亚临床甲减与2型糖尿病患者颈动脉粥样硬化和糖尿病肾脏病的相关性研究

发布时间：2017-12-26 23:08

本文关键词：亚临床甲减与2型糖尿病患者颈动脉粥样硬化和糖尿病肾脏病的相关性研究　出处：《山西医科大学》2016年硕士论文　论文类型：学位论文

【摘要】：目的:本研究旨在分析亚临床甲状腺功能减退与2型糖尿病患者颈动脉粥样硬化和糖尿病肾脏病的相关性,从而探讨亚临床甲状腺功能减退对2型糖尿病患者血管并发症的影响。方法:连续收集2015年8月至2015年12月间于山西医科大学第一医院内分泌科住院的T2DM患者310例进行横断面研究,其中男性182例,女性128例,平均年龄(59.1±8.8)岁,平均糖尿病病程(9.8±6.6)年,平均体重指数(BMI)(24.77±2.92)kg/m2。所有患者均符合1999年WHO糖尿病诊断分型标准。排除标准:合并有糖尿病急性并发症、感染、妊娠、严重的心肝肾功能不全、恶性肿瘤者,以及既往有甲状腺疾病史,或使用对甲状腺功能有影响的药物者。采集患者的一般资料包括:年龄、性别、糖尿病病程、既往史、吸烟史、记录入院时血压、身高、体重,计算BMI。身高测定:被测者脱去身上较重的衣物、鞋、包等,赤脚以立正姿势站于标准体重计的中部,头摆正,眼睛平视前方,测量精确到0.01m。体重测定:被测者空腹,脱去身上较重的衣物、鞋、包等,身上仅留单衣,赤脚站于标准体重计的中部,测量精确到0.1kg。血压测量:所有患者均于安静的环境中至少休息30分钟(期间禁止抽烟,喝酒,饮用咖啡、茶等饮料),然后用标准水银血压计按照袖带加压法于右上臂进行测量,每人最少测量2次(中间需相隔3分钟),最后取其平均值作为血压的测定值。全部患者均于入院后次日清晨空腹8-12小时后留取肘静脉血,检测指标包括:游离三碘甲状原氨酸(FT3)、游离甲状腺素(FT4)、促甲状腺素(TSH)、空腹血糖(FPG)、糖化血红蛋白(hba1c)、总胆固醇(tc)、甘油三酯(tg)、血肌酐(scr)、高密度脂蛋白胆固醇(hdl-c)、低密度脂蛋白胆固醇(ldl-c)、超敏c反应蛋白(hs-crp)、血清天门冬氨酸氨基转移酶(ast)、血清丙氨酸氨基转移酶(alt)。同时留取晨尿检测尿微量白蛋白和尿肌酐,计算尿微量白蛋白和尿肌酐的比值(uacr)。依据scr值计算肾小球滤过率(egfr),采用适于中国人的改良mdrd公式,egfr[ml/(min·1.73m2)]=175×scr-1.234×年龄-0.179(如果是女性×0.79)。所有患者行颈动脉彩超检查来获得内膜中层厚度(imt)和有无斑块的形成,将imt≥1.0mm或合并有明显斑块者定义为颈动脉粥样硬化(cas),imt1.0mm以及管壁光滑者定义为无cas。依据《糖尿病肾病防治专家共识》(2014版)将uacr≥30mg/g或有糖尿病视网膜病合并egfr异常者(egfr90ml/(min·1.73m2))视为糖尿病肾脏病(dkd)。亚临床甲状腺功能减退(sch)参照《成人甲状腺功能减退治疗指南》(2012版)的诊断标准:血清tsh水平高于正常值上限,血清ft3、ft4在正常范围。结合本院甲功的参考范围,以tsh4.2uiu/ml为sch诊断切点,即tsh≥4.2uiu/ml,且ft3、ft4正常者诊断sch。依据甲状腺功能将患者分为2组:单纯t2dm组、t2dm合并sch组。比较两组cas和dkd的差异。logistic回归分析探讨sch与cas和dkd的关系。所有数据用spss20.0统计软件进行分析,计量资料以均数±标准差(x±s)表示,对数据进行正态性检验,偏态分布计量资料如tsh、fpg、tg、tc等应用自然对数转换后再分析,组间比较采用t检验。计数资料以百分率表示,组间比较采用卡方检验。危险因素分析采用logistic回归分析。p0.05表示差异有统计学意义。结果:1.t2dm合并sch组与单纯t2dm组的临床参数比较:与单纯t2dm组相比,t2dm合并sch组的hs-crp水平高、tc水平高、tg水平高,差异有统计学意义(p0.05);两组性别、年龄、bmi、糖尿病病程、高血压病史、吸烟、sbp、dbp、fpg、hba1c、hdl-c、ldl-c相比较,差异无统计学意义(p0.05)。2.t2dm合并sch组与单纯t2dm组cas和dkd发生率的比较:t2dm合并sch组cas和dkd发生率均高于单纯t2dm组,差异有统计学意义(p0.05)。3.T2DM患者CAS的logistic回归分析:3.1单因素logistic回归分析:以有无CAS为因变量,分别以有无SCH、性别、年龄、糖尿病病程、有无高血压、是否吸烟、SBP、DBP、FPG、HbA1c、TC、TG、HDL-C、LDL-C为自变量做单因素logistic回归分析,结果显示:SCH(OR值为2.214,P0.05)、高血压(OR值为2.451,P0.05)、年龄(OR值为1.062,P0.05)、糖尿病病程(OR值为1.054,P0.05)、TC(OR值为1.079,P0.05)与CAS相关。3.2多因素logistic回归分析:以有无CAS为因变量,以单因素分析筛选出的和临床中有共识的指标为自变量做多因素logistic回归分析,结果显示:在调整年龄、性别、糖尿病病程、BMI、高血压、吸烟、TC后,SCH与CAS相关(OR值为2.364,P0.05),SCH患者发生CAS的风险是无SCH患者的2.364倍。4.T2DM患者DKD的logistic回归分析:4.1单因素logistic回归分析:以有无DKD为因变量,分别以有无SCH、性别、年龄、糖尿病病程、有无高血压、是否吸烟、SBP、DBP、FPG、HbA1c、TC、TG、HDL-C、LDL-C为自变量做单因素logistic回归分析,结果显示:SCH(OR值为1.849,P0.05)、高血压(OR值为2.091,P0.05)、SBP(OR值为1.028,P0.05)、HbA1c(OR值为1.272,P0.05)、TG(OR值为1.350,P0.05)与DKD相关。4.2多因素logistic回归分析:以有无DKD为因变量,以单因素分析筛选出的和临床中有共识的指标为自变量做多因素logistic回归分析,结果显示:在调整性别、年龄、糖尿病病程、高血压、BMI、SBP、HbA1c、TG后,SCH与DKD相关(OR值为2.053,P0.05),SCH患者发生DKD的风险是无SCH患者的2.053倍。结论:1.2型糖尿病合并亚临床甲减者颈动脉粥样硬化的发生率增高,亚临床甲减可能会增加2型糖尿病患者颈动脉粥样硬化的发生风险。2.2型糖尿病合并亚临床甲减者糖尿病肾脏病的发生率增高,亚临床甲减可能会增加2型糖尿病患者糖尿病肾脏病的发生风险。
