血液透析对2型糖尿病终末期肾病患者糖代谢的影响

发布时间：2018-04-23 08:05

本文选题：2型糖尿病 + 终末期肾病　；参考：《福建医科大学》2015年硕士论文

【摘要】：目的:观察血液透析(Hemodialysis,HD)对2型糖尿病终末期肾病(End-stage renal disease,ESRD)患者糖代谢的影响,并通过检测相关激素水平,初步探讨影响机制。方法:1、纳入ESRD即将开始长期HD治疗的患者65例,按引起ESRD的病因不同分为糖尿病肾病(Diabetic nephropathy,DN)组和非DN组,其中DN组30例,均为2型糖尿病患者,非DN组35例。检测HD治疗开始前及规律HD治疗3个月后的空腹血浆葡萄糖(Fasting plasma glucose,FPG)、糖化血红蛋白(Hemoglobin A1c,Hb A1c)、空腹胰岛素(Fasting insulin,FINS)、空腹C肽(Fasting C-peptide,FCP)、胰升糖素样肽1(Glucagon-like peptide-1,GLP-1)、胰升糖素(Glucagon,GC)及其它一般指标。2、对DN组中在本院行HD治疗的12例患者在进入规律HD治疗后,安装实时动态血糖监测系统(Continuous glucose monitoring system,CGMS)监测围HD期的血糖波动情况,并于HD开始、HD2小时以及HD结束时外周静脉抽血检测患者的血浆葡萄糖(Plasma glucose,PG)、胰岛素(Insulin,INS)、C肽(C-peptide,CP)、GLP-1、GC水平。结果:1、60例患者完成试验,其中DN组完成28例,非DN组完成32例。2组患者一般资料比较显示,DN组体重指数(Body mass index,BMI)较非DN组高(P0.05),性别、年龄差异无统计学意义(P0.05)。2、2组患者的生化指标,在HD治疗前的比较显示:DN组血肌酐(Serum creatinine,Scr)、尿素(Urea,Ur)、全段甲状旁腺素(Intact parathyroid hormone,i PTH)较非DN组低(P0.05),而尿酸(Uric acid,UA)、血脂及电解质在2组间差异无统计学意义(P0.05)。HD3个月后,DN组Scr、i PTH较非DN组低(P0.05),余指标差异无统计学意义(P0.05)。自身前后比较发现,2组患者的Scr、Ur、UA、i PTH、低密度脂蛋白胆固醇(Low density lipoprotein cholesterol,LDL-C)、血磷均较HD治疗前显著降低(P0.05),而总胆固醇(Total cholesterol,TC)、高密度脂蛋白胆固醇(High density lipoprotein cholesterol,HDL-C)、甘油三脂(Triglyceride,TG)、血钠、血钾、血钙与HD治疗前比较差异无统计学意义(P0.05)。3、2组患者的糖代谢指标与相关激素,在HD治疗前的比较显示:DN组FPG、Hb A1c、稳态模型评估胰岛素抵抗指数(Homeostasis model assessment of insulin resistance,HOMA-IR)较非DN组高(P0.05),稳态模型评估胰岛细胞分泌指数(Homeostasis model assessment ofβ-cell function,HOMA-β)较非DN组低(P0.05),而FINS、FCP、GLP-1、GC差异无统计学意义(P0.05)。HD3个月后,DN组FPG、Hb A1c、FINS、HOMA-IR较非DN组高(P0.05),FCP、HOMA-β较非DN组低(P0.05),GLP-1、GC差异无统计学意义(P0.05)。自身前后比较发现,2组患者的FCP、HOMA-IR均较HD治疗前显著降低(P0.05);FPG、Hb A1c、HOMA-β、GLP-1、GC与HD治疗前比较差异均无统计学意义(P0.05);而FINS在DN组明显降低(P0.05),在非DN组比较差异无统计学意义(P0.05)。对2组患者HOMA-IR与GLP-1、GC的相关性分析显示,在DN组HOMA-IR改变与GLP-1(r=0.384,p0.05)及GC(r=0.392,p0.05)均呈正相关,非DN组HOMA-IR改变与GLP-1及GC无相关。4、CGMS示12例DN组患者在HD期间血糖明显下降,HD开始与结束时PG和同时间段CGM值的平均下降水平比较(5.15±3.42 mmol/L对5.16±3.28 mmol/L)差异无统计学意义(P0.05),但HD期间PG与同时间段CGM值的平均水平的比较(9.54±3.45mmol/L对10.46±3.10 mmol/L)显示CGM值明显高于PG(p0.05)。按血糖监测系统国际标准化组织(International Organization for Standardization,ISO)标准CGMS的点准确度为69.44%(25/36),进一步分析显示当PG≤6.8 mmol/L时点准确度仅为20%(2/10),当PG6.8mmol/L时点准确度为88.46%(23/26)。HD期间PG与CGM值的相关性分析显示呈显著正相关(r=0.976,p0.05),根据线性方程计算当PG5 mmol/L时,CGM值6.49mmol/L。5、12例DN患者HD期间患者均无低血糖症状,仅1例患者发生无症状性低血糖(HD结束时PG 3.7mmol/L,CGM值为6.6mmol/L)。HD期间的PG与相关激素的变化显示:PG、INS及CP在HD期间呈持续性下降,HD开始、HD2小时及HD结束时的两两比较,均有显著性降低(P0.05)。GLP-1在HD期间先下降后保持平稳,HD2小时与HD开始、HD结束时与HD开始比较均明显降低(P0.05),但HD结束时与HD2小时差异无统计学意义(P0.05);GC在HD开始、HD2小时与HD结束时的差异均无统计学意义(P0.05)。HD期间PG与INS、CP、GLP-1、GC的相关性分析显示,PG与INS呈正相关(r=0.495,p0.05),PG与CP、GLP-1、GC无相关。结论:1、2型糖尿病ESRD患者Hb A1c与FPG在HD治疗前与3个月后的比较无明显差异,但胰岛素抵抗程度有所改善,胰岛素抵抗的改善可能与GLP-1、GC有关。2、2型糖尿病ESRD患者单次HD期间,PG呈持续降低,INS、CP也呈持续降低,但GLP-1在HD前2小时下降,随后保持稳定水平,而GC无明显变化。3、在2型糖尿病ESRD患者中CGM值与PG具有良好的相关性,CGMS可用于2型糖尿病ESRD患者HD期间的血糖监测,但当PG≤6.8mmol/L时,CGM检测值大于实际PG浓度。当CGM值6.49mmol/L时,不论患者有无低血糖症状,即应检测PG水平,积极预防低血糖的发生。
