不同Wagner分级糖尿病足患者肾损害的临床研究

Clinical analysis on kidney damage in diabetic foot patients with different Wagner grades

目的 探讨不同严重程度的糖尿病足（Wagner 1-5级）患者的肾损害情况,了解糖尿病足与肾病之间的临床关系,提高临床实践中对糖尿病足的诊治.方法 对解放军第306医院内分泌科2009年6月至2014年6月收治的622例2型糖尿病合并糖尿病足的患者及2 1 5例2型糖尿病非足病的患者作回顾性分析,将足病与非足病各分为一组,收集相关临床资料并检测相关生化指标分析糖尿病足的影响因素.将非足病、Wagner 1级、2级、3级各分为一组,Wagner 4级和5级分为一组,以尿白蛋白肌酐比值（UACR）、估算的肾小球滤过率（eGFR）为指标分析不同程度足病的肾损害情况.应用SPSS19.0统计软件进行统计学分析.结果 糖尿病足病组与非足病组相比UACR明显升高,（78.00 vs 10.60mg/g,P＜0.05）,eGFR明显下降[（100.91＆#177;44.98） vs （114.27＆#177;35.88） ml/ （min＆#183; 1.73m2）,P＜0.05];多元逐步回归分析结果显示性别、糖尿病视网膜病变、血清白蛋白、尿酸、餐后2h血糖、UACR与2型糖尿病足发生、发展相关（β=0.707、0.850、-0.183、-0.006、0.104、0.003,均P＜0.05）;Wagner 3级组与Wagner 2级组相比微量白蛋白尿（UACR 30-300mg/g）发生率明显升高[49.7％（87/175）vs 39.2％（67/171）,x2=3.885],Wagner4-5级组与Wagner 3级组相比肾功能不全[eGFR＜ 60ml/（min＆#183;1.73m2）]的发生率明显升高[23.5％ （43/183） vs 11.0％ （24/220）,x2=11.421],差异均有统计学意义（均P＜0.05）;大量白蛋白尿（UACR≥300mg/g）、肾功能不全在Wagner 3级组的发生率低于2级组,但在Wagner 4-5级组重新升高.结论 糖尿病足Wagner分级越高,肾损害越严重,微量白蛋白尿较肾小球滤过率能更早提示糖尿病肾损害,Wagner 3级是肾病进展及临床治疗的转折点,当患者处于Wagner 3级时应加强足部护理及肾脏保护的力度.

Objective To investigate the kidney damage of the patients who have different severity of diabetic foot （Wagner grades 1 to 5） and investigate the relationship of diabetic foot with kidney disease in order to improve the clinical practice for diagnosis and treatment for diabetic foot. Methods A retrospective study was carried out on 622 type 2 diabetes mellitus （T2DM） patients with diabetic foot and 215 T2DM patients of non-foot disease admitted to the Department of Endocrinology of Chinese PLA Hospital No.306 from June 2009 to June 2014. Their clinical data were collected and biochemical indicators were measured. The patients with non-foot disease or Wagner grades I to 3 were assigned into a group, and those with Wagner grades 4 to 5 into another group. Urinary albumirdcreatinine ratio （UACR） and estimated glomerular filtration rate （eGFR） were used to evaluate the kidney damage. The relationship of the renal function with varying degrees of diabetic foot was analyzed by SPSS19.0 software. Results The diabetic foot group had significantly higher UACR （78.00 vs 10.60mg/g, P 〈 0.05）, but lower eGFR [（100.91 ± 44.98） vs （114.27 ± 35.88）ml]min · 1.73m2, P 〈 0.05] when compared with the non-foot group. Multivariate stepwise regression analysis indicated that gender, diabetic retinopathy, serum albumin, uric acid, 2-hour postprandial plasma glucose （2hPPG）, UACR were associated with the incidence and development of type 2 diabetic foot （9 = 0.707, 0.850, -0.183, -0.006, 0.104, 0.003, all P 〈 0.05）. The incidence of microalbuminuria （UACR 30-300mg/g） were significantly higher in the patients with Wagner grade 3 than those with grade 2 [49.7% （87/175） vs 39.2% （67/171）, 23 = 3.885]. The ratio of renal insufficiency [eGFR 〈 60mI/（min · 1.73m2）] was obviously higher in those with Wagner grades 4-5 compared with those with grade 3 [23.5% （43/183） vs 11.0% （24/220）, 23 = 11.421, all P 〈 0.05]. Those with Wagner grade 3 had less incidences of macroalbuminuria （UACR〉300mg/g） and renalinsufficiency than those with grade 2, but the incidences were increased again in those with Wagner grades 4-5. Conclusion The higher the Wagner classification grade is for diabetic foot, the more severe the kidney damage is. Microalbuminuria is superior to GFR to suggest kidney damage in diabetic patients. Wagner grade 3 is a turning point of the deterioration of kidney damage and clinical treatment. Clinicians should strengthen foot care and kidney protection when the patient is in Wagner grade 3.