2型糖尿病者微血管并发症相关危险因素分析

目的探讨2型糖尿病微血管并发症的相关危险因素,为干预治疗提供依据。方法2型糖尿病患者342例,分为合并微血管并发症组158例和无微血管病并发症组184例,比较两组临床及生化指标的差异。结果2型糖尿病合并微血管病并发症组与无微血管病并发症组比较,病程、空腹血糖、肌酐、尿酸、甘油三酯有统计学差异（P〈0．05或〈0．01）;Logistic回归分析显示,糖尿病微血管并发症的发生与病程、血压、血糖、尿酸、甘油三酯密切相关（r分别为2．840、1．975、1．785、2．983、1．513,P均〈0．05）。结论长病程、高血糖、高血压、高甘油三酯、高尿酸是2型糖尿病患者发生微血管并发症的独立危险因素。     

2型糖尿病并发症对患者治疗费用的影响评估

目的 测量与评估中国大城市2型糖尿病并发症对患者年治疗费用的影响。方法 将2型糖尿病患者分为无并发症组、仅有微血管并发症组、仅有大血管并发症组以及同时伴有大、小血管并发症组，并分别计算四组患者的年治疗费用。结果 ①在医院接受治疗的患者中，仅46．7％的患者无任何并发症；而53．3％的患者至少伴有一种并发症。其中仅有大血管并发症的患者占13．3％，仅有微血管并发症的患者占22．3％，同时伴有大、小血管并发症的患者占17．7％。②在微血管并发症患者中，外周神经病变占39．55％，视网膜病变37．69％，肾病13．81％，糖尿病足6．16％。在大血管并发症患者中，短暂性脑缺血发作38．24％，心绞痛31．01％，脑卒中16．80％，慢性心衰6．20％。⑧有并发症的2型糖尿病患者的年直接医疗费用是无并发症患者的3．71倍。但是，若同时伴有大、小血管并发症的2型糖尿病患者年直接医疗费用则是无并发症的10．35倍。④中国大城市2001年治疗2型糖尿病及其并发症的直接医疗总费用为187．5亿元，占卫生总费用3．94％。其中81％的费用用于治疗与2型糖尿病相关的并发症，治疗无并发症的直接医疗费用仅占19％。结论研究结果证明并发症是影响2型糖尿病年治疗费用的重要因素。     

糖尿病低血糖的防治

糖尿病治疗中可能发生低血糖 低血糖在糖尿病治疗过程中并不罕见。糖尿病的治疗目的在于使血糖正常，从而减少并发症的发生。例如DCCT研究中对1型糖尿病治疗6．5年的结果，强化治疗组发生视网膜病变为14％，常规治疗组为32％。又例如在UKPDS研究，对2型糖尿病观察微血管在10年中发生病变情况，强化治疗组为8％，常规治疗组为11％。     

视野：国外

银屑病增加糖尿病并发症发生风险 美国一项大型研究表明：糖尿病合并银屑病患者较无银屑病的糖尿病患者更易发生糖尿病并发症。该研究纳入6164名成人糖尿病合并银屑病患者,6164名成人银屑病非糖尿病患者作为对照组,在为期5年的随访期间,糖尿病合并银屑病组较无银屑病的糖尿病组发生微血管并发症风险增加14％,发生大血管并发症（心肌梗死、心脏衰竭、卒中）风险增加13％。     

2型糖尿病患者餐后甘油三酯水平与血管并发症关系的研究

目的 研究２型糖尿病患者餐后甘油三酯水平与血管并发症的关系。方法 ４４例２型糖尿病患者以空腹和餐后４小时甘油三酯（ＴＧ和ＴＧ４ｈ）水平分组：空腹及餐后ＴＧ正常组（１９例）、空腹正常餐后增高组（１４例）、空腹增高组（１０例）、分析其血管并发症的发生情况,结果 按上述分组次序,微血管并发症发生率分别为２１．０５％、４２．８５％和７０％,大血管并发症分别为１０．５２％、５７．１４％和８０％。前两组微血管     

糖尿病与微循环

早已证实,糖尿病微血管病变及微循环障碍是糖尿病患者多种并发症的病理基础。糖尿病合并足坏疽的病因除大血管病变外,微血管病变及微循环障碍是导致糖尿病足坏疽发生、发展的重要原因之一。因此．糖尿病病人检测微循环,了解微循环的障碍程度．及时给予活血化瘀治疗对疾病的控制有重要意义。     