[Abstract]:Objective: To observe the effect of Hemodialysis (HD) on glucose metabolism in patients with End-stage renal disease (ESRD), and to explore the influence mechanism by detecting the related hormone levels. Methods: 1, 65 patients who were about to start long-term HD treatment were included in ESRD, and diabetic nephropathy was divided into diabetic nephropathy according to the cause of ESRD (Di). Abetic nephropathy, DN) and non DN groups, of which 30 cases of group DN were all type 2 diabetes and 35 non DN groups. The fasting plasma glucose (Fasting plasma glucose, FPG), glycosylated hemoglobin, fasting insulin, and fasting insulin were detected before and 3 months after the regular HD treatment. Eptide, FCP), glucagon like peptide 1 (Glucagon-like peptide-1, GLP-1), glucagon (Glucagon, GC) and other general indicators.2. In the DN group, 12 patients who had been treated with HD in our hospital were enrolled in a regular and dynamic glucose monitoring system. At the beginning of HD, the plasma glucose (Plasma glucose, PG), insulin (Insulin, INS), C peptide (C-peptide, CP), GLP-1, and GLP-1 were measured at the end of HD2 hours and at the end of HD. Mass index, BMI) was higher than that of non DN group (P0.05), sex, age difference was not statistically significant (P0.05) the biochemical indexes of the patients in the.2,2 group, and the comparison before the HD treatment showed that the serum creatinine (Serum creatinine, Scr), the urea and the whole segment parathyroid hormone were lower than those before the HD treatment. There was no significant difference in lipid and electrolyte between the 2 groups (P0.05).HD3 months later, group DN was Scr, I PTH was lower than that of non DN group (P0.05), and there was no significant difference in the residual index (P0.05). The results of the 2 groups were Scr, Ur, UA, and low density lipoprotein cholesterol. Reduction (P0.05), total cholesterol (Total cholesterol, TC), high density lipoprotein cholesterol (High density lipoprotein cholesterol, HDL-C), glycerol three fat (Triglyceride, TG), blood sodium, blood potassium, blood calcium and HD before treatment, there was no significant difference between the glucose metabolism indexes and related hormones before the treatment. DN group FPG, Hb A1c, steady-state model evaluation of insulin resistance index (Homeostasis model assessment of insulin resistance, HOMA-IR) is higher than that of non DN groups. After.HD3 months of P0.05, FPG, Hb A1c, FINS, HOMA-IR of group DN were higher than non DN group (P0.05), FCP, and HOMA- beta was not statistically significant. There was no statistical significance (P0.05), while