2型糖尿病患者非糖尿病肾脏疾病的患病率分析

目的 鉴别2型糖尿病患者蛋白尿的肾脏病因,估算非糖尿病肾病的患病率.方法 回顾性研究分析46例2型糖尿病合并肾损伤的患者,比较病史、心脏彩超、颈动脉多普勒彩超、眼底检查结果、肾小球滤过率、肝功能、肾功能、血脂、血糖、HbA1c、尿蛋白等临床指标,所有患者通过肾脏穿刺明确诊断,根据病理结果分为糖尿病肾病组和非糖尿病肾病组.结果 46例患者确诊糖尿病肾病比例占47.8%,52.2%患者是糖尿病合并其他肾小球疾病,即非糖尿病.肾病,在非糖尿病肾病组中以局灶节段肾小球硬化比例最高.糖尿病肾病组空腹血糖较高(P<0.05).心脏彩超各项指标中,糖尿病肾病组的射血分数显著低于非糖尿病肾病组(P<0.05).颈动脉彩超检测中发现,糖尿病肾病组存在动脉粥样斑块患者显著高于非糖尿病肾病组,其颈动脉内膜中层厚度均较非糖尿病肾病组高(P<0.05).值得注意的是,非糖尿病肾病与糖尿病视网膜病变关系不大,糖尿病视网膜病变对诊断糖尿病肾病具有较高的敏感性(72.2%)和特异性(91.7%,P<0.01).结论 2型糖尿病合并有蛋白尿时,空腹血糖、心脏射血分数、颈动脉粥样斑块和内膜中层厚度,以及眼底的改变作为临床鉴别糖尿病肾病和非糖尿病肾病的参考指标,肾活检则是明确糖尿病伴肾脏病变性质的重要手段.     

2型糖尿病患者非糖尿病肾脏疾病的患病率分析

目的 鉴别2型糖尿病患者蛋白尿的肾脏病因,估算非糖尿病肾病的患病率.方法 回顾性研究分析46例2型糖尿病合并肾损伤的患者,比较病史、心脏彩超、颈动脉多普勒彩超、眼底检查结果、肾小球滤过率、肝功能、肾功能、血脂、血糖、HbA1c、尿蛋白等临床指标,所有患者通过肾脏穿刺明确诊断,根据病理结果分为糖尿病肾病组和非糖尿病肾病组.结果 46例患者确诊糖尿病肾病比例占47.8%,52.2%患者是糖尿病合并其他肾小球疾病,即非糖尿病.肾病,在非糖尿病肾病组中以局灶节段肾小球硬化比例最高.糖尿病肾病组空腹血糖较高(P<0.05).心脏彩超各项指标中,糖尿病肾病组的射血分数显著低于非糖尿病肾病组(P<0.05).颈动脉彩超检测中发现,糖尿病肾病组存在动脉粥样斑块患者显著高于非糖尿病肾病组,其颈动脉内膜中层厚度均较非糖尿病肾病组高(P<0.05).值得注意的是,非糖尿病肾病与糖尿病视网膜病变关系不大,糖尿病视网膜病变对诊断糖尿病肾病具有较高的敏感性(72.2%)和特异性(91.7%,P<0.01).结论 2型糖尿病合并有蛋白尿时,空腹血糖、心脏射血分数、颈动脉粥样斑块和内膜中层厚度,以及眼底的改变作为临床鉴别糖尿病肾病和非糖尿病肾病的参考指标,肾活检则是明确糖尿病伴肾脏病变性质的重要手段.     

