2型糖尿病患者骨密度变化的相关危险因素分析

Risk factors of bone mineral density changes in patients with type 2 diabetes mellitus

目的探讨2型糖尿病患者骨密度年变化率相关的危险因素,为降低2型糖尿病患者骨折风险提供理论依据。方法选取2018年1月—2019年1月在同济大学附属同济医院内分泌代谢科就诊的2型糖尿病患者,符合入选和排除标准后,通过面对面的问卷调查形式收集153名患者的基线临床资料,收集患者血常规、肝肾功能、糖脂代谢相关指标、尿微量白蛋白/肌酐比值、骨转换相关指标,并使用双能X线骨密度仪测定研究对象的骨密度(腰椎、股骨颈和全髋)。将随访患者按照尿白蛋白/肌酐比值(urine albumin creatine ratio,UACR)水平分为3组:对照组(UACR<30 mg/g)、微量白蛋白尿组(30 mg/g≤UACR<300 mg/g)、大量白蛋白尿组(UACR≥300 mg/g),平均随访(1.7±0.7)年,分析各部位骨密度的变化并分析相关危险因素。结果在153名研究对象中,40.5%为老年男性,59.5%为绝经后女性。在老年男性中,股骨颈、腰椎、全髋骨密度年变化率组间均无显著性差异(P>0.05)。在绝经后女性患者中,与对照组相比,大量白蛋白尿组股骨颈骨密度下降最快[-0.71(-3.21-0.41)%vs 1.25(-0.743.61)%,P=0.029],其余部位的骨密度年变化率组间无显著差异(P>0.05)。单因素相关分析提示,绝经后女性患者UACR与股骨颈骨密度年变化率呈显著负相关(r=-0.241,P=0.022),血红蛋白与股骨颈骨密度年变化率呈显著正相关(r=0.244,P=0.020)。多元线性回归分析发现,在校正了性别、糖尿病病程、估算肾小球滤过率(estimated glomerular filtration rate,eGFR)、血红蛋白、初次股骨颈骨密度之后,UACR和股骨颈骨密度年变化率并无相关性。但即便校正了性别、糖尿病病程、eGFR、UACR、初次股骨颈骨密度之后,血红蛋白与股骨颈骨密度年变化率仍呈正相关(B=0.064,95%CI:0.0050.122,P=0.032)。结论2型糖尿病患者的血红蛋白水平与股骨颈骨密度下降相关,改善2型糖尿病患者的低血红蛋白水平可能有助于延缓其骨密度的下降。但该结论仍需要在更大样本的前瞻性研究中验证。

Objective To investigate the risk factors of bone mineral density(BMD)changes in patients with type 2 diabetes mellitus(T2DM).Methods A total of 153 patients with T2DM,62 elderly men and 91 postmenopausal women with a mean age of 66.46±8.75 years(51-89 years),who visited the Department of Endocrinology,Shanghai Tongji Hospital from January 2018 to January 2019 were enrolled in the study.The general information of patients were collected by face-to-face questionnaire survey,the whole blood count,liver and kidney function,glucose and lipid metabolism related indexes,urinary microalbumin/creatinine and bone turnover markers were detected.BMD of lumbar spine,femoral neck and total hip was measured by dual-energy X-ray absorptiometry(DEXA).Patients were divided into three groups according to urine albumin creatine ratio(UACR):control group(UACR<30 mg/g),microalbuminuria group(30≤UACR<300 mg/g)and macroalbuminuria group(UACR≥300 mg/g).Patients were followed-up for(1.7±0.7)years,the change of BMD and the related risk factors were analyzed.Results There were no significant differences in the annual change rate of femoral neck,lumbar spine,and total hip BMD among 3 groups.However,compared with the control group,the femoral neck BMD in the macroalbuminuria group of postmenopausal women showed a significant decrease[-0.71(-3.21--0.41)%vs 1.25(-0.74-3.61)%,P=0.029].Univariate correlation analysis showed that the level of UACR was negatively correlated with the annual change rate of femoral neck BMD(r=-0.241,P=0.022),and hemoglobin was positively correlated with the annual change rate of femoral neck BMD(r=0.244,P=0.020)in postmenopausal women.Multiple linear regression analyses found no correlation between the level of UACR and the annual change rate of femoral neck BMD after adjusted by gender,duration of diabetes,estimated glomerular filtration rate(eGFR),hemoglobin and baseline BMD at femoral neck.After adjusting for gender,duration of diabetes,eGFR,UACR and baseline BMD at femoral neck,the level of hemoglobin was still positively correlated with the annual change rate of femoral neck BMD(B=0.064,95%CI:0.005-0.122,P=0.032).Conclusion The hemoglobin level is positively correlated with the annual change rate of femoral neck BMD in postmenopausal women with T2DM,indicating that the decline of BMD may be prevented by improving the low hemoglobin level in this group of patients.However,the conclusion needs to be confirmed in long-term clinical studies with larger samples.