2型糖尿病合并慢性肾脏病且尿白蛋白正常者脉搏波传导速度变化及其危险因素分析

Change of pulse wave velocity and its risk factors in type 2 diabetes mellitus with normoalbuminuric chronic kidney disease

目的探讨2型糖尿病(T2DM)患者中正常白蛋白尿合并肾功能受损人群的肱-踝脉搏波传导速度(baPWV)变化及其危险因素。方法以2015年1月至2020年5月在复旦大学附属华山医院内分泌科住院的1 567例T2DM患者为研究对象,其中男性953例,女性614例,平均年龄(60.9±13.2)岁,平均病程10(4,14)年。根据预估肾小球滤过率(eGFR)及尿白蛋白/肌酐(UACR)分为无慢性肾脏病(CKD)组[eGFR≥60 ml·min-1·(1.73 m2)-1且UACR<30 mg/g]、正常白蛋白尿的CKD(NACKD G3)组[eGFR 30~60 ml·min-1·(1.73 m2)-1且UACR<30 mg/g]、白蛋白尿伴肾功能未受损(ALB-CKD G1~2)组[eGFR≥60 ml·min-1·(1.73 m2)-1且UACR≥30 mg/g]和白蛋白尿伴肾功能受损(ALB-CKD G3)组[eGFR 30~60 ml·min-1·(1.73 m2)-1且UACR≥30 mg/g],其中NACKD G3组46例,余各组按年龄、性别与之1∶3匹配138例。收集患者一般临床资料并计算体质指数(BMI),检测低密度脂蛋白胆固醇(LDL-C)等实验室指标并测定baPWV。组间比较采用t检验、非参数检验以及χ2检验。结果与正常蛋白尿者相比,T2DM患者合并微量白蛋白尿者和大量白蛋白尿者baPWV显著升高(P<0.01),其中大量白蛋白尿者baPWV又明显高于微量白蛋白尿者(P<0.01)。与无CKD组相比, ALB-CKD G1~2组、ALB-CKD G3组与NACKD G3组的baPWV均显著升高[(1 839.2±458.2)、(2 114.2±695.6)、(1 892.4±551.7)比(1 665.7±391.9)mm/s,P<0.01],其中以ALB-CKD G3大量白蛋白尿亚组升高最为显著。ALB-CKD G3微量白蛋白亚组的baPWV仍明显高于NACKD G3组[(2 013.9±559.7)比(1 884.5±557.4)mm/s,P<0.05]。NACKD G3组的baPWV与ALB-CKD G1~2组大量白蛋白尿亚组差异无统计学意义(P>0.05),明显高于ALB-CKD G1~2微量白蛋白亚组[(1 884.5±557.4)比(1 788.4±351.7)mm/s,P<0.05]。非条件logistic回归分析表明,年龄[比值比(OR)=1.105,95%可信区间(CI)(1.013~1.605)]、女性(OR=1.198,95%CI 1.021~2.914)、BMI(OR=1.041,95%CI 1.009~1.104)和LDL-C(OR=3.771,95%CI 1.076~20.892)是正常白蛋白尿伴肾功能受损的T2DM患者baPWV升高的危险因素。结论正常白蛋白尿伴肾功能受损的T2DM患者较白蛋白尿不伴肾功能受损者存在更高的心血管事件发生和全因死亡风险,年长、女性、肥胖、LDL-C水平升高是其baPWV升高的危险因素。

Objective To explore the brachial-ankle pulse wave velocity(baPWV)and its potential risk factors in type 2 diabetes mellitus(T2DM)patients with normoalbuminuric chronic kidney disease(CKD).Methods T2DM patients hospitalized in the Department of Endocrinology,Huashan Hospital Affiliated to Fudan University from January 2015 to May 2020 were selected as the research objects.1567 T2DM patients(953 males and 614 females)with an average age of(60.9±13.2)years and an average course of 10(4,14)years were enrolled in this study.According to the estimated glomerular filtration rate(eGFR)and urinary albumin/creatinine(UACR),the patients were divided into three groups:non CKD group[eGFR≥60 ml·min-1·(1.73 m2)-1 and UACR<30 mg/g],normoalbuminuric CKD(NACKD)group[eGFR 30-60 ml·min-1·(1.73 m2)-1 and UACR<30 mg/g],ALB-CKD G1-2 group[eGFR≥60 ml·min-1·(1.73 m2)-1 and UACR≥30 mg/g]and ALB-CKD G3 group[eGFR 30-60 ml·min-1·(1.73 m2)-1 and UACR≥30 mg/g].There were 46 cases in NACKD group and 138 cases in other groups matched with age and gender 1∶3.The general clinical data were collected and body mass index(BMI)was calculated,laboratory parameters such as low density lipoprotein cholesterol(LDL-C)and baPWV were detected.The t test,non-parametric test andχ2 test were used for comparison between groups.Results Compared with normal albuminuria patients,baPWV in T2DM patients with micro-albuminuria and macro-albuminuria were significantly higher(P<0.01).BaPWV in those with macro-albuminuria was also significantly higher than that in T2DM patients with microalbuminuria(P<0.01).Compared with the group without CKD,the baPWV of ALB-CKD G1-2 group,ALB-CKD G3 group and NACKD G3 group were significantly higher[(1839.2±458.2),(2114.2±695.6),(1892.4±551.7)vs(1665.7±391.9)mm/s,P<0.01],especially ALB-CKD G3 macro-ALB subgroup.BaPWV of ALB-CKD G3 micro-ALB subgroup was significantly higher than that of NACKD G3 Group[(2013.9±559.7)vs(1884.5±557.4)mm/s,P<0.05].BaPWV of NACKD G3 group was similar to ALB-CKD G1-2 macro-ALB subgroup(P>0.05),but significantly higher than ALB-CKD G1-2 micro-ALB subgroup[(1884.5±557.4)vs(1788.4±351.7)mm/s,P<0.05].Unconditional logistic regression analysis showed that age[odds ratio(OR)=1.105,95%confidence interval(CI)1.013-1.605],female(OR=1.198,95%CI 1.021-2.914),BMI(OR=1.041,95%CI 1.009-1.104)and LDL-C(OR=3.771,95%CI 1.076-20.892)were the risk factors for the increase of baPWV in T2DM patients with normal albuminuria but impaired renal function.Conclusion T2DM patients with normal albuminuria but impaired renal function have higher risk of cardiovascular events and all-cause death than those with albuminuria but without impaired renal function.Elderly,female,obesity and poor control of LDL-C are the risk factors of increased baPWV in T2DM patients with normal albuminuria but impaired renal function.