2型糖尿病患者合并非糖尿病肾病的临床诊断

目的　分析 2型糖尿病 (DM )患者合并非糖尿病肾病 (NDRD)与糖尿病肾病 (DN )在临床表现、病程、病理改变的异同 ,以指导临床诊断与治疗。方法　 2型DM患者 3 4例分为两组 ,合并NDRD组 2 2例 ,单纯DN组 12例。对两组发病年龄、糖尿病病程、蛋白尿、血尿、肾功能、高血压、视网膜病变、肾脏病理等资料进行对比分析。结果　DM病程在NDRD组短于DN组 ;两组蛋白尿程度相似 ;血尿伴蛋白尿的发生率在NDRD组略多于DN组 ;肾功能损害在NDRD组更显著 ;伴高血压者DN组多于NDRD。视网膜病变并发率在DN组为 10 0 % ,且为Ⅱ～Ⅳ期病变 ,NDRD组仅有 2例伴发Ⅱ期病变。 3 0例患者行肾穿刺活检 ,12例呈不同阶段的DN ,18例伴发不同类型的肾小球肾炎。结论　糖尿病合并非糖尿病肾病者平均糖尿病病程多 <5年 ;突然出现大量蛋白尿、水肿、而肾功能正常者 ;单纯肾性血尿 ,或血尿加蛋白尿者 ;肾功能迅速减退者 ;不伴视网膜病变者 ;肾小管功能受损显著者 ,应考虑为DM并发非糖尿病性肾病     

2型糖尿病伴肾脏病变患者肾活检指征探讨

目的 研究2型糖尿病(DM)伴肾脏病变怀疑合并非糖尿病肾病(NDN)患者肾活检的指征及临床特征.方法 对53例2型糖尿病患者[因①急性肾衰竭7例;②突出的肾小球源性血尿6例;③糖尿病病程＜5年而蛋白尿＞0.5 g/24h者29例;④糖尿病病程＞5年、大量蛋白尿而血压正常者(肾活检指征)11例]行肾活检、眼底和常规实验室检查.24例因其他原因肾活检、住院期间发现2型糖尿病的患者做对照.结果 糖尿病肾病(DN)占51%,非糖尿病肾病占49%,其中系膜增生性肾炎最多见占1/3.病程越长,糖尿病肾病发生率越高;伴有糖尿病眼部病变[糖尿病视网膜病、白内障、晶体或(和玻璃体)浑浊]者肾活检均为糖尿病肾病.非糖尿病肾病患者糖尿病眼部病变少,糖尿病肾病病程短.肾活检指征②非糖尿病肾病的检出率最高(83.3%),指征④最低(18.2%).结论 糖尿病眼部病变预测糖尿病肾病的特异性为100%;2型糖尿病合并非糖尿病肾病患者血尿突出,糖尿病病程短,糖尿病眼部病变少见.     

彩色多普勒超声对糖尿病肾病患者颈动脉病变的检测价值

目的探讨彩色多普勒超声对糖尿病肾病患者颈动脉结构及血流动力学改变的检测价值。方法应用彩色多普勒超声检测158例糖尿病肾病患者(糖尿病肾病组)及123例糖尿病患者(对照组)颈动脉内、中膜厚度(intima-media thickness,IMT)、斑块发生率、血流收缩期峰值流速、舒张末期血流速度、阻力指数(resistanceindex,RI)。比较糖尿病肾病组与对照组以及糖尿病肾病组早中期亚组、中晚期非透析亚组及透析亚组间上述指标的差异。结果糖尿病肾病组颈动脉IMT、斑块发生率明显高于对照组,差异有统计学意义[0.69(0.62～0.78)mm vs.0.56(0.51～0.69)mm,P<0.05;81.0%vs.47.2%,χ2=35.4,P<0.05];糖尿病肾病组中早中期亚组、中晚期非透析亚组及透析亚组3组间随着疾病的发展,颈动脉IMT、斑块发生率也逐渐增加;且透析亚组颈总动脉内径与早中期亚组对比明显增厚,差异有统计学意义[7.36(6.79～7.80)mm vs.7.01(6.36～7.31)mm,P<0.05]。糖尿病肾病组颈动脉舒张末期血流速度减小、RI增大,与对照组相比,差异有统计学意义(P<0.05)。结论糖尿病肾病患者普遍存在颈动脉结构及血流动力学改变,应用彩色多普勒超声检测颈动脉粥样硬化的发生与发展对预测糖尿病肾病患者发生心、脑血管事件具有重要意义。     

