糖尿病患者手部深度烧伤创面修复临床疗效分析

目的讨论糖尿病患者手部深度烧伤创面修复临床疗效。方法选取2019年4月—2020年4月期间该院收治的118例手部深度烧伤患者作为该次研究对象,根据是否患有糖尿病分为糖尿病组和非糖尿病组,每组59例。两组患者均采用皮瓣、全厚皮和中厚皮进行创面修复治疗,观察两组患者的治疗效果。结果①干预前,糖尿病组和非糖尿病组患者的空腹血糖以及餐后2 h血糖水平差异有统计学意义(t=14.147、4.998,P<0.001);治疗后,糖尿病组空腹血糖为(5.9±1.2)mmol/L,非糖尿病组空腹血糖为(5.5±1.4)mmol/L,差异无统计学意义(t=1.666,P=0.098>0.05),说明糖尿病患者治疗后血糖水平接近正常值;糖尿病组餐后2 h血糖为(7.4±0.4)mmol/L,非糖尿病组餐后2 h血糖为(7.3±0.3)mmol/L,差异无统计学意义(t=1.563,P=0.127>0.05),说明糖尿病患者治疗后血糖水平接近正常值。②糖尿病组患者的手功能恢复优良率为86.4%,与非糖尿病组的98.3%,组间数据差异有统计学意义(χ²=4.330,P=0.037)。结论对于手部深度烧伤患者来讲,在采用相同的床修复方法时非糖尿病患者的治疗效果相对较好,糖尿病患者恢复效果则相对较差,临床对于糖尿病手部深度烧伤患者应给与高度关注,并积极进行进一步治疗。     

¿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.     

非糖尿病冠心病患者糖化血红蛋白与颈动脉病变相关性分析

目的探讨非糖尿病冠心病患者糖化血红蛋白（HbA1c）水平与颈动脉病变的相关性。方法选择经冠脉造影明确诊断冠心病的非糖尿病患者275例,按照HbA1c水平以三分位法分为低水平组（HbA1c≤5.6%,n=103例）,中水平组（HbA1c：5.6%-5.9%,n=93例）,高水平组（HbA1c〉5.9%,n=79例）。颈动脉超声测定颈总动脉内膜中膜厚度（IMT）,分为正常对照组（IMT≤0.9mm）,轻度增厚组（IMT0.9mm-1.2mm）,明显增厚组或斑块形成组（IMT〉1.2mm）。分析HbA1c水平与颈动脉病变的相关性。结果 HbA1c高水平组中IMT〉1.2mm者共56例,占70.9%,比例大于中水平组（64例,占68.8%）,大于低水平组（67例,占65%）,但无统计学意义。经Pearson相关分析及偏相关分析,校正年龄、性别、吸烟状况、饮酒状况、心梗史、病变支数、空腹血糖、尿酸、甘油三酯、总胆固醇、高密度脂蛋白胆固醇、低密度脂蛋白胆固醇、高敏C反应蛋白、BMI（体重指数）等因素后,HbA1c水平与颈动脉内中膜及斑块厚度无显著关系。结论在非糖尿病的冠心病人群中,HbA1c水平与颈动脉内中膜及斑块厚度无明显相关性。     

SELF-MEASURED SYSTOLIC BLOOD PRESSURE IN THE MORNING IS A STRONG INDICATOR OF DECLINE OF RENAL FUNCTION IN HYPERTENSIVE PATIENTS WITH NON-DIABETIC CHRONIC RENAL INSUFFICIENCY

While blood pressure is a recognized major determinant of renal function deterioration, the role of self blood pressure measurement (BPM) in predicting the loss of renal function in hypertensive patients with chronic renal insufficiency (CRI) has not been adequately addressed. One hundred and thirteen patients (F/M: 46/67; 56±1 years) with CRI (mean serum creatinine: 1.87±0.08; range: 1.4 to 3.5?mg/dl; average urinary protein excretion: 1.2±0.2?g/24?hrs.) were followed for 3 years. The record of renal biopsy revealed that 74 patients had IgA nephropathy, 16 had chronic glomerulonephritis, and 6 had membranous nephropathy, while 17, unbiopsied patients had underlying renal disease of unknown origin. Self BPM were made at regular intervals throughout the course of the study. All recorded blood pressures were included in a stepwise multiple regression analysis in which the decline in GFR per year was the dependent variable. Patients were primarily treated with a combination of amlodipine (5 to 20?mg daily), a calcium antagonist, and benazepril(2.5 to 5?mg daily), an ACE inhibitor in an effort to reduce their blood pressure at the office to <130/85?mmHg. The simple correlation between blood pressures (i.e., office, home morning and home evening) and the decline in GFR were all statistically significant. The correlation coefficients of determination for this model were as follows: r=0.64 for home morning SBP; 0.43 for office SBP; 0.39 for office DBP; and 0.38 for home morning DBP. The level of urinary protein excretion did not correlate with the decline in GFR. These data suggest that self BPM improves prognostic ability in hypertensive patients with CRI.     

