2型糖尿病患者发生慢性肾脏病的危险因素及与肥胖的相关性研究

目的研究2型糖尿病(T2DM)患者发生慢性肾脏病(CKD)的危险因素,并着重分析肥胖与CKD发生的关系。方法纳入2009年1月至2019年6月在南京鼓楼医院就诊的18至75岁诊断为T2DM的患者,收集一般资料包括性别、年龄、体重指数(BMI)、收缩压、舒张压、糖尿病病程以及实验室指标包括血红蛋白(Hb)、白蛋白、丙氨酸转氨酶(ALT)、天冬氨酸氨基转移酶(AST)、总胆红素(TBIL)、尿酸、空腹血糖(FPG)、糖化血红蛋白(HbA1c)、甘油三酯(TG)、总胆固醇(TC)、低密度脂蛋白胆固醇(LDL-C)、高密度脂蛋白胆固醇(HDL-C)、尿白蛋白/肌酐比值和估算的肾小球滤过率。肥胖定义为BMI≥28 kg/m²,超重定义为24 kg/m²≤BMI<28 kg/m²。根据是否合并CKD,将研究对象分为合并CKD组和不合并CKD组。在不合并CKD的T2DM患者中,选取至少随访一次,随访时间超过12个月且随访数据完整的患者,按是否发生CKD分为发生CKD组和未发生CKD组。两组间各指标的比较采用t检验、非参数检验以及χ²检验。采用单因素及多因素logistic回归分析法分析T2DM患者发生CKD的危险因素,采用Cox比例风险模型分析随访的T2DM患者CKD发生的危险因素。采用限制性立方样条(RCS)拟合Cox回归模型来评估不同的BMI截点与CKD的关系。结果共纳入3194例T2DM患者,其中合并CKD组620例,不合并CKD组2574例。与不合并CKD组相比,合并CKD组T2DM患者BMI明显增高(P=0.005)。单因素logistic回归分析结果显示,性别、肥胖、收缩压、舒张压、Hb、白蛋白、TG、TC、FPG及HbA1c为T2DM患者发生CKD的影响因素(均P<0.05),将上述指标作为自变量,进行多因素logistic回归分析,结果显示,肥胖(OR=1.058,95%CI 1.079~2.018),收缩压增高(OR=1.027,95%CI 1.018~1.035),TG增加(OR=1.087,95%CI 1.008~1.171),FPG增高(OR=1.042,95%CI 1.003~1.083)是T2DM患者发生CKD的影响因素(均P<0.05)。不合并CKD组中随访时间超过12个月且随访数据完整的T2DM患者共753例,其中,发生CKD组182例,未发生CKD组571例。Cox比例风险模型分析结果显示,在校正年龄、糖尿病病程、收缩压、AST、TG及FPG后,超重为发生CKD的危险因素(OR=1.95,95%CI 1.05~3.61)。RCS拟合Cox回归模型结果显示,T2DM患者BMI与CKD发生风险呈非线性关系,BMI在28~31 kg/m²的T2DM患者CKD的发生风险增加(均P<0.05)。结论T2DM患者肥胖与CKD密切相关,肥胖的T2DM患者,特别是BMI在28~31 kg/m²,容易发展为CKD。

Risk factors of chronic kidney disease and its correlation with obesity in type 2 diabetic patients

Objective To explore the risk factors of chronic kidney disease(CKD)in patients with type 2 diabetes mellitus(T2DM)and analyze the correlation between obesity and the incidence of CKD.Methods Patients aged 18 to 75 years old who were diagnosed with T2DM and treated in Nanjing Drum Tower Hospital from January 2009 to June 2019 were included.General data such as gender,age,body mass index(BMI),systolic blood pressure,diastolic blood pressure,and course of diabetes,laboratory indicators such as hemoglobin(Hb),albumin,alanine aminotransferase(ALT),aspartate aminotransferase(AST),total bilirubin(TBIL),uric acid,fasting blood glucose(FPG),glycated hemoglobin A1c(HbA1c),triglyceride(TG),total cholesterol(TC),low-density lipoprotein-cholesterol(LDL-C),high-density lipoprotein-cholesterol(HDL-C),urine albumin/creatinine ratio and estimated glomerular filtration rate were collected.Obesity and overweight were defined as BMI≥28 kg/m² and 24 kg/m²≤BMI<28 kg/m²,respectively.The patients were divided into a combined CKD group and a non-combined CKD group according to whether the CKD was combined.Among the T2DM patients in the non-combined CKD group,those followed up at least once for more than 12 months and with complete follow-up data were selected and divided into a non-CKD subgroup and a CKD subgroup according to whether CKD occurred.For the comparison of indicators between the two groups,the t test,non-parametric test andχ² test were used.Single-factor and multiple single logistic regression analyses were applied to analyze the risk factors of CKD in the patients with T2DM,and the Cox proportional hazards model was used to analyze the risk factors of CKD in the T2DM patients who were followed up.Restricted cubic spline(RCS)was employed to fit the Cox regression model to evaluate the correlation between different BMI cut-off points and CKD.Results A total of 3194 patients with T2DM were enrolled,including 620 cases in the combined CKD group and 2574 cases in the non-combined CKD group.Compared with the non-combined CKD group,the BMI of the combined CKD group was significantly higher(P=0.005).The results of the single factor logistic regression analysis showed that gender,obesity,systolic blood pressure,diastolic blood pressure,Hb,albumin,TG,TC,FPG and HbA1c were factors influencing the incidence of CKD in the patients with T2DM(all P<0.05).The above indicators were used as independent variables to carry out the multiple factor logistic regression analysis,of which the results revealed that obesity(OR=1.058,95%CI 1.079—2.018),increased systolic blood pressure(OR=1.042,95%CI 1.018—1.035),increased TG(OR=1.087,95%CI 1.008—1.171)and increased FPG(OR=1.042,95%CI 1.003—1.083)were factors influencing the incidence of CKD in the patients with T2DM(all P<0.05).In the non-combined CKD group,a total of 753 patients with T2DM were followed up,including 571 patients in the non-CKD subgroup and 182 patients in the CKD subgroup.The results of Cox proportional hazards model analysis showed that overweight was a risk factor for the incidence of CKD upon the correction of age,course of diabetes,systolic blood pressure,AST,TG and FPG(OR=1.95,95%CI 1.05—3.61).The results of the restricted cubic spline fitting Cox regression model suggested a non-linear correlation between the BMI and the incidence of CKD in the patients with T2DM,which was reflected in the increased risk of CKD in the T2DM patients with a BMI between 28 and 31 kg/m²(all P<0.05).Conclusions Obesity in T2DM patients is closely correlated with CKD.The T2DM patients with obesity,especially those with a BMI between 28 and 31 kg/m²,are prone to develop CKD.