老年2型糖尿病合并脑梗死患者颈动脉粥样病变超声观察

目的探讨老年2型糖尿病患者合并脑梗死颈动脉超声检查的意义。方法选择127例2型糖尿病合并脑梗死(DMCI)患者为观察组,119例单纯脑梗死(CI)患者为对照组,行颈动脉超声检测,检测颈动脉内—中层膜厚度(IMT),斑块性质及动脉管腔狭窄程度。结果 DMCI组颈动脉IMT、颈动脉狭窄程度及不稳定斑块发生率,与CI组比较有明显差异(P<0.05)。结论老年2型糖尿病合并脑梗死患者的颈动脉粥样病变是脑梗死的主要原因,颈动脉超声对老年2型糖尿病患者脑血管病的预防及治疗有重要意义。     

高血压合并2型糖尿病患者的颈动脉病变

目的探讨高血压合并2型糖尿病患者颈动脉内膜-中层厚度改变及粥样斑块形成情况。方法采用超声多谱勒技术高频探头对76例高血压伴2型糖尿病患者8、3例高血压患者7、9例2型糖尿病患者进行颈动脉超声检测,观察颈动脉病变,并作血脂检查。结果高血压伴2型糖尿病组颈动脉斑块的检出率76.3%,显著高于高血压组56.6%和2型糖尿病组50.6%(P<0.05)。结论高血压合并2型糖尿病颈动脉斑块更易形成。     

糖尿病肾病合并IgA肾病的临床病理特征及预后分析探讨

目的总结2型糖尿病肾病合并Ig A肾病的临床病理特征及预后分析探讨。方法选取2013年10月—2014年10月该院病理确诊的糖尿病肾病合并Ig A(简称为DN+Ig AN)患者39例,将其设置为观察组;41例病理确诊为DN非合并糖尿病肾病患者设置为对照组。对两组患者治疗前、中、后期所有的资料进行对比评估,采用相关的病理分型标准进行总结。结果对两组患者进行肾活检时,发现肾功能水平没有明显的差异。另外,两组患者在高血压、视网膜病变发生率、结节性硬化等病理表现上具有一致性,两组患者的临床资料、病理特征等方面差异无统计学意义。结论经研究发现,糖尿病肾病合并Ig A患者与DN非合并糖尿病肾病患者相比具有糖尿病病程短、蛋白尿水平较低、相关病变发生几率较低、肾小球病变较小的特点,但是DN+Ig AN患者的病理特征常常伴随着DN非合并糖尿病肾病的特征,且在两种类型的预后方面差异无统计学意义。     

磁共振成像评估脑梗死合并糖尿病患者颈动脉粥样硬化斑块稳定性及相关因素

目的应用磁共振成像(MRI)评估脑梗死合并糖尿病患者颈动脉粥样硬化斑块稳定性及其相关危险因素。方法 84例急性脑梗死患者,采用MRI检查颈动脉血管及斑块稳定性,并对图像及影响斑块稳定性的因素进行分析。结果 84例患者共168支颈动脉,有124支发现斑块。糖尿病组发现58支,非糖尿病组发现66支。糖尿病易损斑块占84.48%(49/58),非糖尿病组占37.88%(25/66),糖尿病组易损斑块比非糖尿病组增加了46.60%;糖尿病组斑块最大厚度明显高于非糖尿病组(P0.05)。男性易损斑块的发生率为66.22%(49/74)。多因素Logistic回归分析发现,性别、糖尿病以及饮酒史成为影响斑块稳定性的独立危险因素(P0.05)。结论 MRI能够有效评估颈动脉粥样硬化斑块稳定性;脑梗死合并糖尿病的患者颈动脉粥样硬化斑块的稳定性较差;是否合并糖尿病、过量饮酒被认为是影响斑块稳定性的重要因素。     

