Thomson Hilary J, Ekinci Elif I, Radcliffe Nicholas J, Seah Jas-mine, MacIsaac Richard J, Jerums George, Premaratne Erosha
Austin Health Endocrine Centre, Heidelberg, Melbourne, VIC, Australia.
Austin Health Endocrine Centre, Heidelberg, Melbourne, VIC, Australia; Department of Medicine, Austin Health, The University of Melbourne, Melbourne, VIC, Australia; Menzies School of Health-Darwin, Casuarina NT 0810, Australia.
J Diabetes Complications. 2016 Mar;30(2):256-61. doi: 10.1016/j.jdiacomp.2015.11.003. Epub 2015 Nov 11.
Renal hyperfiltration is observed prior to the development of diabetic kidney disease (DKD) in patients with type 1 diabetes (T1DM); however its significance remains uncertain. Longitudinal data were used to investigate the association between measured baseline glomerular filtration rate (GFR) and renal function decline in patients with T1DM.
This study included 142 adult patients with T1DM and ≥2 measurements of glomerular filtration rate (mGFR; determined by diethylene-triamine-penta-acetic acid plasma clearance). Median follow up was 19 years. Patients were stratified by baseline mGFR quartile. The relationship between baseline mGFR and rate of renal function decline was assessed using random-effect generalized least squares regression, adjusted for age, duration of diabetes, HbA1c, blood pressure, renin-angiotensin-aldosterone system inhibitor therapy, LDL and BMI.
The average rates of decline in renal function for the 2nd (baseline mGFR: 96.4-112.6 ml min-(1) 1.73 m-(2)), 3(rd) (baseline mGFR: 112.6-125.5 ml min- (1) 1.73 m-(2)) and 4th quartiles (baseline mGFR >125.5 ml min-(1) 1.73 m-(2)) were significantly faster than the first quartile (baseline mGFR: 60.9-96.4 ml min-(1) 1.73 m-(2)). In further detail, the average rates of decline in the 2nd (rate of decline 1.25 ml min- (1) 1.73 m-(2) per year, 95% CI: 0.97; 1.52, p=0.008), 3rd (rate of decline 1.35 ml min-(1) 1.73 m-(2) per year, 95% CI: 1.08; 1.62, p= 0.001) and 4th quartiles (rate of decline 1.6 ml min-(1) 1.73 m-(2) per year, 95% CI: 1.34, 1.88, <0.0001) were significantly faster when compared to the first quartile (rate of decline 0.67 ml min-(1) 1.73 m-(2) per year, 95% CI: 0.37; 0.96). Sub-analysis of quartile 4 revealed higher HbA1c measurements throughout follow-up in those with rapid mGFR decline (>3.0 ml min(-1)1.73 m(-2)/year).
In patients with T1DM, higher baseline mGFR is associate ed with more rapid mGFR decline. Patients with high baseline mGFR who developed rapid mGFR decline had higher HbA1c measurements throughout the study. These findings are consistent with the concept that poor glycaemic control over time may be a determining factor for the rapid renal function decline observed in some hyperfiltering patients.
在1型糖尿病（T1DM）患者发生糖尿病肾病（DKD）之前可观察到肾高滤过；然而其意义仍不确定。采用纵向数据研究T1DM患者测得的基线肾小球滤过率（GFR）与肾功能下降之间的关联。
本研究纳入了142例成年T1DM患者，且对肾小球滤过率（mGFR；通过二乙烯三胺五乙酸血浆清除率测定）进行了≥2次测量。中位随访时间为19年。患者按基线mGFR四分位数分层。使用随机效应广义最小二乘法回归评估基线mGFR与肾功能下降速率之间的关系，并对年龄、糖尿病病程、糖化血红蛋白、血压、肾素 - 血管紧张素 - 醛固酮系统抑制剂治疗、低密度脂蛋白和体重指数进行了校正。
第二四分位数（基线mGFR：96.4 - 112.6 ml·min⁻¹·1.73 m⁻²）、第三四分位数（基线mGFR：112.6 - 125.5 ml·min⁻¹·1.73 m⁻²）和第四四分位数（基线mGFR >125.5 ml·min⁻¹·1.73 m⁻²）的肾功能平均下降速率显著快于第一四分位数（基线mGFR：60.9 - 96.4 ml·min⁻¹·1.73 m⁻²）。更详细地说，第二四分位数（每年下降速率1.25 ml·min⁻¹·1.73 m⁻²，95%CI：0.97；1.52，p = 0.008）、第三四分位数（每年下降速率1.35 ml·min⁻¹·1.73 m⁻²，95%CI：1.08；1.62，p = 0.001）和第四四分位数（每年下降速率1.6 ml·min⁻¹·1.73 m⁻²，95%CI：1.34，1.88，p<0.0001）与第一四分位数（每年下降速率0.67 ml·min⁻¹·1.73 m⁻²，95%CI：0.37；0.96）相比，下降速率显著更快。对第四四分位数的亚组分析显示，mGFR快速下降（>3.0 ml·min⁻¹·1.73 m⁻²/年）者在整个随访期间糖化血红蛋白测量值更高。
在T1DM患者中，较高的基线mGFR与更快的mGFR下降相关。基线mGFR高且mGFR快速下降的患者在整个研究期间糖化血红蛋白测量值更高。这些发现与长期血糖控制不佳可能是一些高滤过患者肾功能快速下降的决定因素这一概念一致。
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