【作者】 周幼芬；

【导师】 冯烈；

【作者基本信息】 暨南大学 ， 内科学， 2009， 硕士

【摘要】 目的:分析糖尿病肾病的影响因素,探讨Cockcroft-Gault公式、简化MDRD^*方程及改良简化MDRD方程评价糖代谢紊乱人群肾小球滤过功能的应用价值,并开发适合糖尿病患者的GFR^*估算方程,以指导临床的治疗。方法:以2000年1月～2009年1月间,曾经在暨南大学附属第一医院检查^99m锝-二乙烯三胺五乙酸肾动态显像法肾小球滤过率的454例患者（材料一）为研究病例,该群体中有188例患者是泌尿系B超检查正常且无肾脏疾病史的糖代谢紊乱患者（材料二）及130例是2007年10月～2009年1月间,在暨南大学附属第一医院住院或门诊就诊的糖尿病患者（材料三）。以^99mTc-DTPA肾动态显像法GFR为金标准,分别比较Cockcroft-Gault公式、简化MDRD方程及改良简化MDRD方程估算GFR值在预测不同糖代谢状态下GFR时与金标准的符合程度,并探讨分析糖尿病患者肾脏滤过功能的影响因素。以糖尿病患者为研究人群,重新引入新的参数,形成新方程,比较在不同GFR水平,新旧方程评估糖尿病及非糖尿病患者的GFR时与金标准的符合程度。结果:1.既有公式与金标准的符合程度:①对于混合人群,Cockcroft-Gault公式低估了GFR,简化MDRD方程及改良简化MDRD方程则高估了GFR,差别具有统计学意义;对于CKD5期的患者,3个公式的估测值接近,与金标准比较,差别无统计学意义。②对于非糖代谢紊乱患者,Cockcroft-Gault公式低估了1期及2期的GFR;简化MDRD方程低估了1期的GFR,而高估了3期的GFR;改良简化MDRD方程高估了3期的GFR,差别均具有统计学意义。对于糖代谢紊乱患者,Cockcroft-Gault公式低估了1期及2期的GFR;简化MDRD方程高估了2期及3期的GFR;改良简化MDRD方程高估了1～3期的GFR,差别均具有统计学意义。对于CKD4期以后的患者,无论糖代谢状态如何,3个公式的估测值与金标准的差别无统计学意义。2.糖尿病肾病的影响因素分析:①糖代谢紊乱合并高血压组GFR低于血压正常组,GFR与高血压病程呈负相关;尿白蛋白排泄率高于血压正常组,但CKD各期之间的尿白蛋白排泄率、尿白蛋白/肌酐比值的差别无统计学意义。②GFR与年龄、体表面积、糖尿病病程、视网膜病变程度、收缩压、血肌酐、血尿素氮及血尿酸呈负相关,与糖化血红蛋白、空腹血糖及高密度脂蛋白C呈正相关。③糖代谢紊乱出现非增殖型糖尿病视网膜病变时,其GFR低于正常眼底者,差别具有统计学意义。3.新旧方程的比较:基于糖尿病人群开发的新GFR估算方程具有较高的敏感度（77.62%）和特异度（85.19%）,应用于一定范围的糖尿病人群时,其与金标准的符合程度达0.72,优于既有的3个公式;但对于混合人群,新方程的准确性则不及既有的3个公式。结论:糖尿病肾病是一多因素疾病,有其独特的致病机制,不同于普通肾脏病患者。既往应用于慢性肾脏病人的GFR估测公式用于评估糖尿病人群的肾小球滤过率欠准确。基于糖尿病人群开发的新方程有较高的敏感度和特异度,可能为临床评估糖尿病人群的GFR带来一定帮助,但本研究受其研究人群的限制,暂适于严格限定范围的糖尿病患者。更多还原

【Abstract】 Objective:To analyze the influencing factors of diabetic nephropathy and evaluate the applied value of Cockcroft-Gault formula,simplified MDRD formula and modified simplified MDRD formula in glycometabolic disorder subjects.Meanwhile,we tend to develop a new GFR estimated formula specialized for diabetes in order to assist clinical treatment.Methods:454 patients（as the First Group） who had accepted examination of ^99mTc-diethylenetriaminepentaacetic acid(^99mTc-DTPA)nephro-dynamic imaging GFR in the first affiliated hospital of JI NAN University during January 2000 to January 2009 were treated as case groups,containing the second Group,which contained 188 diabetes who had normal ultrasound examination result in urinary system and had no history in kidney diseases,and the third Group,which contained 130 diabetes who had been hospitalized in the first affiliated hospital of JI NAN University during January 2000 to January 2009.Using ^99mTc-DTPA nephro-dynamic imaging GFR as gold standard,compare the coincidence of the three known formulae with the gold standard separately at different glycometabolic stations and analyze the influencing factors of the glomerular filtration function of the diabetics.Using the data from diabetic subjects as study cases,to develop a new formula by redrawing into new parameters and compare the coincidence with the gold standard between the new one and the three known formulae at different GFR levels while evaluating the GFR of the diabetics and the non-diabetics.Results:1.Coincidence between the known formulae and gold standard:①With regard to the mixed subjects,Cockcroft-Gault formula underestimated the GFR while simplified MDRD formula and modified simplified MDRD formula overestimated the GFR,the difference of which had statistic significance.Regard to the patients after CKD4,the estimated value of the three formulae was near indistinctively,comparing with gold stantard.②Regard to the non-diabetics,Cockcroft-Gault formula underestimated the GFR of the CKD1 and CKD2 patients,simplified MDRD formula underestimated the GFR of CKD1 patients but overestimated the GFR of CKD3,modified simplified MDRD formula overestimated the GFR of CKD3 patients,all of which had statistic significance.For the diabetics,Cockcroft-Gault formula underestimated the GFR of CKD1 and CKD2 patients,simplified MDRD formula overestimated the GFR of CKD2 and CKD3 patients,modified simplified MDRD formula overestimated the GFR of CKD2 to CKD3 patients,all of which had statistic significance.Finally for the CKD4 and CKD5 patients,the estimated value of the three formulae were similar whatever the glycometabolic station,the difference of which had no statistic significance.2.Influencing factors analysis of diabetic nephropathy:①Glycometabolic disorther with hypertension had lower GFR and higher urinary albumin excretion rate,and GFR had negative correlation with hypertension course.But the differences of the urinary albumin excretion rate and the urinary albumin/urinary creatinine ratio between each CKD stage had no statistic significance.②The GFR had negative correlation with age,body surface area,diabetic course,retinopathy level, systolic blood pressure,serum creatinine,blood urea nitrogen and blood uric acid while having positive correlation with glycosylated hemoglobin,fasting plasma glucose and high density lipoprotein C.③The GFR of the diabetics with nonproliferative diabetic retinopathy was lower than the group with normal fundus,the difference of which had statistic significance.3. Comparison between the new formula based on the data from diabetes and the three known formulae:the new one had higher sensitivity（77.62%） and specificity（85.19%）.The coincidence of the new formula with the gold standard was 0.72,which was better than the three known formulae when it was applied in a certain diabetic subjects,but was inferior when applied in mixed subjects.Conclusions:Diabetic nephropathy is a disease affected by multiple factors,which had distinct pathogenic mechanism.Using the known formulae which was applied to the patients with chronic kidney disease was insufficient when being applied to evaluate the GFR of the diabetics.The new formula based on the diabetics had higher sensitivity and specificity,which may help to more accurately evaluate the GFR of the diabetics in clinical practice.However,this study was limited by the research subjects,thus it can only be applied to the limited diabetics temporarily.更多还原