糖尿病肾病合并非糖尿病肾脏病变的临床病理分析

目的　回顾性分析糖尿病肾病合并非糖尿病肾脏病变的发生率和临床病理特征。方法　回顾性研究了 1 990～ 2 0 0 0年诊断为糖尿病肾病的 1 1 4例患者。结果　糖尿病肾病患者中有 1 4 .9%的患者合并非糖尿病肾脏病变 ,男性 1 3例 ,女性 4例 ,平均就诊年龄为 (51± 1 0 .2 )岁 ,31～ 65岁。在所有的非糖尿病肾脏病变中 ,IgA肾病的比率最高为 47.1 % ,其他依次为膜性肾病 1 7.6 % ,间质性肾炎 1 1 .7% ,高血压肾损害 5 .9% ,微型多动脉炎5 .9% ,肾淀粉样变性 5 .9% ,紫癜性肾炎 5 .9%。所有患者临床均表现为蛋白尿 ,8例为镜下血尿 ,糖尿病视网膜病变发病率低。患者组织学呈现上述肾脏疾病相应的病理特征。结论　糖尿病肾病患者合并非糖尿病肾脏病变的发生率为 1 4 .9% ,其中发生率最高的是IgA肾病和膜性肾病 ,其次为间质性肾炎、高血压肾损害、微型多动脉炎、肾淀粉样变性、紫癜性肾炎。这部分患者的糖尿病病程相对较短 ,临床和病理表现呈多样化特点 ,缺乏特征性的诊断指标。对于临床表现为蛋白尿和 (或 )血尿的患者 ,不论有无眼底病变 ,肾活检都是一项排除非糖尿病肾脏病变的重要手段。     

Clinical features of non-diabetic renal diseases in patients with type 2 diabetes

Although persistent proteinuria is characteristic of diabetic nephropathy (DN), it is important to differentiate non-diabetic renal diseases (NDRD) in diabetic patients with proteinuria. In order to re-evaluate the indications for renal biopsy in the diabetic patients, we retrospectively analyzed the relationship between clinical features and histological diagnosis in 97 Japanese patients with type 2 diabetes manifesting overt proteinuria. Renal biopsy was performed because they were clinically suspected to have NDRD. Patients were divided into three groups according to the histological diagnosis: (1) the DN group (n=35) had only diabetic lesions, (2) the complicated group (n=16) had histological changes of NDRD superimposed on DN and (3) the non-DN group (n=46) had NDRD without diabetic lesions. We evaluated the specificity and sensitivity of four clinical parameters (duration of diabetes, presence or absence of diabetic retinopathy, microscopic hematuria and granular casts as urinary sediments) for the prediction of NDRD. Short duration of diabetes (<5 years) showed high sensitivity (75%) and specificity (70%). Diabetic retinopathy showed the highest sensitivity (87%) and specificity (93%). The sensitivity and specificity of microscopic hematuria (56 and 58%) and granular casts (68 and 47%) were lower. Our study confirmed that the absence of retinopathy and short duration of diabetes are useful clinical indications for renal biopsy in diabetic patients with overt proteinuria.     

Renal outcomes in patients with type 2 diabetes with or without coexisting non-diabetic renal disease

Aims

We sought not only to determine the independent predictors of non-diabetic renal disease (NDRD) but also to investigate the impact of NDRD on renal outcomes in patients with type 2 diabetes who underwent renal biopsy and were followed-up longitudinally.

Methods

The present study was conducted by reviewing the medical records of 119 type 2 diabetic patients who underwent renal biopsy at Yonsei University Health System from January 1988 to December 2008.

Results

Renal biopsy findings declared that 43 patients (36.1%) had diabetic nephropathy alone, 12 (10.1%) had NDRD superimposed on diabetic nephropathy, and 64 (53.8%) had only NDRD. On multivariate analysis, the absence of diabetic retinopathy, higher hemoglobin levels, and shorter duration of diabetes were independent predictors of NDRD in these patients. During the follow-up period, end-stage renal disease (ESRD) developed in 33 patients (27.7%). On multivariate Cox regression, higher serum creatinine levels, higher systolic blood pressure, longer duration of diabetes, and the presence of diabetic nephropathy were identified as significant independent predictors of ESRD. When the presence of diabetic retinopathy was included in the multivariate model, higher serum creatinine levels, higher systolic blood pressure, and the presence of retinopathy were shown to be independent predictors of ESRD.

