Division of Metabolism, Endocrinology, and Nutrition, University of Washington, 4245 Roosevelt Way NE, Box 354691, Seattle, WA, 98105, USA.
Curr Diab Rep. 2018 Feb 15;18(3):13. doi: 10.1007/s11892-018-0979-3.
Diabetes is the leading cause of kidney disease globally. Diabetic kidney disease (DKD) is a heterogeneous disorder manifested as albuminuria and/or decreasing GFR. Hyperglycemic burden is the major contributor to the development of DKD. In this article, we review the evidence for the contribution of glycemic variability and the pitfalls associated with use of hemoglobin A1c (A1C), the gold standard for assessment of glucose control, in the setting of DKD.
Glycemic variability, characterized by swings in blood glucose levels, can result in generation of mitochondrial reactive oxygen species, a putative inciting factor for hyperglycemia-induced alterations in intracellular metabolic pathways. While there is indirect evidence supporting the role of glycemic variability in the pathogenesis of DKD, definitive data are lacking. A1C has many limitations and is a particularly suboptimal measure in patients with kidney disease, because its accuracy is compromised by variables affecting RBC survival and other factors. Continuous glucose monitoring (CGM) technology has the potential to enable us to use glucose as a more important clinical tool, for a more definitive understanding of glucose variability and its role in DKD. Glycemic variability may be a factor in the development of DKD, but definitive evidence is lacking. Currently, all available glycemic biomarkers, including A1C, have limitations and in the setting of DKD and should be used cautiously. Emerging data suggest that personal and professional CGM will play an important role in managing diabetes in patients with DKD, where risk of hypoglycemia is high.
糖尿病是全球范围内导致肾脏疾病的主要原因。糖尿病肾病（DKD）是一种异质性疾病，表现为蛋白尿和/或肾小球滤过率下降。高血糖负担是 DKD 发展的主要原因。本文综述了血糖变异性在 DKD 中的作用的证据，以及糖化血红蛋白（HbA1c）作为评估血糖控制的金标准在 DKD 中的应用所存在的缺陷。
血糖波动特征为血糖水平波动，可导致线粒体活性氧的产生，这可能是高血糖引起细胞内代谢途径改变的一个引发因素。虽然有间接证据支持血糖变异性在 DKD 发病机制中的作用，但缺乏明确的数据。HbA1c 有许多局限性，在肾病患者中尤其不是一个理想的衡量标准，因为其准确性受到影响红细胞生存和其他因素的变量的影响。连续血糖监测（CGM）技术有可能使我们能够将血糖作为一种更重要的临床工具，更明确地了解血糖变异性及其在 DKD 中的作用。血糖变异性可能是 DKD 发展的一个因素，但缺乏明确的证据。目前，所有可用的血糖生物标志物，包括 HbA1c，都有其局限性，在 DKD 中应谨慎使用。新出现的数据表明，个人和专业 CGM 将在 DKD 患者的糖尿病管理中发挥重要作用，因为这些患者低血糖风险较高。
