HR, 1.563; 95% CI, 1.078-2.267; P  =  .02; >300: HR, 2.707; 95% CI, 1.640-4.470; -2.707; P  <  0.001) was associated with the development of DME. After adjusting the baseline values, the mean follow-up renal profiles, including a higher serum creatinine level (HR, 2.369 per mg/dL; 95% CI, 1.704-3.293; P  <  .001), an estimated glomerular filtration rate of less than 30 mL/min/1.73m2 (HR, 4.215; 95% CI, 1.265-14.039; P  =  .02), and a urinary ACR of more than 30 mg/g (31-300: HR, 2.344; 95% CI, 1.200-4.503; P  =  .01; >300: HR, 4.193; 95% CI, 1.638-10.735; P  =  .003) were still correlated with new-onset PDR during the follow-up periods.Conclusions and Relevance:Abnormal renal profiles at baseline, including a high serum creatinine level, low estimated glomerular filtration rate, and high urinary ACR, were associated with the development of PDR in patients with type 2 diabetes. A high baseline urinary ACR was associated with DME. Abnormal mean follow-up renal profiles were still correlated with new-onset PDR after adjusting for baseline values. Aggressive treatment for chronic kidney disease may have a role in preventing the deterioration of DR.


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