糖尿病视网膜病变发展影响因素及进展预测模型临床研究

发布时间：2018-05-18 03:26

本文选题：发生 + 进展　；参考：《北京中医药大学》2016年博士论文

【摘要】：目的和意义：研究糖尿病视网膜病变发生及进展的相关影响因素,探讨糖尿病视网膜病变进展的预测方法,以指导临床早期诊断糖尿病视网膜病变,预防其进展。研究方法：1.糖尿病视网膜病变发生影响因素的临床研究：本研究以2014年3月就诊295例患者为研究对象。根据眼底表现情况,分为糖尿病视网膜病变(DR)组和非DR组,对比分析两组患者一般资料、伴随疾病、家族史、临床测量指标、理化指标、中医症状及中医证素,筛查糖尿病视网膜病变发生的影响因素。2.糖尿病视网膜病变进展危险因素及预测模型的建立：本研究以2014年3月-2015年12月完成随访的58例患者为研究对象。根据眼底视网膜病变变化情况,分为进展组和未进展组,比较两组入组时一般资料、伴随疾病、家族史、临床测量指标、理化指标、中医症状及中医证素,筛查DR进展的危险因素。采用多因素Logistic分析,筛查DR进展的独立危险因素,制定DR进展预测模型。结果：一、基于差异性分析,得出与糖尿病视网膜病变发生与否有关影响因素1.一般资料：基于纳入及排除标准,去掉不符合条件者,非DR组入组183例,其中男103例,女80例,平均年龄58.67±11.30岁；DR组入组112例,其中男61例,女51例,平均年龄59.97±10.91岁,两组年龄及性别分布无显著差别；与非DR组相比,DR组吸烟比例、饮酒比例明显高于非DR组,差异具有统计学意义。2.伴发病症及家族史：与非DR组相比,DR组高血压病、脑梗死病及低血糖比例明显高于非DR组,差异具有统计学意义；与非DR组相比,DR组脂肪肝比例明显低于非DR组,差异具有统计学意义；两组伴发冠心病、高血脂、高尿酸血症、父亲家族史、母亲家族史、兄弟姐妹家族史无显著差别。3.临床测量指标：与非DR组相比,DR组收缩压明显高于非DR组,差异具有统计学意义；两组舒张压、体重指数、腰臀比无显著差别,差异不具有统计学意义。4.理化指标：与非DR组相比,DR组24h尿蛋白定量、尿微量白蛋白／血肌酐比值、血肌酐、血尿素氮、血尿酸、糖化血红蛋白、血钾、血磷明显高于非DR组,差异具有统计学意义；与非DR组相比,DR组红细胞计数、血总蛋白、血白蛋白明显低于非DR组,差异具有统计学意义；两组内生肌酐清除率、肾小球滤过率、空腹血糖、总胆固醇、甘油三酯、高密度脂蛋白、低密度脂蛋白、血红蛋白、血钙无显著差别,差异不具有统计学意义。5.中医症状：非DR组中医四诊信息频次最高的十个症状依次分别是：倦怠乏力、咽燥口干、性欲减退、腰膝酸痛、齿松动脱发、肢体困重、口干口苦、目睛干涩、健忘、自汗；DR组中医四诊信息频次最高的十个症状依次分别是：倦怠乏力、少气懒言、性欲减退、咽燥口干、齿松动脱发、腰膝酸痛、视物昏花、肢体困重、目睛干涩、夜尿频多；与非DR组相比,DR组少气懒言、小便黄赤、周身浮肿症状频次分布明显升高,差异具有统计学意义；与非DR组相比,DR组自汗、头晕眼花、五心烦热、喘促气短、健忘、口苦口干症状频次分布明显低于非DR组,差异具有统计学意义。6.中医证素：非DR组中医各证素频次分布高低依次分别是：阴虚、气虚、阳虚、血瘀、血虚、湿热、痰浊、气滞、热盛；DR组中医各证素频次分布高低依次分别是：气虚、阴虚、血虚、阳虚、血瘀、热盛、痰浊、气滞、湿热；与非DR组相比,DR组阴虚、湿热证素频次分布明显降低,差异具有统计学意义。二、基于差异性分析,得出与糖尿病视网膜病变进展与否有关影响因素1.基线一般资料：未进展组基线入组43例,其中男20例,女23例,平均年龄63.28±7.48岁；进展组基线入组15例,其中男10例,女5例,平均年龄59.97±10.91岁：与未进展组相比,进展组年龄明显低于未进展,差异具有统计学意义；两组性别分布无统计学差异；与未进展组相比,进展组吸烟、饮酒比例无显著差别,差异不具有统计学意义。2.伴发病症及家族史：与未进展组相比,进展组高血压病病史比例明显高于未进展,差异具有统计学意义；与未进展组相比,进展组冠心病、脑梗死病、高血脂、脂肪肝、高尿酸血症、低血糖、家族史比例无显著差别,差异不具有统计学意义。3.临床测量指标：与未进展组相比,进展组收缩压、舒张压无显著差别,差异不具有统计学意义；与未进展组相比,进展组体重指数、腰臀比明显高于未进展,差异具有统计学意义。4.理化指标：与未进展组相比,进展组24小时尿蛋白定量、尿液微蛋白/肌酐比值、血肌酐、血尿素氮、血糖、糖化血红蛋白、血磷明显高于未进展,内生肌酐清除率、肾小球滤过率低于未进展组,差异具有统计学意义；。与未进展组相比,进展组尿酸、总胆固醇、甘油三酯、低密度脂蛋白、高密度脂蛋白、红细胞计数、血红蛋白、血钾、血钙、血总蛋白、血白蛋白无显著差别,差异不具有统计学意义。5.中医症状：未进展组基线水平中医四诊信息频次最高的十个症状依次分别是：倦怠乏力、肢体困重、性欲减退、咽燥口干、腰膝酸痛、齿松动脱发、健忘、视物昏花、皮肤瘙痒、自汗；进展组患者基线水平中医四诊信息中出现频次最高的前十个症候是：倦怠乏力、目睛干涩、肢体困重、头晕眼花、齿松动脱发、口干口苦、皮肤瘙痒、形寒肢冷、腰膝酸痛、性欲减退；与非进展组相比,进展组基线水平心悸怔仲、失眠多梦、爪甲不荣症状频次分布明显低于未进展,差异具有统计学意义。6.中医证素：非进展组基线水平中医各证素频次分布高低依次分别是：气虚、阴虚、血虚、湿热、血瘀、气滞、痰浊、热盛、阳虚；进展组基线水平中医各证素频次分布高低依次分别是：气虚、阴虚、阳虚、血虚、湿热、血瘀、痰浊、热盛、气滞；与未进展组相比,进展组阳虚证素频次分布明显高于未进展,差异具有统计学意义。三、DR进展预测模型的建立：1.多因素分析结果显示：体重指数(OR=2.125, P=0.754)、ACR (OR=1.002, P=0.002)、 Scr (OR=1.018, P=0.018)、糖化血红蛋白(OR=2.705,P=0.995)与DR进展独立相关。2.建立DR进展预测方程：P= exp(-31.913+0.754BMI+0.002ACR+0.018SCR+0.995HBA)/[1+exp(-31.913+0.754BMI+0.002ACR+0.018SCR+0.995HBA)]ROC曲线下面积为0.974。结合临床实际,以youde n指数最大为原则,确定DR进展概率的诊断界值为0.30,此时诊断灵敏度为100%,特异度为95.3%。3.验证结果显示灵敏度为81.8%、特异度为97.4%和准确率为94%。结论1.DR发生与否的相关影响因素包括：吸烟、饮酒、伴发高血压病、伴发脑梗死病、低血糖病史、高24h尿蛋白定量、高尿微量白蛋白血肌酐比值、高血肌酐、高血尿素氮、高血尿酸、高糖化血红蛋白、低红细胞计数、高血钾、高血磷、低血总蛋白、低血白蛋白、少气懒言、小便黄赤、周身浮肿； DR组自汗、头晕眼花、五心烦热、喘促气短、健忘、口苦口干症状频次分布明显降低。2.DR进展与否的相关影响因素包括：低龄、伴发高血压病、高体重指数、高腰臀比、高24小时尿蛋白定量、高尿液微蛋白肌酐比值、高血肌酐、高血尿素氮、低内生肌酐清除率、低肾小球滤过率、高空腹血糖、高糖化血红蛋白、高血磷、阳虚。3.(1)多因素logistic回归结果显示：体重指数、ACR、血肌酐、糖化血红蛋白与DR进展与否独立相关。(2)建立DR进展预测方程小样本验证显示灵敏度100%,特异度为95.3%。验证灵敏度为81.8%、特异度为97.4%和准确率为94%。所建模型可靠、可取。