Conclusions

Since diabetic patients with NDRD have significantly better renal outcomes compared to patients with biopsy-proven diabetic nephropathy, it is important to suspect, identify, and manage NDRD as early as possible, especially in type 2 diabetic patients with short duration of diabetes and those without diabetic retinopathy or anemia.     

2型糖尿病非糖尿病性肾病流行病学及病理变化研究

65例 2型糖尿病患者肾活检发现, 46. 2% (30 /65)有非糖尿病性肾病 (NDRD)。与糖尿病肾病对比,NDRD男性多见、病程短,浮肿、蛋白尿明显,系膜细胞增生及免疫球蛋白沉积显著,病理组织学类型多样,多见的是IgA肾病(占 43. 3% )。     

Renal histological lesions in patients with type II diabetes mellitus

Diabetic glomerulosclerosis is the most frequent cause of renal disease in patients with type II diabetes mellitus (DM), sometimes accompanied by vascular lesions. However, other glomerular pathologies are important in these patients. The aim of this study was to evaluate the prevalence of non-diabetic nephropathy (NDN) in selected patients with type II DM, and to identify clinical markers that may predict its presence in this population. We reviewed 20 renal biopsies performed on twenty patients with type II DM. Nine of them showed diabetic nephropathy (DN) (45%), whereas eleven showed NDN (55%): 1 IgA nephropathy, 3 vasculitis and 7 membranous nephropathy. We found no differences between the two groups with regard to sex, duration of DM, insulin therapy, glycosylated haemoglobin, proteinuria, presence of nephrotic syndrome, hypertension, serum IgA level or renal size. The NDN group had haematuria in 63.6%, whereas the patients with NDN had it in 44.4% (NS). Body mass index was higher in NDN patients (30 +/- 6.7 vs 22 +/- 2.9; p < 0.01), The same was true for creatinine clearance (82.2 +/- 51.4 ml/m vs 40.4 +/- 19.6 ml/m; p < 0.05). The age at the moment of diagnosis was higher in ND patients (67 +/- 11.2 vs 54.3 +/- 4.6; p < 0.05). The 3 patients who had diabetic retinopathy were found to have DN on renal biopsy (diagnostic specificity = 100%), although 66.7% of the patients with diabetic glomerulopathy had no retinopathy. We conclude that patients with type II DM with renal findings suggesting non-diabetic renal disease frequently it have NDN, and a renal biopsy must be performed. The presence of retinopathy has a predictive value of 100% in predicting DN, therefore its existence may make this diagnostic procedure unneccesary.     

¿Cuándo realizar biopsia renal en pacientes con diabetes mellitus tipo 2? Modelo predictivo de enfermedad renal no diabética

