Diabetes Care：糖尿病视网膜病和微量白蛋白尿可预测T2DM患者大量白蛋白尿和肾功能减退

为了评价2型糖尿病患者糖尿病视网膜病(DR)和糖尿病肾病(DN)间的相互作用关系，同时阐明DR和微量白蛋白尿对出现大量白蛋白尿和肾功能减退的影响，来自日本北里大学健康护理中心的Moriya博士等人进行了一项研究，作者认为，蛋白尿和DR应被视为2型糖尿病患者肾脏预后的危险因素。研究结果在线发表于2013年4月25日的美国《糖尿病护理》(Diabetes Care)杂志上。
该项研究是日本糖尿病并发症研究(JDCS)(一项对2型糖尿病患者进行的全国性随机对照关注改变生活方式的研究)的一部分，主要探讨DR和微量白蛋白尿对DN从正常白蛋白尿和低微量白蛋白尿(<150mg/gCr)进展为大量白蛋白尿和肾功能减退的影响。根据DR和MA，将患者分为4个组：正常白蛋白尿无DR[NA(DR-), n=773]、正常白蛋白尿伴有DR[NA(DR+), n=279]、微量白蛋白尿无DR[MA (DR-), n=277]和微量白蛋白尿伴有DR[MA(DR+), n=146]。测定基线和中位随访8年的基础尿白蛋白/肌酐比值和DR情况。
结果显示，4组患者每年大量白蛋白尿发生率分别为：1.6/1000人年(9例)、3.9/1000人年(8例)、18.4/1000人年(34例)和22.1/1000人年(22例)。经多因素调整后，与NA(DR-)组比较，NA (DR+)、MA (DR-)和MA (DR+)组患者进展为大量白蛋白尿的危险比分别为2.48 (95% CI 0.94-6.50; P = 0.07)、10.40 (4.91-22.03; P<0.01)和11.55 (5.24-25.45; P<0.01)。MA(DR+)组每年估算肾小球滤过率(GFR)下降比其它几组快2-3倍(-1.92mL/min/1.73m2/年)。
研究发现，在正常白蛋白尿和低微量白蛋白尿的日本2型糖尿病患者中，基线有微量白蛋白尿与8年内大量白蛋白尿风险升高具有相关性。微量白蛋白尿和DR患者GFR下降最快。蛋白尿和DR应被视为2型糖尿病患者肾脏预后的危险因素。因此，实行开放式的信息共享将有益于眼科专家和糖尿病专家。
与糖尿病相关的拓展阅读：

• NEJM：糖尿病治疗领域的进展与不足
• JAMA：研究支持对糖尿病患者进行更强力的抗血小板治疗
• Obes Surg：减重手术可能不能“治愈”糖尿病
• Cell Metab:新的血清标志物提前数年预测糖尿病风险
• Circulation：精氨酸酶抑制剂治疗糖尿病患者并发症
• Diabetologia：维生素D缺乏与1型糖尿病
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Diabetic Retinopathy and Microalbuminuria Can Predict Macroalbuminuria and Renal Function Decline in Japanese Type 2 Diabetic Patients: Japan Diabetes Complications Study.
OBJECTIVE
To examine the interactive relationship between diabetic retinopathy (DR) and diabetic nephropathy (DN) in type 2 diabetic patients, and to elucidate the role of DR and microalbuminuria on the onset of macroalbuminuria and renal function decline.
RESEARCH DESIGN AND METHODS
We explored the effects of DR and microalbuminuria on the progression of DN from normoalbuminuria and low microalbuminuria (<150 mg/gCr) to macroalbuminuria or renal function decline in the Japan Diabetes Complications Study (JDCS), which is a nationwide randomized controlled study of type 2 diabetic patients focusing on lifestyle modification. Patients were divided into four groups according to presence or absence of DR and MA: normoalbuminuria without DR [NA(DR-)] (n = 773), normoalbuminuria with DR [NA(DR+)] (n = 279), microalbuminuria without DR [MA(DR-)] (n = 277), and microalbuminuria with DR [MA(DR+)] (n = 146). Basal urinary albumin-to-creatinine ratio and DR status were determined at baseline and followed for a median of 8.0 years.
RESULTS
Annual incidence rates of macroalbuminuria were 1.6/1,000 person-years (9 incidences), 3.9/1,000 person-years (8 incidences), 18.4/1,000 person-years (34 incidences), and 22.1/1,000 person-years (22 incidences) in the four groups, respectively. Multivariate-adjusted hazard ratios of the progression to macroalbuminuria were 2.48 (95% CI 0.94-6.50; P = 0.07), 10.40 (4.91-22.03; P < 0.01), and 11.55 (5.24-25.45; P < 0.01) in NA(DR+), MA(DR-), and MA(DR+), respectively, in comparison with NA(DR-). Decline in estimated glomerular filtration rate (GFR) per year was two to three times faster in MA(DR+) (-1.92 mL/min/1.73 m2/year) than in the other groups.
CONCLUSIONS
In normo- and low microalbuminuric Japanese type 2 diabetic patients, presence of microalbuminuria at baseline was associated with higher risk of macroalbuminuria in 8 years. Patients with microalbuminuria and DR showed the fastest GFR decline. Albuminuria and DR should be considered as risk factors of renal prognosis in type 2 diabetic patients. An open sharing of information will benefit both ophthalmologists and diabetologists.