[Abstract]:Objective: the purpose of this study is to analyze the correlation between subclinical hypothyroidism and carotid atherosclerosis and diabetic nephropathy in type 2 diabetic patients, so as to explore the effect of subclinical hypothyroidism on vascular complications in patients with type 2 diabetes. Methods: from August 2015 to December 2015 in 310 cases of T2DM patients hospitalized in the Department of Endocrinology, the first hospital of Shanxi Medical University were investigated, of which 182 were male, 128 were female, the average age (59.1 + 8.8) years old, the average duration of diabetes (9.8 + 6.6) years, the average body mass index (BMI) (24.77 + 2.92) kg/m2. All patients were in accordance with the diagnostic criteria for WHO diabetes in 1999. Exclusion criteria: those with diabetes, acute complications, infection, pregnancy, severe heart, liver and kidney dysfunction, malignant tumor, and past history of thyroid disease, or those who have influence on thyroid function. The general data of the patients included age, sex, course of diabetes, history, history of smoking, history of smoking, blood pressure, height, weight, and BMI. Height determination: measured by removing his heavy clothing, shoes, bags, barefoot in the central station to stand at attention posture, the standard weight of head upright, eyes straight ahead, accurate to 0.01m. Weight determination: measured fasting, removing his heavy clothing, shoes, bags and other body, leaving only unlined, standing barefoot in the central standard weight measurement, accurate to 0.1kg. Blood pressure measurement: all the patients were in a quiet environment to rest for at least 30 minutes (smoke, drink alcohol during prohibition, drinking coffee, tea and other drinks), and then use the standard mercury sphygmomanometer cuff compression method according to the measurement in the right arm, each at least 2 measurements (which requires 3 minutes apart), finally take the average as the blood pressure measurement. All patients were admitted to hospital after fasting for 8-12 hours after leaving the umbilical venous blood, the indexes included: free three iodine thyroid original acid (FT3), free thyroxine (FT4), thyroid stimulating hormone (TSH), fasting blood glucose (FPG), glycosylated hemoglobin (HbA1c), total cholesterol (TC), triglyceride (TG), serum creatinine (SCR), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), high sensitive C reactive protein (hs-CRP), serum aspartate aminotransferase (AST), serum alanine aminotransferase (ALT). The urine microalbuminuria and urinary creatinine were measured at the same time, and the ratio of urine microalbuminuria and urine creatinine (UACR) was calculated. According to the SCR value, we calculated glomerular filtration rate (EGFR) and adopted the modified MDRD formula suitable for Chinese people, egfr[ml/ (min. 1.73m2)]=175 * scr-1.234 * age -0.179 (if female X 0.79). All patients underwent carotid artery ultrasonography to obtain the intima-media thickness (IMT) and plaque formation, IMT = 1.0mm or with obvious plaque were defined as carotid atherosclerosis (CAS), imt1.0mm and the smooth tube wall is defined as cas. On the basis of "expert consensus" prevention and treatment of diabetic nephropathy (2014 Edition) UACR = 30mg/g or diabetic retinopathy with abnormal EGFR (egfr90ml/ (min, 1.73m2)) as diabetic kidney disease (DKD). Subclinical hypothyroidism (SCH) is based on the diagnostic criteria of the treatment