FINS was significantly lower in the DN group (P0.05), and there was no significant difference in the non DN group (P0.05). The correlation analysis between HOMA-IR and GLP-1 in the 2 groups showed that the HOMA-IR changes in the DN group were positively correlated with GLP-1. Blood glucose decreased significantly during the period of HD in 12 cases of DN, and there was no significant difference in the difference between the beginning and the end of HD at the end of the PG and the average level of CGM in the same time period (5.15 + 3.42 mmol/L to 5.16 + 3.28 mmol/L), but the ratio of PG to the average level of CGM at the same time period was compared with that of 9.54 + 3.45mmol/L against 10.46 + 3.10. The point accuracy of the standard CGMS (International Organization for Standardization, ISO) is 69.44% (25/36) according to the blood glucose monitoring system (International Organization for Standardization, ISO). Further analysis shows that when PG < 6.8 mmol/L, the accuracy is only 20% (2/10), and when the time point accuracy is 88.46%, it is related to the value. The sex analysis showed a significant positive correlation (r=0.976, P0.05). According to the linear equation, when PG5 mmol/L was calculated, there was no hypoglycemic symptoms in HD during HD of 6.49mmol/L.5,12 cases, and only 1 patients had asymptomatic hypoglycemia (PG 3.7mmol/L at the end of HD, and the CGM value) During the period of HD, HD began to decrease, HD2 hours and HD at the end of the 22, both decreased significantly (P0.05).GLP-1 in HD and remained stable, HD2 hours and HD began, HD end and HD began to significantly lower (P0.05). There was no significant difference between PG and INS, CP, GLP-1 and GC during the period of P0.05.HD, and there was no correlation between PG and INS (r=0.495, P0.05). Conclusion: there was no significant difference between the 3 months before and after the treatment, but the degree of insulin resistance was changed. Good, the improvement of insulin resistance may be associated with GLP-1, GC related to type.2,2 diabetes ESRD patients during a single HD period, PG continues to decrease, INS, CP also continues to decrease, but GLP-1 decreased at 2 hours before HD, and then remains stable, while GC has no obvious change in.3, which can be used in type 2 sugar. Blood glucose monitoring during HD in ESRD patients with urinary disease, but when PG is less than 6.8mmol/L, the CGM detection value is greater than the actual PG concentration. When CGM value 6.49mmol/L, whether the patient has no hypoglycemic symptoms, that is, the level of PG should be detected, and the occurrence of hypoglycemia should be actively prevented.

【学位授予单位】：福建医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R587.2

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