【作者】 陈凤锟；

【导师】 魏日胞； 孙雪峰；

【作者基本信息】 中国人民解放军军医进修学院 ， 内科学， 2010， 硕士

【摘要】 目的国外研究提出,由于贫血和促红细胞生成素(EPO)应用等原因,导致糖化血红蛋白(HbAlc)低估维持性血液透析(MHD)患者的实际血糖控制水平,并推荐以糖化白蛋白(GA)作为替代指标,但国内缺乏验证性研究。我们对合并和未合并糖尿病(DM)的MHD患者,以其全天的7次血糖测定值为参照标准,评估GA和HbAlc在这些患者中的血糖控制效能,以及寻找其非血糖的影响因素。方法病例选自四家医院的血透中心。入选和2月后随访时,均在透析前一日测量三餐前、三餐后2小时以及睡前共7次血糖,计算均值。次日(透析日)测量HbAlc及血色素(Hb)、白蛋白(ALB)等指标,并留取备用标本集中检测GA。最终对符合入选标准的109例病例以血糖的实际控制状况为标准,进行非糖尿病(NDM)(n=41)、DM (n=68)的分组研究。结果2组患者包括年龄、性别、透析龄等一般临床资料基本均衡。在总体和DM组患者中GA、HbAlc与平均血糖显著相关(p<0.01),但难以从相关系数r中得出两者间的区别。在DM患者中比较接收者工作特征(ROC)曲线的曲线下面积(AUC), HbAlc的评估效能明显优于GA(p<0.05)。我们还发现Hb和EPO剂量对HbAlc、ALB对GA以及炎症指标高敏C反应蛋白(HsCRP)对GA和HbAlc的影响均不明显。结论虽然在MHD患者中使用HbAlc会低估实际血糖水平,但就与血糖的相关性而言,它并不逊于GA,而在评估血糖控制效能时,甚至优于后者。因此HbAlc尚不能被取代,但其在MHD患者中的控制目标可能需要重新单独制定。在MHD患者中,Hb和促红素剂量对HbAlc并没有显著的影响；ALB对GA、炎症对GA和HbAlc的影响在本研究中也表现不明显,还难以得出令人信服的结论。更多还原

【Abstract】 Objective Foreign studies suggested that glycated hemoglobin (HbAlc) underestimate the actual glycemic control levels in maintenance hemodialysis (MHD) patients, because of anemia and using of erythropoietin (EPO), and recommended that glycated albumin (GA) should be an alternative marker, but there wasn’t domestic verification study yet. We assess glycemic control performance of GA and HbAlc in MHD patients with diabetes mellitus (DM) and without DM by regarding 7 measure values of their blood glucose during a whole day as reference standard, and look for the non-blood glucose factors of them. Methods The cases were enrolled from blood purification centers of four hospitals. At the time registered and 2 months later when follow-up,7 glycemic levels were measured before and at 2 hours after three meals, and at bedtime, in the day before dialysis, so as to calculate the mean blood glucose. At the next day (dialysis day), the indicators such as HbAlc, hemoglobin (Hb), albumin (ALB), and so on were measured. We also retained plasma and serum samples to detect GA concentrately. At last,109 cases who meet inclusion criteria were divided to non-diabetes mellitus (NDM) group (n=41) and DM group (n=68), and then were investigated. Results There were no difference in these 2 groups by comparing indicators including age, gender, vintage and other general clinical information. In the patients of population and DM group, both GA and HbAlc were significantly correlated with mean blood glucose (p<0.01), but the distinction between them didn’t be given by their correlation coefficients r. By comparing the area under curve (AUC) of receiver operating characteristic (ROC) curve in DM patients, assessment performance of HbAlc is better than GA (p<0.05). We found that the effects of Hb and EPO dose on HbAlc, ALB on GA, and inflammatory markers such as high sensitivity C-reactive protein (HsCRP) on GA and HbAlc were all not obvious. Conclusion Although using HbAlc in MHD patients may underestimate actual glycemic level, but in terms of correlation with blood glucose, it isn’t lower than GA, and it is still a better indicator than latter in assessing glycemic control performance, Therefore, HbAlc cannot be replaced currently, but the control target in MHD patients may need to be reevaluated separately. Hb and EPO dose haven’t obvious effect on HbAlc. The effects of ALB on GA, inflammation on GA and HbAlc isn’t obvious in our study too, it is still difficult to draw convincing conclusions.更多还原