Predictors of hospitalization and death among pre-dialysis patients: a retrospective cohort study.

BACKGROUND: Although there is abundant research describing predictors of patient morbidity and mortality among dialysis patients, predictors of adverse clinical outcomes among pre-dialysis patients are less well defined. The purpose of this study was to identify baseline predictors of first non-elective hospitalization among a retrospective cohort of 362 pre-dialysis patients. METHODS: Univariate and multivariate Cox proportional hazard models were used to identify predictors of hospitalization prior to dialysis initiation, adjusted for baseline creatinine level. Dialysis initiation, loss to follow-up, and study conclusion were censored events. Secondary outcomes included cause-specific hospitalization and death. RESULTS: Univariate analysis indicated that advanced age (RR 1.026, CI 1.016-1.037), number of prescribed anti-hypertensive medications (RR 1.149, CI 1.019-1.296), history of myocardial infarction (RR 1.979, CI 1.339-2.926), congestive heart failure (RR 2.299, CI 1.616-3.270), angina (RR 2.289, CI 1.695-3.091), peripheral vascular disease (RR 1.841, CI 1.282-2.644), renal failure secondary to nephrosclerosis (RR 1.413, CI 1.033-1.933) or renal artery stenosis (RR 1.587, CI 1.036-2.430), lower baseline haemoglobin level (RR 0.986, CI 0.979-0.992), and baseline creatinine greater than 300 micromol/l (RR 1.636, CI 1.233-2.171) were predictors of hospitalization. Gender, diabetes, diastolic blood pressure, mean arterial pressure, history of stroke, and hypoalbuminaemia did not predict outcome. Multivariate analysis, adjusted for baseline creatinine level, selected advanced age (RR 1. 017, CI 1.006-1.027), angina (RR 1.893, CI 1.371-2.613), peripheral vascular disease (RR 1.545, CI 1.054-2.266), and haemoglobin level (RR 0.987, CI 0.944-0.979) as independent predictors of hospitalization. CONCLUSION: Advanced age, co-morbid cardiovascular illness and anaemia are independent predictors of non-elective hospitalization prior to dialysis initiation. Further study is needed to determine the extent to which aggressive pre-dialysis management of anaemia and cardiovascular disease can improve patient outcomes.     

Development and validation of a predictive model for the differential diagnosis of diabetic nephropathy and non-diabetic renal disease in patients with type 2 diabetes mellitus

Objective To develop and validate a predictive model for the differential diagnosis of diabetic nephropathy (DN) and non-diabetic renal disease (NDRD) in patients with type 2 diabetes mellitus. Methods A retrospective study with patients with type 2 diabetes who underwent renal biopsy in the First Affiliated Hospital of Zhengzhou University from February 2012 to January 2015 was conducted. The dataset was randomly split into development (70.0%) and validation (30.0%) cohorts. Baseline predictors for model development was selected by using univariable and multivariable logistic regression. The model's performance in the two cohorts, including discrimination and calibration, was evaluated by the C-statistic, calibration curve and the P value of the Hosmer-Lemeshow test. Results Among the 931 patients with type 2 diabetes, 478 cases (51.3%) diagnosed as DN alone, 214 cases (23.0%) as NDRD alone and 239 cases (25.7%) as DN plus superimposed NDRD (MIX). Among NDRD and MIX patients, membranous nephropathy was the most common pathological type, followed by IgA nephropathy. The variables selected in the final predictive model were age, duration of diabetes, diabetic retinopathy, systolic blood pressure, hemoglobin, fasting blood glucose, glycosylated hemoglobin, cystatin C. The model performed well with good discrimination and calibration. The C-statistics were 0.913(95%CI 0.892-0.935) in the derivation cohort and 0.897(95%CI 0.876-0.919) in the validation cohort. The model had the best P value of 0.934 of the Hosmer-Lemeshow test. Conclusions A simple predictive model with high accuracy is constructed for predicting the presence of NDRD and MIX for type 2 diabetic patients. The nomogram can be used as a decision support tool to provide a non-invasive method for differential diagnosis of DN and NDRD, which may help clinicians assess the risk-benefit ratio of kidney biopsy for type 2 diabetic patients with renal impairment.     

