Panzetta Giovanni, Basile Carlo, Santoro Antonio, Ancarani Enzo, Costantini Stefano, Guarnieri Francesco, Verzetti Giuseppe
Unità Operativa Complessa di Nefrologia e Dialisi, Azienda Ospedaliero-Universitaria Ospedali Riuniti di Trieste, Trieste, Italy.
Nephrol Dial Transplant. 2008 Dec;23(12):3988-95. doi: 10.1093/ndt/gfn413. Epub 2008 Jul 25.
Diabetes mellitus is a common disease, comprising 4-8% of the general population and up to 45% of new dialysis patients in industrialized countries.
We performed a nationwide study with the aim of analysing the approach of various centres to diabetic patients and to gather data on the epidemiology, clinical characteristics and complications of type 1 and type 2 diabetics.
We acquired the data from 513 dialysis centres, 3665 prevalent diabetic patients and 4337 diabetic patients who started dialysis in the previous 10 years. Patient education and dialysis initiation: Sixty percent of the centres educate the patient regarding diet, pharmacological therapy and prevention of diabetic complications; in 245 centres (48%), this task belonged exclusively to the nephrologist and not to a multidisciplinary team. Seventy percent of the centres reported planning the initiation of dialysis and preparing the fistula between 1 and 3 months (78.5%) before the initiation of dialysis. Epidemiological and clinical data: Diabetic patients (56.9% males) represented 12.5% of the total dialysis population in Italy. The ratio between diabetes type 2 and type 1 was 5.3. The initial treatment was haemodialysis (HD) in 2533 patients (bicarbonate HD 88.8%) and peritoneal dialysis (PD) in 405 patients (CAPD 82.2%). During their dialytic life, 383 patients (226 from HD and 157 from PD) changed treatment modality, mainly because of cardiocirculatory instability (158 cases) or infection of the catheter tunnel/peritoneum (89 cases). The changes were mainly directed from bicarbonate HD and CAPD towards diffusive-convective extracorporeal techniques. Blood glucose (mean 154 +/- 56.8 mg/dl) exceeded 200 mg/dl in 15.2% of patients; serum cholesterol was >200 mg/dl in 39.3% of patients; serum triglycerides exceeded 200 mg/dl in 39.2% of patients and mean values for glycosylated haemoglobin was 7.2 +/- 1.8%. The nutritional state was judged to be normal in 59.6% of patients, 16.2% appeared to be mildly malnourished and 3% severely malnourished; 21.1% of subjects were obese. Echocardiography showed left ventricular hypertrophy in 90% of patients and echocolordoppler examination of the great vessels showed pathological findings (plaques and stenoses) in 73%. Pharmacological therapy. Sixty-nine percent of patients were treated with antihypertensive drugs, mainly calcium antagonists (50%) and ACE inhibitors (27%). Nitrates were prescribed for 33% of patients; antiplatelet or anticoagulant drugs were prescribed for 37% of patients.
The present study demonstrates that the prevalence of diabetics in dialysis continues to increase in Italy, but remains less than that in Northern European countries. Type 2 diabetes is as dangerous as type 1 in terms of serious complications. There appears to be a greater awareness on the part of nephrologists of the serious problems associated with the care of diabetic patients in dialysis. The ideal dialytic modality has not been determined, dialysis is often not initiated in a timely manner and optimal drug therapy is not always prescribed. The aspirations to treat the diabetic dialysis patient according to currently accepted best practice guidelines still need to be fully realized.
糖尿病是一种常见疾病，在工业化国家普通人群中占4% - 8%，在新透析患者中占比高达45%。
我们开展了一项全国性研究，旨在分析各中心对糖尿病患者的治疗方法，并收集1型和2型糖尿病患者的流行病学、临床特征及并发症数据。
我们从513个透析中心、3665例糖尿病现患患者以及过去10年开始透析的4337例糖尿病患者中获取了数据。患者教育与透析启动：60%的中心对患者进行饮食、药物治疗及糖尿病并发症预防方面的教育；在245个中心（48%），此任务仅由肾病科医生负责，而非多学科团队。70%的中心报告在开始透析前1至3个月（78.5%）计划启动透析并准备动静脉内瘘。流行病学及临床数据：糖尿病患者（男性占56.9%）占意大利透析总人群的12.5%。2型糖尿病与1型糖尿病的比例为5.3。初始治疗时，2533例患者采用血液透析（HD）（碳酸氢盐血液透析占88.8%），405例患者采用腹膜透析（PD）（持续性非卧床腹膜透析占82.2%）。在透析期间，383例患者（血液透析226例，腹膜透析157例）改变治疗方式，主要原因是心血管循环不稳定（158例）或导管隧道/腹膜感染（89例）。改变主要是从碳酸氢盐血液透析和持续性非卧床腹膜透析转向扩散对流体外技术。15.2%的患者血糖（平均154±56.8mg/dl）超过200mg/dl；39.3%的患者血清胆固醇>200mg/dl；39.2%的患者血清甘油三酯超过200mg/dl，糖化血红蛋白平均值为7.2±1.8%。59.6%的患者营养状况被判定为正常，16.2%似乎轻度营养不良，3%严重营养不良；21.1%的受试者肥胖。超声心动图显示90%的患者有左心室肥厚，大血管超声彩色多普勒检查显示73%有病理表现（斑块和狭窄）。药物治疗：69%的患者接受降压药物治疗，主要是钙拮抗剂（50%）和血管紧张素转换酶抑制剂（27%）。33%的患者使用硝酸盐类药物；37%的患者使用抗血小板或抗凝药物。
本研究表明，意大利透析患者中糖尿病的患病率持续上升，但仍低于北欧国家。就严重并发症而言，2型糖尿病与1型糖尿病一样危险。肾病科医生似乎更意识到透析糖尿病患者护理相关的严重问题。理想的透析方式尚未确定，透析往往未及时启动，最佳药物治疗也并非总是得到处方。按照目前公认的最佳实践指南治疗糖尿病透析患者的愿望仍需充分实现。
