1型糖尿病病程30年后的现代临床进程：糖尿病控制与并发症试验/糖尿病干预与并发症流行病学及匹兹堡糖尿病并发症流行病学经验（1983 - 2005年）
Modern-day clinical course of type 1 diabetes mellitus after 30 years' duration: the diabetes control and complications trial/epidemiology of diabetes interventions and complications and Pittsburgh epidemiology of diabetes complications experience (1983-2005).
作者信息
Nathan David M, Zinman Bernard, Cleary Patricia A, Backlund Jye-Yu C, Genuth Saul, Miller Rachel, Orchard Trevor J
机构信息
Diabetes Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114-2698, USA.
出版信息
Arch Intern Med. 2009 Jul 27;169(14):1307-16. doi: 10.1001/archinternmed.2009.193.
BACKGROUND
Clinical treatment goals of type 1 diabetes mellitus (T1DM) have changed since the Diabetes Control and Complications Trial (DCCT) demonstrated reduced long-term complications with intensive diabetes therapy. There have been few longitudinal studies to describe the clinical course of T1DM in the age of intensive therapy. Our objective was to describe the current-day clinical course of T1DM.
METHODS
An analysis of the cumulative incidence of long-term complications was performed. The DCCT (1983-1993) assigned patients to conventional or intensive therapy. Since 1993, the DCCT has been observational, and intensive therapy was recommended for all patients. The Pittsburgh Epidemiology of Diabetes Complications (EDC) study is an observational study of patients with T1DM from Allegheny County, Pennsylvania. The study population comprised the DCCT T1DM cohort (N = 1441) and a subset of the EDC cohort (n = 161) selected to match DCCT entry criteria. In the DCCT, intensive therapy aimed for a near-normal glycemic level with 3 or more daily insulin injections or an insulin pump. Conventional therapy, with 1 to 2 daily insulin injections, was not designed to achieve specific glycemic targets. Main outcome measures included the incidences of proliferative retinopathy, nephropathy (albumin excretion rate >300 mg/24 h, creatinine level >or=2 mg/dL [to convert to micromoles per liter, multiply by 88.4], or renal replacement), and cardiovascular disease.
RESULTS
After 30 years of diabetes, the cumulative incidences of proliferative retinopathy, nephropathy, and cardiovascular disease were 50%, 25%, and 14%, respectively, in the DCCT conventional treatment group, and 47%, 17%, and 14%, respectively, in the EDC cohort. The DCCT intensive therapy group had substantially lower cumulative incidences (21%, 9%, and 9%) and fewer than 1% became blind, required kidney replacement, or had an amputation because of diabetes during that time.
CONCLUSION
The frequencies of serious complications in patients with T1DM, especially when treated intensively, are lower than that reported historically.
背景
自从糖尿病控制与并发症试验（DCCT）表明强化糖尿病治疗可减少长期并发症以来，1型糖尿病（T1DM）的临床治疗目标已经发生了变化。在强化治疗时代，很少有纵向研究来描述T1DM的临床病程。我们的目的是描述当今T1DM的临床病程。
方法
对长期并发症的累积发病率进行了分析。DCCT（1983 - 1993年）将患者分配至常规治疗或强化治疗组。自1993年以来，DCCT转变为观察性研究，并建议所有患者接受强化治疗。匹兹堡糖尿病并发症流行病学（EDC）研究是一项对宾夕法尼亚州阿勒格尼县T1DM患者的观察性研究。研究人群包括DCCT的T1DM队列（N = 1441）和为匹配DCCT入组标准而从EDC队列中选取的一个子集（n = 161）。在DCCT中，强化治疗旨在通过每日3次或更多次胰岛素注射或胰岛素泵实现接近正常的血糖水平。常规治疗采用每日1至2次胰岛素注射，并非旨在实现特定的血糖目标。主要结局指标包括增殖性视网膜病变、肾病（白蛋白排泄率>300 mg/24 h、肌酐水平>或=2 mg/dL [换算为微摩尔每升时，乘以88.4]或肾脏替代治疗）以及心血管疾病的发病率。
结果
糖尿病病程30年后，DCCT常规治疗组增殖性视网膜病变、肾病和心血管疾病的累积发病率分别为50%、25%和14%，EDC队列中分别为47%、17%和14%。DCCT强化治疗组的累积发病率显著更低（分别为21%、9%和9%），在此期间因糖尿病导致失明、需要肾脏替代治疗或截肢的患者不到1%。
结论
T1DM患者严重并发症的发生率，尤其是在接受强化治疗时，低于历史报告水平。
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