[Abstract]:Objective and significance: To study the related factors of the occurrence and progress of diabetic retinopathy and to explore the prediction method of diabetic retinopathy in order to guide the early diagnosis of diabetic retinopathy and prevent its progress. 1. clinical study on the influencing factors of diabetic retinopathy: This study was 2014 In March, 295 patients were enrolled in the study. According to the performance of the fundus, they were divided into diabetic retinopathy (DR) group and non DR group. The general data of the patients were compared and analyzed with the disease, family history, clinical measurement index, physical and chemical index, TCM symptoms and TCM syndrome, and the screening of diabetic retinopathy in.2. diabetes. The risk factors and prediction model of retinopathy were established: 58 patients who were followed up in December -2015 March 2014 were studied in this study. According to the changes of retinopathy of the fundus, they were divided into the progress group and the non progressing group. The general data were compared in the two groups, with the disease, family history, clinical measurement index and physical and chemical index. Traditional Chinese medicine symptoms and TCM syndromes, the risk factors for screening DR progress. Using multiple factor Logistic analysis to screen independent risk factors of DR progress and develop a DR prediction model. Results: first, based on differential analysis, the general data about the incidence of diabetic retinopathy are 1.: Based on inclusion and exclusion criteria, In the non DR group, there were 183 cases in the non group, including 103 males and 80 females, with an average age of 58.67 + 11.30 years, and 112 cases in group DR, including 61 men and 51 women, with an average age of 59.97 + 10.91 years, and there was no significant difference in age and sex distribution in group two. Compared with the non DR group, the proportion of smoking in group DR was significantly higher than that in non DR group, and the difference has unification. Study significance.2. accompanied by disease and family history: compared with the non DR group, the proportion of hypertension, cerebral infarction and hypoglycemia in group DR was significantly higher than that in non DR group, and the difference was statistically significant. Compared with the non DR group, the proportion of fatty liver in group DR was significantly lower than that of non DR group, and the difference was statistically significant; the two groups were accompanied with coronary heart disease, hyperlipidemia, hyperuricemia, father. Family history, mother family history, brothers and sisters family history no significant difference in.3. clinical measurement indicators: compared with the non DR group, DR group systolic pressure was significantly higher than the non DR group, the difference was statistically significant; two groups of diastolic pressure, body mass index, waist hip ratio no significant difference, the difference was not statistically significant.4. physicochemical index: compared with the non DR group, DR group 24 H urine protein quantitative, urine microalbumin / blood creatinine ratio, blood creatinine, blood urea nitrogen, blood uric acid, glycosylated hemoglobin, blood potassium, blood phosphorus were significantly higher than non DR group, the difference was statistically significant. Compared with the non DR group, the number of red blood cells in group DR, blood total protein, blood white egg white were significantly lower than that of non DR group, and the difference was statistically significant; two groups were endogenetic. Creatinine clearance rate, glomerular filtration rate, fasting blood glucose, total cholesterol, triglyceride, high density lipoprotein, low density lipoprotein, hemoglobin, and blood calcium were not significantly different, and the difference was not statistically significant.5. symptoms: the ten symptoms of the non DR group with the highest frequency of four diagnosis were: fatigue, dry mouth, dry mouth, sexual desire. The ten symptoms of the highest frequency of the four diagnosis information of the DR group were: tired lassitude, less breath and laziness, loss of libido, dryness and dryness, loosening of the