血液透析过程中影响伴糖尿病患者血糖波动的危险因素及预防策略

Analysis of risk factors and prevention strategies of blood glucose fluctuation in patients with diabetes during hemodialysis

目的探讨伴糖尿病(DM)患者血液透析(HD)过程中影响血糖波动的危险因素及预防策略。方法回顾性分析2020年8月—2022年2月淮南市东方医院集团总医院收治的86例伴DM并行规律HD的T2DM患者的临床资料,设为训练集;根据HD过程中血糖是否波动,将患者分为血糖波动组(44例)和无血糖波动组(42例)。按照相同标准选取2022年3月—2022年8月的29例伴DM并行规律HD的T2DM患者,设为验证集,行外部验证。通过LASSO回归分析后进行多因素Logistic回归分析,建立列线图预测模型,并进行模型评价。结果HD过程中,患者血糖波动范围为1.62~27.81 mmol/L,平均(8.46±3.25)mmol/L。随着透析的进行,透析1 h血糖下降幅度最大,透析2 h至结束,血糖轻微上升,但血糖变化幅度总体趋于平缓。HD过程中,患者中有19例(30次)出现低血糖(22.09%),有25例患者(47次)出现高血糖(29.07%)。与无血糖波动组相比,血糖波动组患者的DM病程以及HD时间均更长,知晓低血糖定义的患者比例更低,自理能力差的患者比例更高,SBP以及HbAlc水平均更高(均P<0.05)。LASSO回归分析筛选出4个预测因子,多因素Logistic回归分析结果显示,DM病程≥18.2年、自理能力差、收缩压(SBP)≥152.3 mmHg、糖化血红蛋白(HbAlc)≥8.4%,均为患者HD过程中血糖波动的独立危险因素(P<0.05)。模型验证发现,两集校准曲线和理想曲线较为贴近,训练集和验证集的ROC曲线下面积分别为0.807、0.797。DCA曲线显示阈值概率在1%~94%时,具有较高的净获益值。结论DM病程≥18.2年、自理能力差、SBP≥152.3 mmHg、HbAlc≥8.4%均为患者HD过程中血糖波动的独立危险因素。在临床治疗中,需密切关注伴DM患者HD过程中各指标的变化情况,以明确其血糖波动风险,从而更加准确、及时地调整治疗方案。

Objective To explore the risk factors and prevention strategies of blood glucose fluctuation during hemodialysis(HD)in patients with diabetes mellitus(DM).Methods Retrospective analysis of the clinical data of 86 T2DM patients with concurrent pattern HD and DM admitted to Huainan Oriental Hospital Group General Hospital from August 2020 to February 2022,set as a training set;According to whether blood glucose fluctuated during HD,the patients were divided into blood glucose fluctuation group(44 cases)and no blood glucose fluctuation group(42 cases).According to the same criteria,29 T2DM patients with DM parallel regular HD from March to August 2022 were selected as the validation set for external validation.After LASSO regression analysis,multivariate Logistic regression analysis was performed,and establish nomogram prediction model,and the model was evaluated.Results During HD,the blood glucose fluctuation range of patients was 1.62~27.81 mmol/L,with an average of(8.46±3.25)mmol/L.With the progress of dialysis,the blood glucose decreased the most in 1 hour of hemodialysis;After 2 hours of hemodialysis,the blood sugar increased slightly,but the change in blood sugar was generally flat.During HD,19 patients(30 times)had hypoglycemia(22.09%),and 25 patients(47 times)had hyperglycemia(29.07%).Four predictors were screened by LASSO regression analysis,and multivariate Logistic regression analysis showed that DM duration≥18.2 years,poor self-care ability,systolic blood pressure(SBP)≥152.3 mmHg,glycated hemoglobin glycosylated hemoglobin(HbAlc)≥8.4%are independent risk factors for blood glucose fluctuations during HD(P<0.05).The evaluation results show that the nomogram prediction model has good discrimination,high accuracy and good effectiveness.Conclusion Duration of DM≥18.2 years,poor self-care ability,SBP≥152.3 mmHg,HbAlc≥8.4%were independent risk factors for blood glucose fluctuations during HD.In clinical treatment,it is necessary to pay close attention to the changes of various indicators in the process of HD in patients with DM to clarify the risk of blood sugar fluctuations,so as to adjust the treatment plan more accurately and in a timely manner.