2型糖尿病患者血清胆红素水平与糖尿病足的相关性

Correlation between serum bilirubin level and diabetic foot in patients with type 2 diabetes mellitus

目的 探讨2型糖尿病(T2DM)患者血清胆红素水平与糖尿病足的关系。方法 选取2009-2015年海南省第三人民医院收治的1 269例T2DM患者,根据糖尿病足的诊断标准分为糖尿病足组(578例)和非糖尿病足组(NDF组,691例),同时根据Wagner分级将糖尿病足组分为低级别组(40例,Wagner 0级或1级)、中级别组(425例,Wagner 2级或3级)、高级别组(113例,Wagner 4级或5级)。再将578例糖尿病足患者根据是否截肢分为非截肢组(446例)和截肢组(132例)。所有患者入院时检测血清总胆红素、直接胆红素(D-BIL)和间接胆红素(I-BIL)水平,以及白细胞计数、肌酐、收缩压、丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、γ-谷氨酰转肽酶(GGT)、尿酸、总胆固醇、甘油三酯、高密度脂蛋白-胆固醇(HDL-C)、低密度脂蛋白-胆固醇(LDL-C)、HbA1c和血红蛋白。收集糖尿病足患者的Wagner分级和截肢手术资料。进行二元或有序多元logistic回归分析,以确定T2DM患者糖尿病足及截肢的危险因素。结果 与NDF组相比,糖尿病足组患者年龄、吸烟和饮酒患者的比例、大血管并发症患者的比例均较高(χ2=3.852~474.272,P均<0.05);白细胞计数、肌酐、收缩压水平升高(U=6.485、35.421、36.155,P均<0.05),总胆红素、D-BIL、I-BIL、ALT、AST、GGT、尿酸、总胆固醇、甘油三酯、HDL-C、LDL-C、HbA1c、血红蛋白和高脂血症患者的比例降低(U=3.145~68.119,P均<0.05)。血清I-BIL水平≥6.0 μmol/L与糖尿病足呈负相关(OR=0.751,95%CI:0.570~0.980,P<0.05)。血清总胆红素>10.0 μmol/L与Wagner评分较低有关(OR=0.506,95%CI:0.298~0.857,P<0.05),血清I-BIL≥6.0 μmol/L是Wagner评分较低的保护因素(OR=0.280, 95%CI:0.147~0.538,P<0.05)。总胆红素≥10.0 μmol/L是截肢的保护因素(OR=0.474,95%CI: 0.243~0.921,P<0.05)。结论 T2DM患者血清胆红素水平下降与糖尿病足的严重程度以及截肢事件独立相关。

Objective To explore the relationship between serum bilirubin level and diabetic foot(DF)in patients with type 2 diabetes mellitus(T2DM).Methods A total of 1269 patients with T2DM in the Third People′s Hospital of Hainan Province in 2009-2015 were divided into diabetic foot group(DF group,n=578)and non-DF group(NDF group,n=691)according to the diagnostic standard of DF,and patients in DF group were divided into low grade group(40 cases,Wagner 0 grade or 1 grade),intermediate group(425 cases,Wagner 2 or 3 grade),senior group(113 cases,Wagner 4 or 5 grade)according to Wagner classification.Furthermore,patients in DF group were divided into non-amputated group(n=446)and amputation group(n=132)according to whether they were amputated.The levels of serum total bilirubin(T-BIL),direct bilirubin(D-BIL)and indirect bilirubin(I-BIL),white blood cell count,creatinine,systolic blood pressure,alanine aminotransferase(ALT)and aspartate aminotransferase(AST),γ-glutamyl transpeptidase(GGT),uric acid,total cholesterol,triglyceride,high-density lipoprotein-cholesterol(HDL-C),low density lipoprotein-cholesterol(LDL-C),HbA1c and hemoglobin were detected in all patients.Wagner classification and amputation data of patients with DF were collected.Binary or sequential multiple logistic regression analysis was performed to determine the risk factors for DF and amputation in patients with T2DM.Results Compared with NDF group,age,the proportion of smoking and drinking,the proportion of patients with macrovascular complications were higher(χ2=3.852-474.272,all P<0.05),and white blood cell count,the levels of creatinine,systolic blood pressure were increased(U=6.485,35.421,36.155,all P<0.05),T-BIL,D-BIL,I-BIL,ALT,AST,GGT,uric acid,total cholesterol,triglyceride,HDL-C,LDL-C,HbA1c,hemoglobin and the proportion of patients with hyperlipidemia were decreased(U=3.145-68.119,all P<0.05)in DF group.Serum I-BIL level was negatively correlated with diabetic foot(OR=0.751,95%CI:0.570-0.980,P<0.05).Serum T-BIL>10.0μmol/L was correlated with lower Wagner score(OR=0.506,95%CI:0.298-0.857,P<0.05).Serum I-BIL≥6.0μmol/L was a protective factor of lower Wagner score(OR=0.280,95%CI:0.147-0.538,P<0.05),serum T-BIL≥10.0μmol/L was a protective factor of lower extremity amputation(OR=0.474,95%CI:0.243-0.921,P<0.05).Conclusion The decrease of serum bilirubin level is independently associated with the presence and severity of DF and amputation events in patients with T2DM.