Saito Nobumichi, Toyoda Masao, Ono Moe, Kaneyama Noriko, Kimura Moritsugu, Fukagawa Masafumi
Division of Nephrology and Metabolism, Department of Internal Medicine, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa 259-1193, Japan.
Tokai J Exp Clin Med. 2020 Sep 20;45(3):139-143.
The Japan Diabetes Society and the Japan Gerontological Society Collaborative Committee recently released guidelines for the management of elderly diabetes patients. In these guidelines, patients are classified into categories I-III depending on age, cognitive function, activities of daily living (ADL), and presence or absence of multiple functional impairments. The target control value of HbA1c is set for each category. Low (< 30 mL/min/1.73 m2) estimated glomerular filtration rate (eGFR) is an independent highrisk factor for severe hypoglycemia, yet it is not included in the categorization factors. We surveyed elderly diabetes patients with normal cognitive function and ADL (Category I) who were admitted to the emergency department with severe hypoglycemia, retrospectively studied eGFR at the onset of hypoglycemic episode, and checked whether the HbA1c levels matched the guidelines.
Among 129 diabetes patients aged ≥ 65 years admitted to the Tokai University hospital for hypoglycemic emergencies, 73 had normal cognitive function and ADL. HbA1c level and eGFR at the onset of hypoglycemic attack were obtained from the medical records of these subjects.
All subjects were prescribed anti-diabetes agents with high-risk of severe hypoglycemia, including insulin. Sixty-one patients showed eGFR ≥ 30 mL/min/1.73 m2. Among them, 31 (50.8%) had HbA1c levels below the recommended range. Among 12 patients whose eGFR < 30 mL/min/1.73 m2, 6 (50%) had HbA1c levels below the recommended range.
Even with normal cognitive function and ADL, eGFR < 30 mL/min/1.73 m2 a lone i s a s trong risk factor for hypoglycemia in elderly diabetes patients. We propose that the target control HbA1c level in elderly patients with eGFR < 30 mL/min/1.73 m2 should be 7.5-8.4 %, which is equivalent to that of category III patients.
日本糖尿病学会和日本老年医学学会协作委员会最近发布了老年糖尿病患者管理指南。在这些指南中，根据年龄、认知功能、日常生活活动能力（ADL）以及是否存在多种功能障碍，将患者分为I - III类。为每类设定了糖化血红蛋白（HbA1c）的目标控制值。估计肾小球滤过率（eGFR）低（<30 mL/min/1.73 m2）是严重低血糖的一个独立高危因素，但它未被纳入分类因素中。我们调查了认知功能和ADL正常（I类）且因严重低血糖入住急诊科的老年糖尿病患者，回顾性研究低血糖发作时的eGFR，并检查HbA1c水平是否符合指南。
在东海大学医院因低血糖紧急情况入院的129例年龄≥65岁的糖尿病患者中，73例认知功能和ADL正常。从这些受试者的病历中获取低血糖发作时的HbA1c水平和eGFR。
所有受试者均使用了包括胰岛素在内的有严重低血糖高风险的抗糖尿病药物。61例患者的eGFR≥30 mL/min/1.73 m2。其中，31例（50.8%）的HbA1c水平低于推荐范围。在12例eGFR<30 mL/min/1.73 m2的患者中，6例（50%）的HbA1c水平低于推荐范围。
即使认知功能和ADL正常，单独的eGFR<30 mL/min/1.73 m2也是老年糖尿病患者发生低血糖的一个强烈危险因素。我们建议，eGFR<30 mL/min/1.73 m2的老年患者的目标控制HbA1c水平应为7.5 - 8.4%，这与III类患者相当。
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