teeth, pain in the waist and knees, sight of flowers, heavy limbs, eye dry, frequent night urine frequency; Compared with the non DR group, the frequency distribution of the symptom frequency distribution in the DR group was significantly higher than that in the non DR group. Compared with the non DR group, the DR group was sweating, dizzy, five heart annoyances, short breath, forgetful and dry mouth, and the frequency of dry mouth symptoms was lower than the non DR group, and the difference was statistically significant in the non DR group: non DR group: non DR group. The frequency distribution of TCM syndromes is in the following order: Yin deficiency, Qi deficiency, Yang deficiency, blood stasis, blood deficiency, damp heat, phlegm, qi stagnation, heat Sheng in DR group, respectively: Qi deficiency, yin deficiency, blood deficiency, Yang deficiency, blood stasis, heat, phlegm, qi stagnation and damp heat. Compared with the non DR group, the DR group is Yin deficiency, and the damp heat syndrome frequently distributes obvious frequency distribution obvious The difference was statistically significant. Two, based on the difference analysis, the general data of the 1. baseline related factors related to the progression of diabetic retinopathy were obtained: 43 cases in the group of 20 men and 23 women, with an average age of 63.28 + 7.48 years, and 15 cases in the progressive group, including 10 men and 5 women, with an average age of 59.97. 10.91 years old: compared with the non progress group, the age of the progressing group was significantly lower than that of the non progress group, and the difference was statistically significant. There was no statistical difference in the sex distribution in the two groups. Compared with the non progressing group, there was no significant difference in the proportion of smoking and drinking in the progress group, and the difference was not statistically significant.2. associated disease and family history: compared with the non progressing group, the progression group was higher than the progress group. The proportion of the history of blood pressure disease was significantly higher than that of the non progression, and the difference was statistically significant. Compared with the non progressing group, there was no significant difference in the proportion of coronary heart disease, cerebral infarction, hyperlipidemia, fatty liver, hyperuricemia, hypoglycemia, and family history, and the difference was not statistically significant.3. clinical measurement index: compared with the non progressing group, the systolic pressure in the progressive group was compared. There was no significant difference in diastolic pressure, and the difference was not statistically significant. The body mass index (BMI) and the waist to hip ratio of the progressive group were significantly higher than those in the non progress group. The difference was statistically significant.4. physicochemical index: compared with the non progressing group, the 24 hour urine protein quantitative, the urine microprotein / creatinine ratio, the blood creatinine, blood urea nitrogen, blood sugar and saccharification, were compared with the non progressing group. Hemoglobin, blood phosphorus was significantly higher than unprogressed, endogenous creatinine clearance rate, glomerular filtration rate lower than unprogressed group, the difference was statistically significant; compared with the unprogressed group, the progressive group uric acid, total cholesterol, triglyceride, low density lipoprotein, high density lipoprotein, red blood cell count, hemoglobin, blood potassium, blood calcium, blood total protein, white egg There was no significant difference between white and