Töyry J P, Niskanen L K, Mäntysaari M J, Länsimies E A, Uusitupa M I
Department of Clinical Physiology, Kuopio University Hospital, Finland.
Diabetes. 1996 Mar;45(3):308-15. doi: 10.2337/diab.45.3.308.
Little is known about the occurrence and predictive factors of autonomic neuropathy and its relationship to cardiovascular mortality in NIDDM patients, and no long-term follow-up studies including nondiabetic control subjects are available. A total of 133 patients with newly diagnosed NIDDM (70 men) and 144 control subjects (62 men) were examined at baseline and after 5 and 10 years of follow-up. Deep-breathing tests (baseline, 5-year, and 10-year) and active orthostatic tests (5- and 10-year) were performed. Criteria for autonomic neuropathy were parasympathetic (expiration-to-inspiration ratio </- 1.10), sympathetic (systolic blood pressure decrease >/- 30 mmHg in the orthostatic test), and combined autonomic neuropathy (parasympathetic with sympathetic neuropathy). The frequency of parasympathetic neuropathy (NIDDM patients versus control subjects) was 4.9 vs. 2.2% (P = 0.224) at baseline, 19.6 vs. 8.5% (P = 0.017) at 5 years, and 65.0 vs. 28.0% (P < 0.001) at 10 years of follow-up. The frequency of sympathetic neuropathy was 6.8 vs. 5.6% (P = 0.709) at 5 years and 24.4 vs. 9.0% (P = 0.003) at 10 years of follow- up. These figures for combined autonomic neuropathy were 2.1 vs. 1.8% (P = 0.869) at 5 years and 15.2 vs. 4.2% (P = 0.007) at 10 years of follow-up. NIDDM patients with parasympathetic neuropathy at the 10-year examination showed worse glycemic control and higher insulin values than those without parasympathetic neuropathy. Furthermore, in our subjects, women were more prone to have parasympathetic neuropathy than men. Parasympathetic neuropathy at baseline was more frequent in those who died from a cardiovascular cause than those who did not (13 vs. 3%, P = 0.045). Similarly, sympathetic autonomic nervous dysfunction at the 5-year examination predicted the 10-year cardiovascular mortality. In conclusion, the frequency of autonomic neuropathy in NIDDM patients increases sharply with time. The development of autonomic neuropathy is connected with poor glycemic control. Interestingly, a high insulin level seems to have a predictive role in the development of parasympathetic autonomic neuropathy irrespective of obesity and glycemia.
关于非胰岛素依赖型糖尿病（NIDDM）患者自主神经病变的发生率、预测因素及其与心血管死亡率的关系，人们知之甚少，而且目前尚无包括非糖尿病对照受试者的长期随访研究。共有133例新诊断的NIDDM患者（70例男性）和144例对照受试者（62例男性）在基线时以及随访5年和10年后接受了检查。进行了深呼吸试验（基线、5年和10年）和主动直立试验（5年和10年）。自主神经病变的标准为副交感神经（呼气与吸气比值≤1.10）、交感神经（直立试验中收缩压下降≥30 mmHg）和混合性自主神经病变（副交感神经与交感神经病变并存）。随访10年时，副交感神经病变的发生率（NIDDM患者与对照受试者相比）在基线时为4.9%对2.2%（P = 0.224），5年时为19.6%对8.5%（P = 0.017），10年时为65.0%对28.0%（P < 0.001）。交感神经病变的发生率在随访5年时为6.8%对5.6%（P = 0.709），10年时为24.4%对9.0%（P = 0.003）。混合性自主神经病变的这些数据在随访5年时为2.1%对1.8%（P = 0.869），10年时为15.2%对4.2%（P = 0.007）。在10年检查时患有副交感神经病变的NIDDM患者与没有副交感神经病变的患者相比，血糖控制更差，胰岛素值更高。此外，在我们的研究对象中，女性比男性更容易发生副交感神经病变。基线时患有副交感神经病变的患者死于心血管原因的比例高于未患副交感神经病变的患者（13%对3%，P = 0.045）。同样，5年检查时的交感神经自主神经功能障碍可预测10年心血管死亡率。总之，NIDDM患者自主神经病变的发生率随时间急剧增加。自主神经病变的发生与血糖控制不佳有关。有趣的是，无论肥胖和血糖情况如何，高胰岛素水平似乎在副交感神经自主神经病变的发生中具有预测作用。
