Reichard P, Nilsson B Y, Rosenqvist U
Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden.
N Engl J Med. 1993 Jul 29;329(5):304-9. doi: 10.1056/NEJM199307293290502.
A cause-and-effect relation between blood glucose concentrations and microvascular complications in patients with insulin-dependent diabetes mellitus has not been established.
We randomly assigned 102 patients with insulin-dependent diabetes mellitus, nonproliferative retinopathy, normal serum creatinine concentrations, and unsatisfactory blood glucose control to intensified insulin treatment (48 patients) or standard insulin treatment (54 patients). We then evaluated them for microvascular complications after 18 months and 3, 5, and 7.5 years.
Mean (+/- SD) glycosylated hemoglobin values were reduced from 9.5 +/- 1.3 percent to 7.1 +/- 0.7 percent in the group receiving intensified treatment and from 9.4 +/- 1.4 percent to 8.5 +/- 0.7 percent in the group receiving standard treatment (P = 0.001). In 12 of the patients receiving intensified treatment (27 percent of those included in the analysis) and 27 of those receiving standard treatment (52 percent), serious retinopathy requiring photocoagulation developed (P = 0.01). Visual acuity decreased in 6 patients receiving intensified treatment (14 percent) and in 18 receiving standard treatment (35 percent) (P = 0.02). Nephropathy (urinary albumin excretion, > 200 micrograms per minute) developed in one patient in the group receiving intensified treatment, as compared with nine patients in the group receiving standard treatment (P = 0.01). No patient in the intensified-treatment group had nephropathy with subnormal glomerular filtration rates, as compared with six patients in the standard-treatment group (P = 0.02). The conduction velocities of the ulnar, tibial, peroneal, and sural nerves decreased significantly more in the standard-treatment group than in the intensified-treatment group. The odds ratio for serious retinopathy was 0.4 (95 percent confidence interval, 0.2 to 1.0; P = 0.04) in the intensified-treatment group as compared with the standard-treatment group. The corresponding odds ratio for nephropathy was 0.1 (95 percent confidence interval, 0 to 0.8; P = 0.04).
Long-term intensified insulin treatment, as compared with standard treatment, retards the development of microvascular complications in patients with insulin-dependent diabetes mellitus.
胰岛素依赖型糖尿病患者血糖浓度与微血管并发症之间的因果关系尚未确立。
我们将102例胰岛素依赖型糖尿病、非增殖性视网膜病变、血清肌酐浓度正常且血糖控制不佳的患者随机分为强化胰岛素治疗组（48例）和标准胰岛素治疗组（54例）。然后在18个月以及3、5和7.5年后对他们进行微血管并发症评估。
强化治疗组糖化血红蛋白均值（±标准差）从9.5±1.3%降至7.1±0.7%，标准治疗组从9.4±1.4%降至8.5±0.7%（P = 0.001）。强化治疗组中有12例患者（占分析纳入患者的27%）以及标准治疗组中有27例患者（占52%）发生了需要进行光凝治疗的严重视网膜病变（P = 0.01）。强化治疗组中有6例患者（占14%）视力下降，标准治疗组中有18例患者（占35%）视力下降（P = 0.02）。强化治疗组有1例患者发生肾病（尿白蛋白排泄量>200微克/分钟），而标准治疗组有9例患者发生肾病（P = 0.01）。强化治疗组无肾小球滤过率低于正常的肾病患者，而标准治疗组有6例（P = 0.02）。标准治疗组尺神经、胫神经、腓总神经和腓肠神经的传导速度下降幅度显著大于强化治疗组。与标准治疗组相比，强化治疗组发生严重视网膜病变的优势比为0.4（95%置信区间为0.2至1.0；P = 0.04）。肾病的相应优势比为0.1（95%置信区间为0至0.8；P = 0.04）。
与标准治疗相比，长期强化胰岛素治疗可延缓胰岛素依赖型糖尿病患者微血管并发症的发生。