糖尿病合并高血压对微血管病变患病率的影响

目的　为了解糖尿病合并高血压对微血管病变患病率的影响。方法　对３２５ 例２ 型糖尿病合并与不合并高血压对糖尿病微血管病变患病率的影响进行了回顾性分析。结果　２ 型糖尿病合并高血压组糖尿病肾病（ Ｄ Ｎ） 、糖尿病视网膜病变（ Ｄ Ｒ） 、糖尿病周围神经病变（ Ｄ Ｐ Ｎ） 和糖尿病自主神经病变（ Ｄ Ａ Ｎ） 的患病率分别为６１ ．３２ ％ 、４９ ．０６ ％ 、４５ ．２８ ％ 和２４ ．５３ ％ ，均高于血压正常组（ 患病率分别为２７ ．８５ ％ 、２９ ．６８ ％ 、３２ ．４２ ％ 和１５ ．５３ ％ 。有关影响因素拟合 Ｌｏｇｉｓｔｉｃ 逐步回归方程分析，结果显示糖尿病病程是 Ｄ Ｎ、 Ｄ Ｒ、 Ｄ Ｐ Ｎ 和 Ｄ Ａ Ｎ 患病的共同影响因素。高血压是 Ｄ Ｎ、 Ｄ Ｐ Ｎ 患病的危险因素（ Ｏ Ｒ 值分别为２ ．５９ 、２ ．５５ ， Ｐ 值分别为＜ ０ ．０１ 、＜ ０ ．０５） 。结论　糖尿病合并高血压将增加糖尿病微血管病变的患病率。     

亚临床期糖尿病性心脏病及相关因素的初探

目的探讨亚临床期糖尿病性心脏病相关因素，以采取有效的防治对策。方法（１）对２８８例无高血压、心脏病临床表现，并经有关检查基本除外冠心病及其它心脏病的糖尿病患者进行无创性心功能检查。（２）对亚临床期糖尿病性心脏病的相关因素进行单因素和多因素分析。结果（１）３３．６８％的糖尿病病人存在亚临床期糖尿病性心脏病变所导致的心功能异常。（２）年龄、病程、ＢＭＩ、代谢控制状况、微血管并发症与亚临床期糖尿病性心脏病的发生密切相关。结论年龄大、病程长、ＢＭＩ高、代谢控制不良及糖尿病其它微血管并发症是亚临床期糖尿病性心脏病的危险因素，对以上某些因素进行有效的控制，将可能预防和延缓糖尿病性心脏病的发生。     

糖尿病的血糖控制与微血管及大血管并发症

一、IDDM的微血管并发症严格的血糖控制对避免及延缓IDDM病人糖尿病性微血管及神经病变的发生及发展有很大价值。许多小型研究显示，强化胰岛素治疗（观察期内HbA1c平均下降1．4％）与对照相比，能减少糖尿病视网膜及肾脏并发症进展的危险（OR分别为0．49、0．34）。DCCT一级预防组中，强化胰岛素治疗与对照相比，能使进行性发展的三期视网膜病变发生的危险率下降76％，已有的视网膜病变进展延缓54％，增生性及严重非增生性视网膜病变的发生减少47％；使微量白蛋白尿（尿白蛋白＞40mg／24h）的发生率下降39％，大量白蛋白尿下降54％…     

谷胱甘肽治疗糖尿病肾病疗效观察

糖尿病。肾病是糖尿病晚期并发症，糖尿病病程10年以上者约60％并发糖尿病。肾病，故对糖尿病的治疗越来越强调控制和延缓并发症的发生与发展。2003年10～12月，我们应用还原型谷胱甘肽治疗糖尿病。肾病，取得一定疗效。现报告如下。     

Early diabetes-related complications in children and adolescents with type 1 diabetes. Implications for screening and intervention.

Although children and adolescents with type 1 diabetes are faced with the threat of the acute complications of hypoglycemia and ketoacidosis on a day-to-day basis, in the long-term, the microvascular and macrovascular complications of the disease place them at greatest risk for serious morbidity and earlier than expected mortality. The families of children with diabetes should be provided with information about the complications of diabetes beginning at the time of diagnosis, and this information needs to be reinforced throughout the follow-up period. Appropriate surveillance for the earliest evidence of microvascular disease should begin at the onset of puberty and after 3 to 5 years of diabetes. Therapeutic interventions, particularly excellent metabolic control, may be exceedingly effective in preventing complication onset or significantly retarding the rate of progression.     