IntroductionDiabetic nephropathy (DN) is one of the most frequent complications in patients with diabetes mellitus (DM) and its diagnosis is usually established on clinical grounds. However, kidney involvement in some diabetic patients can be due to other causes, and renal biopsy might be needed to exclude them. The aim of our study was to establish the clinical and analytical data that predict DN and no-diabetic renal disease (NDRD), and to develop a predictive model (score) to confirm or dismiss DN.Material and methodsWe conducted a transversal, observational and retrospective study, including renal biopsies performed in type 2 DM patients, between 2000 and 2018.ResultsTwo hundred seven DM patients were included in our study. The mean age was 64.5 ± 10.6 years and 74% were male. DN was found in 126 (61%) of the biopsies and NDRD in 81 (39%). Diabetic retinopathy was presented in 58% of DN patients, but only in 6% of NDRD patients (P < .001). Patients with NDRD were diagnosed of primary glomerulopathies (52%), nephroangiosclerosis (16%), inmunoallergic interstitial nephritis (15%) and vasculitis (8.5%). In the multivariate analysis, retinopathy (OR 26.7; 95% CI: 6.8-104.5), chronic ischaemia of lower limbs (OR 4,37; 95% CI: 1.33-14.3), insulin therapy (OR 3.05; 95% CI: 1.13-8.25), time course of DM ≥ 10 years (OR 2.71; 95% CI: 1.1-6.62) and nephrotic range proteinuria (OR 2.91; 95% CI: 1.2-7.1) were independent predictors for DN. Microhaematuria defined as ≥ 10 red blood cells per high-power field (OR 0.032; 95% CI: 0.01-0.11) and overweight (OR 0.21; 95% CI: 0.08-0.5) were independent predictors of NDRD. According to the predictive model based on the multivariate analysis, all patients with a score > 3 had DN and 94% of cases with a score ≤ 1 had NDRD (score ranked from −6 to 8 points).ConclusionsNDRD is common in DM patients (39%), being primary glomerulonephritis the most frequent ethology. The absence of retinopathy and the presence of microhematuria are highly suggestive of NDRD. The use of our predictive model could facilitate the indication of performing a renal biopsy in DM patients.     

The correlation of common carotid arterial diameter with atherosclerosis and diabetic retinopathy in patients with type 2 diabetes mellitus

The clinical significance of the diameter of the common carotid artery (CCA) measured ultrasonographically in diabetic practice has not been sufficiently established. The objective of this study was to investigate the relationship of the ultrasonic CCA diameter with atherosclerotic measures and diabetic retinopathy as a microvascular complication in patients with type 2 diabetes mellitus (T2DM). This hospital-based cross-sectional study included 102 patients with T2DM (men: 65%, mean age: 57 years) who had no apparent carotid arterial stenosis and no history of cardiovascular or severe renal disease. The current smoking status, body mass index, blood pressure, hemoglobin A1c, serum low-density lipoprotein cholesterol, and ultrasonic measures of carotid arteries (CCA diameter, intima-media thickness (IMT), plaque score) were measured. The cardio-ankle vascular index (CAVI) and the presence of diabetic retinopathy were also assessed. The CCA diameter showed a significant positive correlation with the mean IMT or plaque score. The CAVI had a significant positive correlation with the mean IMT, plaque score, and CCA diameter, while diabetic retinopathy had a significant positive correlation with the CCA diameter, but not the mean IMT or plaque score. These results were unaltered after adjusting for multiple confounders. The CCA diameter may serve as a useful marker for atherosclerosis and diabetic retinopathy, and in particular, may be a marker associated with diabetic retinopathy more clearly than the carotid IMT and plaque score, in patients with T2DM.     

170例糖尿病肾病肾活检分析

目的探讨肾活检对糖尿病肾病(DN)的诊断价值及治疗的指导作用。方法对170例伴有微量白蛋白尿(MAU)或临床蛋白尿(CAU)的2型糖尿病患者(T2DM)进行肾穿刺活检，观察肾活检组织病理与各临床参数之间的关系。结果在170例伴MAU或CAU的DM患者中，DN119例(70．0％)，其中早期系膜增生者22例，典型DN表现者97例。在典型DN表现者中，结节性肾小球硬化47例(39．5％)，弥漫性肾小球硬化50例(42．0％)。DN或DM合并其他肾脏病变51例(30．0％)，其中DN合并IgA肾病13例(25.5％)、间质性肾炎8例(15．7％)、膜增生性肾炎2例(3．9％)，DM合并IgA肾病10例(19．6％)、系膜增生性肾小球肾炎4例(7．8%)、微小病变肾炎4例(7．8％)、间质性肾炎6例(11．8％)、膜性肾病2例(3．9％)、新月体性肾炎2例(3．9％)。结论对临床不能确诊的T2DM蛋白尿患者应提倡做肾活检。