Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Rodolpho Paulo Rocco, 255, Cidade Universitária, Rio de Janeiro, CEP: 21941-913, Brazil.
Civil Engineering Program, COPPE, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
Diabetologia. 2018 Feb;61(2):455-465. doi: 10.1007/s00125-017-4484-z. Epub 2017 Oct 23.
AIMS/HYPOTHESIS: Diabetic kidney disease (DKD) is a microvascular complication associated with poor control of blood glucose and BP. We aimed to evaluate the predictors of development and progression of DKD in a cohort of high-risk individuals with type 2 diabetes, placing emphasis on ambulatory BP and arterial stiffness.
In a prospective study, 629 individuals without advanced renal failure had their renal function evaluated annually over a median follow-up period of 7.8 years. Ambulatory BP was monitored and aortic stiffness was assessed by carotid-femoral pulse wave velocity at baseline. Multivariate competing risks analysis with all-cause mortality, using the Fine and Gray approach, was used to examine the independent predictors of development and progression of DKD, a composite of development or progression of abnormal albuminuria and worsening of renal function (doubling of serum creatinine or progression to end-stage renal disease).
At baseline, 197 individuals had DKD. During follow-up, DKD developed or progressed in 195 individuals, abnormal albuminuria developed or progressed in 125 individuals and renal function deteriorated in 91. After adjustments for baseline albuminuria and renal function, age, sex, diabetes duration and use of renin-angiotensin antagonists, poorer control of blood glucose (HR 1.17; 95% CI 0.98, 1.40; p = 0.09 for each 1 SD increment in mean first-year HbA), higher ambulatory systolic BP (HR 1.28; 95% CI 1.09, 1.50; p = 0.003, for each 1 SD increase in daytime systolic BP [SBP]) and increased aortic stiffness (HR 1.16; 95% CI 1.00, 1.34; p = 0.05) were independent predictors of development or progression of DKD. At baseline, ambulatory BP was a stronger predictor than BP measured in the clinic. Aortic stiffness predicted abnormal albuminuria development or progression (HR 1.26; 95% CI 1.02, 1.56; p = 0.036) whereas ambulatory BP was a stronger predictor of renal function deterioration (HR 1.32; 95% CI 1.09, 1.60; p = 0.005 for daytime SBP).
CONCLUSIONS/INTERPRETATION: Poor blood glucose and BP control and increased aortic stiffness were the main predictors of development or progression of DKD; ambulatory SBP was a better predictor than BP measured in the clinic. Ambulatory BP monitoring and assessment of aortic stiffness should be more widely used in clinical type 2 diabetes management.
目的/假设：糖尿病肾病（DKD）是一种与血糖和血压控制不佳相关的微血管并发症。我们旨在评估 2 型糖尿病高危人群中 DKD 发展和进展的预测因素，重点关注动态血压和动脉僵硬度。
在一项前瞻性研究中，629 名无晚期肾功能衰竭的患者在中位随访 7.8 年期间每年评估肾功能。在基线时监测动态血压并通过颈股脉搏波速度评估主动脉僵硬度。使用 Fine 和 Gray 方法的全因死亡率多变量竞争风险分析，用于检查 DKD 发展和进展的独立预测因素，即异常白蛋白尿和肾功能恶化（血清肌酐加倍或进展至终末期肾病）的复合指标。
基线时，197 人患有 DKD。在随访期间，195 人发生或进展为 DKD，125 人出现白蛋白尿异常，91 人肾功能恶化。在调整基线白蛋白尿和肾功能、年龄、性别、糖尿病病程和使用肾素-血管紧张素拮抗剂后，血糖控制较差（HR 1.17；95%CI 0.98，1.40；每增加 1 SD 平均第一年 HbA1c 时 p=0.09）、较高的日间收缩压（HR 1.28；95%CI 1.09，1.50；p=0.003，日间收缩压[SBP]每增加 1 SD）和增加的主动脉僵硬度（HR 1.16；95%CI 1.00，1.34；p=0.05）是 DKD 发展或进展的独立预测因素。在基线时，动态血压是比诊所测量的血压更好的预测因素。主动脉僵硬度预测白蛋白尿异常的发生或进展（HR 1.26；95%CI 1.02，1.56；p=0.036），而日间 SBP 是肾功能恶化的更强预测因素（HR 1.32；95%CI 1.09，1.60；p=0.005）。
结论/解释：血糖和血压控制不佳以及主动脉僵硬度增加是 DKD 发展或进展的主要预测因素；日间 SBP 是比诊所测量的血压更好的预测因素。动态血压监测和主动脉僵硬度评估应更广泛地应用于 2 型糖尿病的临床管理中。
