De Cosmo Salvatore, Viazzi Francesca, Pacilli Antonio, Giorda Carlo, Ceriello Antonio, Gentile Sandro, Russo Giuseppina, Rossi Maria C, Nicolucci Antonio, Guida Pietro, Pontremoli Roberto
Department of Medical Sciences, Scientific Institute "Casa Sollievo della Sofferenza", San Giovanni Rotondo (FG) Università degli Studi and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genova Diabetes and Metabolism Unit ASL Turin 5, Chieri (TO), Italy Institut d'Investigacions Biomèdiques August Pii Sunyer (IDIBAPS) and Centro de Investigación Biomédicaen Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Barcelona, Spain Department of Clinical and Experimental Medicine, 2 University of Naples, Caserta Department of Clinical and Experimental Medicine, University of Messina, Messina Center for Outcomes Research and Clinical Epidemiology, Pescara Associazione Medici Diabetologi, Rome, Italy.
Medicine (Baltimore). 2016 Jul;95(27):e4007. doi: 10.1097/MD.0000000000004007.
The identification of clinical predictors for the development of chronic kidney disease is a critical issue in the management of patients with type 2 diabetes mellitus.We evaluated 27,029 patients with type 2 diabetes mellitus and estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m and normoalbuminuria from the database of the Italian Association of Clinical Diabetologists network. Primary outcomes were eGFR <60 mL/min/1.73 m and normoalbuminuria; albuminuria and eGFR ≥60 mL/min/1.73 m; and eGFR <60 mL/min/1.73 m and albuminuria. Secondary outcomes were eGFR <60 mL/min/1.73 m and albuminuria.
eGFR from serum creatinine by chronic kidney disease epidemiology collaboration equation (CKD-EPI), urinary albumin excretion, HbA1c, triglycerides, high-density lipoprotein cholesterol (HDL-c) and low-density lipoprotein cholesterol (LDL-c), blood pressure, and body mass index.Over a 4-year period, 33.2% of patients (n = 8973) developed chronic kidney disease, 10.3% (n = 2788) showed a decline in eGFR <60 mL/min/1.73 m, 18.4% (n = 4978) developed albuminuria, and 4.5% (n = 1207) developed both features. Relative risk ratios (RRRs) for age (1.37, P < 0.001 by 5 years), sex (0.77, P < 0.001 for being male), body mass index (1.03, P < 0.001 by 1 kg/m), triglycerides (1.02, P < 0.001 by 10 mg/dL), and LDL-c (0.97, P = 0.004 by 10 mg/dL) were independently related to the onset of eGFR reduction. Age (1.08, P < 0.001 by 5 years), sex (1.36, P < 0.001 for being male), body mass index (1.02, P < 0.001 by 1 kg/m), triglycerides (1.01, P = 0.02 by 10 mg/dL), HDL-c, and LDL-c (0.97, P = 0.008 and 0.99, P = 0.003 by 5 and 10 mg/dL, respectively) were related to the onset of albuminuria. HbA1c and the intensity of antihypertensive treatment showed a weaker association with renal outcome.Reduction in eGFR and albuminuria showed distinct sets of risk factors, suggesting that different mechanisms are involved in the development of these 2 components of diabetic kidney disease.
识别慢性肾脏病发生的临床预测因素是2型糖尿病患者管理中的一个关键问题。我们从意大利临床糖尿病学家协会网络数据库中评估了27029例2型糖尿病患者，其估计肾小球滤过率（eGFR）≥60 mL/min/1.73 m²且尿白蛋白正常。主要结局为eGFR<60 mL/min/1.73 m²且尿白蛋白正常；出现蛋白尿且eGFR≥60 mL/min/1.73 m²；以及eGFR<60 mL/min/1.73 m²且出现蛋白尿。次要结局为eGFR<60 mL/min/1.73 m²且出现蛋白尿。
采用慢性肾脏病流行病学协作方程（CKD-EPI）根据血清肌酐计算eGFR、尿白蛋白排泄率、糖化血红蛋白（HbA1c）、甘油三酯、高密度脂蛋白胆固醇（HDL-c）和低密度脂蛋白胆固醇（LDL-c）、血压以及体重指数。在4年期间，33.2%的患者（n = 8973）发生了慢性肾脏病，10.3%（n = 2788）的患者eGFR下降至<60 mL/min/1.73 m²，18.4%（n = 4978）的患者出现蛋白尿，4.5%（n = 1207）的患者出现了这两种情况。年龄（每5岁相对风险比[RRR]为1.37，P<0.001）、性别（男性RRR为0.77，P<0.001）、体重指数（每增加1 kg/m²RRR为1.03，P<0.001）、甘油三酯（每增加10 mg/dL RRR为1.02，P<0.001）和低密度脂蛋白胆固醇（每增加十10 mg/dL RRR为0.97，P = 0.004）与eGFR降低的发生独立相关。年龄（每5岁RRR为1.08，P<0.001）、性别（男性RRR为1.36，P<0.001）、体重指数（每增加1 kg/m²RRR为1.02，P<0.001）、甘油三酯（每增加10 mg/dL RRR为1.01，P = 0.02）、高密度脂蛋白胆固醇以及低密度脂蛋白胆固醇（分别每增加5和10 mg/dL时RRR为0.97，P = 0.008和RRR为0.99，P = 0.003）与蛋白尿的发生相关。HbA1c和降压治疗强度与肾脏结局的关联较弱。eGFR降低和蛋白尿显示出不同的危险因素组合，提示糖尿病肾病这两个组成部分的发生涉及不同机制。
