National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia.
Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.
Diabetes Care. 2022 Oct 1;45(10):2383-2390. doi: 10.2337/dc22-0071.
Current guidelines recommend biennial diabetic retinopathy (DR) screening commencing at the age of 11 years and after 2-5 years' duration of type 1 diabetes. Growing evidence suggests less frequent screening may be feasible.
Prospective data were collected from 2,063 youth with type 1 diabetes who were screened two or more times between 1990 and 2019. Baseline (mean ± SD) age was 13.3 ± 1.8 years, HbA1c was 8.6 ± 1.3% (70.1 ± 14.7 mmol/mol), diabetes duration was 5.6 ± 2.8 years, and follow-up time was 4.8 ± 2.8 years. DR was manually graded from 7-field retinal photographs using the Early Treatment Diabetic Retinopathy Study (ETDRS) scale. Markov chain was used to calculate probabilities of DR change over time and hazard ratio (HR) of DR stage transition.
The incidence of moderate nonproliferative DR (MNPDR) or worse was 8.6 per 1,000 patient-years. Probabilities of transition to this state after a 3-year interval were from no DR, 1.3%; from minimal DR, 5.1%; and from mild DR, 22.2%, respectively. HRs (95% CIs) for transition per 1% current HbA1c increase were 1.23 (1.16-1.31) from no DR to minimal NPDR, 1.12 (1.03-1.23) from minimal to mild NPDR, and 1.28 (1.13-1.46) from mild to MNPDR or worse. HbA1c alone explained 27% of the transitions between no retinopathy and MNPDR or worse. The addition of diabetes duration into the model increased this value to 31% (P = 0.03). Risk was also increased by female sex and higher attained age.
These results support less frequent DR screening in youth with type 1 diabetes without DR and short duration. Although DR progression to advanced stages is generally slow, higher HbA1c greatly accelerates it.
目前的指南建议，11 岁起且 1 型糖尿病病程达 2-5 年后，每两年进行一次糖尿病视网膜病变（DR）筛查。越来越多的证据表明，更频繁的筛查可能并不必要。
本前瞻性研究收集了 1990 年至 2019 年间接受了两次或两次以上筛查的 2063 名 1 型糖尿病青少年的数据。基线时（均值±标准差）年龄为 13.3±1.8 岁，糖化血红蛋白（HbA1c）为 8.6±1.3%（70.1±14.7mmol/mol），糖尿病病程为 5.6±2.8 年，随访时间为 4.8±2.8 年。采用 7 视野视网膜照片，应用早期糖尿病视网膜病变研究（ETDRS）分级标准对 DR 进行手动分级。采用马尔可夫链计算 DR 随时间变化的概率和 DR 分期转换的危险比（HR）。
中度非增殖性 DR（MNPDR）或更严重病变的发生率为 8.6/1000 患者年。3 年后进展到这一状态的概率分别为：无 DR 为 1.3%；轻度 DR 为 5.1%；以及中度 DR 为 22.2%。当前 HbA1c 每增加 1%，向各状态转变的 HR（95%CI）分别为：从不伴有 NPDR 转变为轻度 NPDR 为 1.23（1.16-1.31）；从不伴有 NPDR 转变为中度 NPDR 为 1.12（1.03-1.23）；从不伴有 NPDR 转变为 MNPDR 或更严重病变为 1.28（1.13-1.46）。HbA1c 单独解释了无 DR 与 MNPDR 或更严重病变之间 27%的转变。将糖尿病病程纳入模型后，这一比例增加到 31%（P=0.03）。女性和较高的实际年龄也增加了风险。
这些结果支持在无 DR 且糖尿病病程较短的 1 型糖尿病青少年中减少 DR 筛查的频率。尽管 DR 向晚期进展通常较为缓慢，但 HbA1c 升高会极大加速这一进程。