Plasmatic nitric oxide,but not von Willebrand Factor,is an early marker of endothelial damage,in type 1 diabetes mellitus patients without microvascular complications

Type 1 diabetes mellitus (IDDM) is associated with coronary artery disease and microvascular damage. Long-term glycemic control reduces but not fully prevents such complications. Recent evidence suggests that microvascular disease associated to IDDM begins with endothelial dysfunction. In this study, we evaluated changes in levels of nitric oxide (NO) and von Willebrand Factor (vWF) to detect early endothelial dysfunction in IDDM patients recently diagnosed. Subjects were included in one of the following groups: Group 1 (n=14): healthy subjects; Group 2 (n=14): IDDM patients recently diagnosed (<1 year), with no clinical evidence of microvascular disease; Group 3 (n=14): IDDM patients with microvascular disease (retinopathy and nephropathy). Urinary NO metabolites were similar in Group 1 (1.45+/-0.13) and Group 2 (1.6+/-0.2 micromol/mg creatinine) (P>.05), as well as vWF (99.6+/-5.7% and 84.3+/-5.1%, Groups 1 and 2, respectively, P>.05). Plasmatic NO metabolites were lower in Groups 2 and 3 (54.6+/-5.1 and 50.02+/-13.65 nmol/ml, respectively) compared with Group 1 (91.1+/-6.6 nmol/ml) (P=.0005). Also, in Group 3, urinary NO metabolites were lower (0.27+/-0.03 micromol/mg creatinine) and vWF was higher (184+/-25%) than Groups 1 and 2. There is evidence of early endothelial dysfunction even in IDDM patients recently diagnosed, with good glycemic control and without systemic hypertension, dyslipidemia or microvascular disease; this endothelial damage was detected as a decrease in plasmatic NO metabolite levels, before appearance of any clinical evidence of microvascular disease.     

Clinical features of diabetes in the young as seen at a diabetes centre in south India

This study reports on the clinical pattern of 545 consecutive young diabetic patients with age at onset below 30 years attending a diabetes centre in Southern India. Three hundred and fourteen patients (57.7%) were classified as having non-insulin-dependent diabetes of the young (NIDDY), 119 (22%) as insulin-dependent diabetes (IDDM) and 28 (5%) as malnutrition-related diabetes (MRDM); 4% fibrocalculous pancreatic diabetes and 1% protein-deficient pancreatic diabetes. The remaining 84 patients could not be classified into any of the above categories. A positive family history of diabetes was more common in NIDDY compared to the other groups (P less than 0.001). While 40.3% of patients with IDDM had age at onset below 15 years, the other types of diabetes were rarely seen in patients younger than this. Body mass index (BMI) did not reliably indicate the MRDM forms of diabetes as 70% of patients with IDDM also had a BMI of less than 18, one of the criteria recommended for the diagnosis of MRDM. C-peptide levels in MRDM were intermediate between the IDDM and NIDDY groups. Microvascular complications were present in all the groups of young diabetics. The frequency was higher in NIDDY patients who also had a longer duration of diabetes. There was an increasing prevalence of complications with increasing duration of diabetes.     

HLA antigens and nailfold capillary microscopy studies in patients with insulin dependent and noninsulin dependent diabetes mellitus and limited joint mobility

We investigated the HLA status of patients with diabetes associated with limited joint mobility and microvascular complications. An increased frequency of HLA-B8, DR3 and DR4 in patients with insulin dependent diabetes mellitus (IDDM) compared to controls and patients with noninsulin dependent diabetes mellitus (NIDDM) was confirmed. HLA antigen DQw1 was detected less frequently in patients with IDDM and was negatively associated with limited joint mobility and retinopathy. Limited joint mobility was significantly correlated with disease duration in IDDM, and was associated with neuropathy in both IDDM and NIDDM and with retinopathy in IDDM. No correlation was found between DR3, DR4 and limited joint mobility or diabetic complications. We also investigated the usefulness of nailfold capillary microscopy in a large group of patients with IDDM and NIDDM. Although capillary enlargement and avascular areas were noted in a few patients, nailfold capillary microscopy was not felt to be a useful tool in the evaluation of diabetes.     