white, the difference was not statistically significant.5. symptoms of traditional Chinese medicine: the ten symptoms of the highest frequency of four diagnosis of TCM in the baseline level of the group were: burnout, limb stranded, hypoderma, dryness and dryness, pain in the waist and knees, loosening of teeth, forgetfulness, visual disturbance, pruritus, perspiration, and the baseline of the progression group The top ten symptoms of the four diagnosis information of the Chinese medicine were: fatigue, eye dry, stiff limbs, heavy limbs, dizziness, loosening of teeth, dry mouth, itching, cold limbs, pain in the waist and knees, loss of sexual desire. Compared with the non progressing group, the progressing group had the baseline palpitation, insomnia and the frequent symptoms of claw armour. The distribution was significantly lower than that of no progress, the difference was statistically significant.6. TCM syndrome: the frequency distribution of TCM syndromes in the baseline level of non progressing group were Qi deficiency, yin deficiency, blood deficiency, damp heat, blood stasis, qi stagnation, phlegm, heat and yang deficiency, and the frequency distribution of TCM syndromes in the baseline level of the progressing group were, in turn, Qi deficiency and yin deficiency, respectively. Yang deficiency, blood deficiency, damp heat, blood stasis, phlegm, heat and qi stagnation; compared with the non progress group, the frequency distribution of the Yang deficiency syndrome was significantly higher than that of the non progress. Three, the establishment of the DR prediction model: the 1. factor analysis results showed that the body mass index (OR=2.125, P=0.754), ACR (OR=1.002, P=0.002), Scr (OR=1.018, P=0) .018), glycosylated hemoglobin (OR=2.705, P=0.995) and DR are independent related.2. to establish the DR progression prediction equation: P= exp (-31.913+0.754BMI+0.002ACR+0.018SCR+0.995HBA) /[1+exp (-31.913+0.754BMI+0.002ACR+0.018SCR+0.995HBA)]ROC curve area is combined with the reality of the bed. The diagnostic boundary value was 0.30, at this time the diagnostic sensitivity was 100%, the specificity of 95.3%.3. was 81.8%, the specificity was 81.8%, the specificity was 97.4% and the accuracy was 94%.. The factors associated with the occurrence of 1.DR were smoking, drinking, associated hypertension, cerebral infarction, the history of hypoglycemia, high 24h proteinuria, hyperuria. The ratio of albumin blood creatinine, high blood creatinine, high blood urea nitrogen, high blood uric acid, high glycosylated hemoglobin, low erythrocyte count, hyperkalemia, high blood phosphorus, low blood total protein, low blood albumin, low blood albumin, low urine, yellow red, swelling around the body; DR group sweating, dizziness, heart trouble, shortness of breath, forgetfulness, and dryness of mouth and mouth. The factors associated with low.2.DR progression include: low age, associated hypertension, high body mass index, high waist to hip ratio, high 24 hour urine protein quantitative, high urine microprotein creatinine ratio, high blood creatinine, high blood urea nitrogen, low endogenous creatinine clearance, low glomerular filtration rate, high glycemic hemoglobin, high glycosylated hemoglobin, high blood phosphorus, and yang deficiency.3. (1) Multiple factor Logistic regression results showed that BMI, ACR, creatinine and glycated hemoglobin were independent of the progress of DR. (2) the sensitivity of DR was 100%, the specificity was 81.8%, the specificity was 81.8%, the specificity was 97.4%, and the accuracy of the model was reliable and desirable.
【学位授予单位】：北京中医药大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R259;R276.7

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