血糖控制与糖尿病视网膜病变的五年观察

A five-year follow-up study on diabetic retinopathy with intensive glucose control in outpatients with type 2 diabetes

目的探讨长期强化控制血糖与一般控制血糖对糖尿病视网膜病变的影响。方法按随机表法将49例年龄为58～70岁、病程为0．6～12．0年的2型糖尿病患者，随机分为强化降糖组（24例）和对照组（25例），于2002年至2007年进行为期5年的门诊血糖管理。两组均行降糖治疗，强化降糖组每3个月测定一次糖化血红蛋白（HbA1c）水平，控制目标为≤6．5％；对照组按我国糖尿病诊治指南，对有心肌梗死史患者或年龄60岁以上、既往无合并症者，血HbA1c控制在7．0％以内，每6个月测定一次血HbA1C水平。每年由同一位眼科医生定期对患者双眼进行眼科检查，观察有无新发糖尿病视网膜病变（微动脉瘤、眼底出血、黄斑水肿、糖尿病性失明）。结果强化降糖组的血HbA1c水平从治疗第2年开始明显低于对照组[（6．3±0．6）％与（7．1±2．0）％，P〈0．05]，并一直维持到第5年；5年间，强化降糖组无新发眼底出血和糖尿病性失明；视力下降2行及以上、新发微动脉瘤、黄斑水肿以及行视网膜激光光凝治疗的人次数，较对照降糖组明显减少（分别为15例次比25例次，5例次比10例次，1例次比3例次，4例次比23例次，P〈0．05）。结论强化血糖管理可显著减少2型糖尿病患者新发糖尿病视网膜病变，门诊进行糖尿病患者的长期强化血糖管理是可行的。

Objective To observe effects of long-term intensive glucose control therapy on diabetic retinopathy in outpatients with type 2 diabetes mellitus （T2DM） . Methods Forty-nine patients with T2DM, aged 58 to 70 years with illness course length of 0. 6 to 12.0 years, were randomly assigned to groups receiving either intensive （24 patients） or standard glucose control （25 patients）. They were all under management with hypoglycemic treatment in the outpatient department of Beijing Tongren Hospital for five years during 2002 to 2007. Serum level of glycosylated hemoglobin A1 c （HbAlc） were measured for the patients in intensive-therapy group every three months targeting at it controlled below 6. 5% with any drugs needed. For the patients in standard glucose control group aged 60 years or over, with history of myocardial infarction, but without other complications, serum level of HbA1 c was measured every a half year and should be controlled under 7.0%. Their visual acuity, lens, vitreous body and fundus oculi were examined after dilatation of the pupil by ophthahnologists to identify any new diabetic retinopathy （DR） , including micro- aneurysm, fundus hemorrhage, edema of the macula lutea, or diabetic associated blindness. Results Serum level of HbAlc had been significantly lower in intensive glucose control group [ （6. 3 ±0. 6） % than that in standard glucose control one [ （7. 1 ±2. 0）% ] since the second year of therapy （P 〈0. 05）, which could be maintained in the next four years of therapy. No new case of fundus hemorrhage or diabetic associated blindness could be found in intensive glucose control group during the five-year period of therapy. Number of new episodes of lowering in visual acuity （15 cases）, occurrence of micro-aneurysm （five cases） , edema of the macula lutea （one case） , as well as those who needed retinal laser photocoagulation （four cases）, were significantly less in intensive glucose control group than that in standard glucose control one （25, 10, three and 23 cases, respectively） during five-year follow-up （P 〈 0. 05）. Conclusions Long-term intensive glucose control in patients with T2DM can significantly reduce new occurrence of diabetic retinopathy in them, which is feasible in outpatient clinics.