Prevalence of diabetes among glycosuric individuals in an urban area of greece

Summary Epidemiologic data on the frequency of diabetes in the urban Greek population were lacking in Greece. Postprandial urine samples of 21,410 inhabitants of a suburb of Athens were examined for glycosuria by two different enzymatic methods. It was found that 569 persons,i.e. 3.20% of the whole population aged 10 or more, presented postprandial glycosuria (cases of previously known diabetes were excluded); 417 persons out of these were submitted to an OGTT (50 g) and 135 new cases of diabetes were discovered. Glycosuria was associated with diabetes mostly in the age-groups above 40. Obesity was frequent among the newly discovered diabetics. Two thirds had abnormal blood sugar levels already in the fasting condition. The prevalence of non-diabetic glycosuria was 2.70% in males and 1.60% in females. The frequency of a family history positive for diabetes was found to be approximately twice as high in diabetics compared to subjects without glycosuria.     

Effect of 18 months of treatment with alfacalcidol on bone in patients with mild to moderate chronic renal failure.

BACKGROUND: The bone abnormalities that lead to symptomatic renal osteodystrophy commence early in the course of renal failure, but the optimal time to start treatment needs clarifying. The present study examined the effect of alfacalcidol treatment on bone metabolism and bone density in patients with pre-dialysis chronic renal failure (CRF) in a prospective, randomized, placebo-controlled double blind design. METHODS: Repetitive measures of bone mineral density (BMD) estimated by dual energy X-ray absorptiometry and plasma levels of biochemical markers of bone turnover [osteocalcin, bone alkaline phosphatase, propeptide of type-I collagen (PICP) and telopeptide of type-I collagen] and parameters of calcium homeostasis were performed in 36 patients with a glomerular filtration rate (GFR) of 6-60 ml/min. RESULTS: A significant difference in BMD between the treatment groups in favour of the alfacalcidol-treated patients was found in the spine (4.2%), the femoral neck (4.9%) and the total femur (3.0%) (P<0.05). In the alfacalcidol group, plasma levels of parathyroid hormone 1-84 decreased from baseline values by 47+/-9%, and p-osteocalcin and bone alkaline phosphatase decreased by 24+/-9% and 48+/-8%, respectively (P<0.05). In the placebo group, PICP increased by 32+/-26% (P<0.05). No significant changes were found in plasma levels of vitamin D metabolites. GFR decreased significantly from baseline values in the alfacalcidol group (by 28+/-4 ml/min) and in the placebo group (by 26+/-5 ml/min) (P<0.05), with no difference being detected between the groups. CONCLUSIONS: Long-term treatment with alfacalcidol is safe and might be beneficial for the preservation of bone mass in the pre-dialysis stages of CRF, most likely through a reduction in bone turnover as estimated from the changes of the biochemical bone markers.     

Folic acid 5 or 15 mg/d similarly reduces plasma homocysteine in patients with moderate-advanced chronic renal failure

BACKGROUND: Hyperhomocysteinaemia is an independent risk factor for cardiovascular disease with a remarkable prevalence in patients with chronic renal failure (CRF). Low doses of folic acid (FA) with or without vitamin B6 and B12 has been shown to effectively reduce plasma homocysteine (Hcy). The aim of this study was to compare the short-term effects of two different oral doses of FA (5 vs 15 mg/d) on plasma Hcy levels in subjects suffering from moderate-severe CRF. METHODS: A double-blind, double-dummy, comparative, two-stage randomised study was performed. Seventeen patients aged 45-71 years, with glomerular filtration rates between 15.4-50 mL/min 1.73/m2 were randomly assigned to receive FA 5 mg/d (FA-5, n: 8) or FA 15 mg/d (FA-15, n: 9) for 30 days. At the end of this 30-day double-blind period, all the participants were placed on FA 5 mg/d (open period), for 5 additional months. Both groups were also supplemented with vitamins B1, B6 and B12 throughout the trial. Blood samples were drawn at 0, 15, 30, 90 and 180 days to assess Hcy, complete blood count (CBC) and sequential multichannel analysis (SMA). Chest X-ray and a 12-lead electrocardiogram (ECG) were also performed. RESULTS: Plasma Hcy (mean +/- SEM) decreased from 27.9 +/- 1.4 (baseline) to 15.1 +/- 0.6, 13.3 +/- 0.9, 14.1 +/- 0.5 and 13.8 +/- 0.5 micromol/L (FA-5) and from 28.8 +/- 2.7 to 15.6 +/- 1.2, 14.4 +/- 1.3, 13.0 +/- 0.7 and 13.1 +/- 0.6 micromol/L (FA-15) at days 15, 30, 90 and 180, respectively. (P < 0.01 from day 15 to 180 vs baseline for both groups with no differences between them). Renal function remained stable throughout the entire period of the study in all but one patient in whom it deteriorated to pre-end stage disease. No adverse cardiovascular events developed during the trial. CONCLUSION: Both folic acid doses induced a significant and similar decrease in plasma Hcy in subjects with moderate-severe chronic renal failure. The possible dose-related effect of this approach in reducing the risk of accelerated sclerotic vascular disease and cardiovascular events in this especially vulnerable population should be a matter of further investigation.