Metabolic memory in diabetes--focus on insulin

Large-scale clinical trials have demonstrated that metabolic control achieved early in the course of diabetes substantially reduces development and progression of diabetes and the associated microvascular complications. Additionally, prospective observational studies have demonstrated that atherogenic and inflammatory mediators are elevated even prior to the onset of diabetes and significantly contribute to subsequent development of macrovascular complications. Collectively, these data suggest that metabolic memories are stored early in the course of diabetes. We believe that insulin suppresses inflammation and also suppresses glucotoxicity and lipotoxicity (and the consequences thereof, such as the formation of advanced glycation end products and epigenetic phenomena), and thus has a pivotal and beneficial role. Comprehensive metabolic control, especially when instituted early, may alter the natural history of diabetic complications by affecting this metabolic memory. Thus, our overall goal is to understand in more detail the molecular mechanisms involved in these changes, thereby affording us opportunities to reduce the long-term effects of diabetes.     

The role of lipoprotein(a) in the vascular complications of diabetes mellitus

Abstract. Lipoprotein(a) has been identified as an independent risk factor for atherosclerotic vascular disease in non-diabetic populations. Because of its potential role in the pathogenesis of both microvascular and macrovascular complications in diabetes, there have recently been many reports on lipoprotein(a) in diabetic populations. Some studies indicate an association between elevated lipoprotein(a) and macro-vascular disease in non-insulin-dependent diabetes mellitus (NIDDM), but this link has not been found with insulin-dependent diabetes mellitus (IDDM). In IDDM, elevated lipoprotein(a) has been found in groups with diabetic nephropathy and retinopathy, raising the possibility that it plays a causative role. The relationship between glycaemic control and the lipoprotein(a) level has not been fully resolved. Most studies have not found any connection in NIDDM, but some found higher lipoprotein(a) levels in hyper-glycaemic IDDM patients. Potentially, lipoprotein(a) is an important factor linking the microvascular and macrovascular complications of diabetes.     

Microalbuminuria and increased plasma prorenin. Prevalence in diabetics followed up for four years

When urinary albumin excretion was measured by radioimmunoassay, most diabetics excreted more albumin than nondiabetic subjects. Microalbuminuria was defined as an albumin excretion greater than 30 mg/g of urinary creatinine, more than twice the upper limit of normal. Intermittent microalbuminuria was found in 20% of patients with insulin-dependent diabetes mellitus (IDDM) or non-insulin-dependent diabetes mellitus (NIDDM). Continuous microalbuminuria occurred in a similar percentage of patients with NIDDM, but less frequently in patients with IDDM. Rigorous control of glycemia was followed by cessation of microalbuminuria in nearly half of these patients. Microalbuminuria was associated with an increased incidence of other microvascular complications, as well as a distinctly higher plasma prorenin value in IDDM. Hypertension of 160/100 mm Hg or above was accompanied by increased albumin excretion and lower plasma prorenin values than in normotensive diabetics.     

2型糖尿病胰岛素治疗的时机

早期胰岛素强化治疗控制血糖,通过减轻糖毒性、脂毒性以及控制炎症,可以改变糖尿病并发症的自然病程,具有持久益处.因此,现在对于2型糖尿病胰岛素治疗的理念已经发生了很大变化,特别是对于诱导病情缓解和口服用药失效的2型糖尿病患者;为尽早和尽可能使血糖达标及恢复β细胞功能,应尽早启用胰岛素治疗.     

Thiazolidinediones-benefits on microvascular complications of type 2 diabetes

Type 2 diabetes is associated with serious microvascular complications, such as nephropathy, retinopathy, and neuropathy, which have a significant impact on patients' quality of life, morbidity, and mortality. Type 2 diabetes management strategies to reduce the risk of microvascular complications include treatment of hyperglycaemia, hypertension, and other vascular risk factors. The importance of glycaemic control in reducing the risk of microvascular complications of diabetes is well established. However, many antihyperglycaemic therapies fail to provide adequate glycaemic control and do not prevent complications in the long term. The thiazolidinediones (TZDs) are a class of agents that provide sustained glycaemic control, mediated primarily by reductions in insulin resistance. Evidence reviewed suggests that the TZDs may have the potential to reduce microvascular complications through benefits that go beyond glycaemic control. Insulin resistance underlies a range of metabolic abnormalities, collectively known as the metabolic syndrome (MS), which are cardiovascular (CV) risk factors. Components include visceral obesity, hyperglycaemia, hypertension, dyslipidaemia, low-grade inflammation and microalbuminuria (an early manifestation of target organ damage). Reducing insulin resistance, therefore, has the potential to reduce both microvascular and macrovascular complications.