2型糖尿病肾脏损害病理类型分类初探

Patterns of renal injury in type 2 diabetic patients with macroalbuminuria

目的探讨2型糖尿病肾脏损害病理类型的分类方法。方法回顾性分析49例除外非糖尿病肾病的伴显性白蛋白尿2型糖尿病患者的肾脏病理表现及临床特点，根据病理表现分为典型糖尿病肾小球病（DG）组和不典型糖尿病相关肾脏疾病（ADRD）组。结果DG占59．2％，ADRD占40.8％。病理表现上，DG的肾小球系膜区体密度、肾小球基底膜厚度、肾小管间质病变积分和肾小动脉玻璃样变发生率均大于ADRD，而是细胞相对密度低于ADRD。临床表现上，DG的糖尿病病程较长，糖尿病视网膜病变（DR）发生率高，空腹血糖较高，收缩压和平均动脉压较高，尿蛋白量较多，GFR下降更明显，而ADRD的体质量指数和肥胖比例较高，血脂紊乱更显著。DG和ADRD的GFR均与肾小球球性硬化率呈负相关，而DG的尿蛋白量水平与肾小球系膜区体密度呈正相关，ADRD的尿蛋白量水平与病理指标无显著相关。对DG诊断预测价值较高的有DR（阴性预测值94.8％）和已知糖尿病病程超过5年（阴性预测值90．7％）。结论2型糖尿病肾损害的病理表现多样，ADRD与DG是两种差异显著的2型糖尿病肾损害的病理表现，区分ADRD与DG能更好地从临床预测病理。

Objective To find out a more rational pathological classification criteria for renal injury in patients with type 2 diabetes mellitus. Methods The renal clinicopathological features of forty-nine type 2 diabetic patients with macroalbuminuria were collected and were compared retrospectively. The patients without diabetic renal disease were excluded. According to the pathological features, the patients were divided into two groups： typical diabetic glomerulopatby （DG） and atypical diabetes-related renal disease （ADRD）. Results The renal biopsy revealed DG accounted for 59.2% of the patients, while the remaining 40.8% presented atypical renal injury defined as ADRD. In DG group, volume fraction of mesangium per glomerulus, glomerular basement membrane width, atrophic tubules index, intersititium injury index and prevalence of hyalinization of renal arteriole were higher; podocyte density per glomerulus was lower; duration of type 2 diabetes was longer; the level of fast blood glucose, systolic blood pressure, mean arterial pressure, proteinuria and prevalence of diabetic retinopathy （DR） were higher; glomerular filtration rate （GFR） was lower. In ADRD group, body mass index and prevalence of obesity were higher; dyslipidemia was more severe. GFR was negatively correlated with glomerular global sclerosis rate in both DG and ADRD group. Proteinuria was positively correlated with volume fraction of mesangium per glomerulus in DG. No correlation between proteinuria and pathological features was found in ADRD. DR （94.8%） and duration of type 2 diabetes over five years （90.7%） had high negative predictive value for DG. Conclusions Renal injuries in type 2 diabetes patients are heterogeneous. ADRD is an atypical renal injury in type 2 diabetes patients which is different from DG. DR and duration of diabetes are more helpful in predicting DG separating from ADRD.