guidelines for adult hypothyroidism (2012 Edition): serum TSH level is higher than the upper limit of normal value, serum FT3 and FT4 are in normal range. With the reference range of thyroid function in our hospital, to tsh4.2uiu/ml for the diagnosis of SCH sites, TSH is more than 4.2uiu/ml, FT3, FT4 and sch of normal diagnosis. According to the thyroid function, the patients were divided into 2 groups: simple T2DM group, T2DM combined with Sch group. The differences between the two groups of CAS and DKD were compared. Logistic regression analysis was used to investigate the relationship between Sch and CAS and DKD. All data were analyzed by spss20.0 statistical software. The data were represented by mean + standard deviation (x + s). The normality of data was tested, and the skewed distribution data such as TSH, FPG, TG and TC were re analyzed after natural logarithmic transformation. T test was used in comparison between groups. The count data were expressed as a percentage, and the chi square test was used among the groups. Logistic regression analysis was used for the analysis of risk factors. P0.05 indicated that the difference was statistically significant. Results: compare the clinical parameters of 1.t2dm combined with Sch group and T2DM group: compared with T2DM group, T2DM Sch group with high hs-CRP level, high Tc level, TG level is high, the difference was statistically significant (P0.05); the two groups of gender, age, BMI, duration of diabetes, hypertension, smoking history, SBP FPG, HbA1c, DBP, HDL-C, and LDL-C, the difference was not statistically significant (P0.05). The incidence of CAS and DKD in group 2.t2dm combined with Sch and T2DM alone: the incidence of CAS and DKD in T2DM plus Sch group were all higher than those in simple T2DM group, the difference was statistically significant (P0.05). Patients with 3.T2DM CAS logistic regression analysis: 3.1 single factor Logistic regression analysis: the CAS as the dependent variable, respectively, with no SCH, gender, age, duration of diabetes, hypertension, smoking, no SBP, DBP, FPG, HbA1c, TC, TG, HDL-C and LDL-C as independent variables to do single factor Logistic regression analysis results showed that: SCH (OR = 2.214, P0.05), hypertension (OR = 2.451, P0.05), age (OR = 1.062, P0.05), diabetes (OR = 1.054, P0.05), TC (OR = 1.079, P0.05) and CAS. Logistic 3.2 multi factor regression analysis: with or without CAS as the dependent variable, using single factor analysis results are consensus screened and clinical index for logistic independent multi factor regression analysis showed that after adjusting for age, sex, duration of diabetes, hypertension, smoking, BMI, TC, SCH and CAS (OR = 2.364, P0.05), risk of patients with SCH CAS is 2.364 times higher than in patients without SCH. Logistic regression analysis of DKD in patients with 4.T2DM: 4.1 univariate logistic regression analysis: whether DKD was the dependent variable, whether there were SCH, gender, age, duration of diabetes, hypertension, smoking, SBP, D.
【学位授予单位】：山西医科大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R587.2;R581.2

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