肾损伤和脂质异常与非清蛋白尿DKD发生的关系

Correlation between kidney injury and dyslipidemia with non-albuminuric DKD occurrence

目的探讨肾损伤和脂质异常与非清蛋白尿糖尿病肾脏病(NADKD)发生的关联性及其常见标志物对NADKD的预测价值。方法收集2017年1月至2018年12月每1~2个月定期连续随访3次的NADKD患者(NADKD组)151例和改善全球肾脏病预后组织(KIDGO)指南A1期的单纯糖尿病患者(SDM组)720例的临床资料,纳入同期健康对照(HC组)201例。测定其肾功能和脂代谢标志物水平,分析各指标与NADKD的关系,以及其中关系密切指标对NADKD的风险预测程度和诊断性能。结果本组151例NADKD患者高血糖患者占17.3%。以末次检测结果统计,NADKD患者估算肾小球过滤率(eGFR)分布在G2期4.6%、G3a期占61.6%、G3b期占28.5%和G4期占5.3%,而尿清蛋白/肌酐比值(ACR)筛查NADKD的判断界值为10.4 mg/gCr(Cr,肌酐)。所有观察指标在相互影响下,仅ACR、eGFR、中性粒细胞明胶酶相关脂质运载蛋白(NGAL)和同型半胱氨酸(HCY)与NADKD相关联(OR=1.143、0.847、1.025、1.095,P<0.01)。以ACR分层的风险分析显示,NGAL对NADKD的风险高于HCY(MH-OR=36.70 vs.11.71,Z=3.461,P<0.05),且在ACR≥10 mg/gCr时更具风险(OR=51.27 vs.8.72,Z=4.080,P<0.05)。在目前有效用于NADKD筛查的指标eGFR的基础上,只需补充NGAL联合检测,即可改善NADKD的筛查性能(AUC=0.976 vs.0.960;Se=97.5%vs.87.1%,Sp=97.5%vs.95.0%,P<0.05)。结论肾小管损伤与NADKD发生的关联性更甚于脂质异常。对于KIDGO指南A1期SDM患者,若ACR>10 mg/gCr,则应同时关注eGFR和NGAL的变化,以尽早预防NADKD的发生。

Objective To explore the relationship between the kidney injury and dyslipidemia with non-albuminuric diabetic kidney disease(NADKD)and the predictive values of the common markers to NADKD.Methods A total of 151 NADKD patients with regular follow up for continuous 3 times per 1-2 months during 2017-2018(NADKD group)and 720 patients with simple diabetes mellitus(SDM group)in KIDGO A1 phase were collected,and contemporaneous 201 healthy controls(HC group)were included.The kidney function and levels of lipid metabolism markers were measured.Then the relationship between these markers with NADKD was analyzed,and the risk degree and diagnostic performance of those closely-related markers to NADKD were analyzed.Results Among 151 cases of NADKD,the hyperglycemia cases accounted for 17.3%.In the statistics with the last detection results,the estimated glomerular filtration ratio(eGFR)distribution in the NADKD patients was 4.6%in the stage G2,61.6%in the stage G3a,28.5%in the stage G3b and 5.3%in the stage G4,while the judging boundary value of urinary albumin/creatinine ratio(ACR)for screening NADKD was 10.4 mg/gCr.All observation markers were under the mutual effect,only ACR,eGFR,NGAL and HCY were correlated to NADKD(OR=1.143,0.847,1.025,1.095,P<0.01).The risk analysis by ACR stratification showed that the risk of NGAL to NADKD was higher than that of HCY(MH-OR=36.70 vs.11.71;Z=3.461,P<0.05),moreover which had more risk when ACR≥10 mg/gCr(OR=51.27 vs.8.72;Z=4.080,P<0.05).On the basis of eGFR,which was an effective indicator used for screening NADKD at present,the performance for screening NADKD could be improved by only needing to supplement with NGAL combined test(AUC=0.976 vs.0.960;Se=97.5%vs.87.1%;Sp=97.5%vs.95.0%;all P<0.05).Conclusion The relationship of renal tubule injury with NADKD occurrence is even more than dyslipidemia.For the SDM patients with KIDGO A1 phase in the KIDGO guidance,if ACR≥10 mg/gCr,the attention should be paid to both eGFR and NGAL changes in order to early discover NADKD occurrence.