Intensive diabetes therapy and glomerular filtration rate in type 1 diabetes.
Intensive diabetes therapy and glomerular filtration rate in type 1 diabetes.
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DOI：
10.1056/nejmoa1111732
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发表时间：
2011-12-22
期刊：
影响因子：
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通讯作者：
Zinman B
中科院分区：
文献类型：
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作者：
DCCT/EDIC Research Group;de Boer IH;Sun W;Cleary PA;Lachin JM;Molitch ME;Steffes MW;Zinman B
肾小球滤过率（GFR）受损会导致终末期肾病，并增加心血管疾病和死亡的风险。1型糖尿病患者患肾脏疾病的风险很高，但没有干预措施已被证明可以预防这一人群的GFR受损。在糖尿病控制和并发症试验（DCCT）中，1441名1型糖尿病患者被随机分配到6.5年的强化糖尿病治疗组，目的是达到接近正常的血糖浓度，或常规糖尿病治疗，目的是预防高血糖症状。随后，1375名参与者参加了观察性糖尿病干预和并发症流行病学（EDIC）研究。在两项研究期间，每年测量一次血清肌酐水平。使用慢性肾脏病流行病学协作组公式估计GFR。我们分析了这两项研究的数据，以确定强化糖尿病治疗对GFR损害风险的长期影响，GFR损害定义为连续两次研究访视时每分钟每1.73 m2体表面积低于60 ml的事件估计GFR。在联合研究中，中位随访期为22年，24名接受强化治疗的受试者和46名接受常规治疗的受试者出现GFR受损（强化治疗风险降低50%; 95%置信区间为18至69; P = 0.006）。在这些参与者中，强化治疗组有8名参与者发生终末期肾病，常规治疗组有16名。与常规治疗相比，在DCCT研究期间，强化治疗与平均估计GFR降低1.7 ml/min/1.73 m2相关，但在EDIC研究期间，强化治疗与GFR降低速率较慢和平均估计GFR增加2.5 ml/min/1.73 m2相关（两种比较均P<0.001）。在调整糖化血红蛋白水平或白蛋白排泄率后，强化治疗对GFR受损风险的有益作用完全减弱。在1型糖尿病病程早期接受强化糖尿病治疗的患者中，GFR受损的长期风险显着低于接受传统糖尿病治疗的患者。（由国家糖尿病、消化和肾脏疾病研究所等资助; DCCT/EDIC ClinicalTrials.gov编号，NCT 00360815和NCT 00360893。
An impaired glomerular filtration rate (GFR) leads to end-stage renal disease and increases the risks of cardiovascular disease and death. Persons with type 1 diabetes are at high risk for kidney disease, but there are no interventions that have been proved to prevent impairment of the GFR in this population. In the Diabetes Control and Complications Trial (DCCT), 1441 persons with type 1 diabetes were randomly assigned to 6.5 years of intensive diabetes therapy aimed at achieving near-normal glucose concentrations or to conventional diabetes therapy aimed at preventing hyperglycemic symptoms. Subsequently, 1375 participants were followed in the observational Epidemiology of Diabetes Interventions and Complications (EDIC) study. Serum creatinine levels were measured annually throughout the course of the two studies. The GFR was estimated with the use of the Chronic Kidney Disease Epidemiology Collaboration formula. We analyzed data from the two studies to determine the long-term effects of intensive diabetes therapy on the risk of impairment of the GFR, which was defined as an incident estimated GFR of less than 60 ml per minute per 1.73 m2 of body-surface area at two consecutive study visits. Over a median follow-up period of 22 years in the combined studies, impairment of the GFR developed in 24 participants assigned to intensive therapy and in 46 assigned to conventional therapy (risk reduction with intensive therapy, 50%; 95% confidence interval, 18 to 69; P = 0.006). Among these participants, end-stage renal disease developed in 8 participants in the intensive-therapy group and in 16 in the conventional-therapy group. As compared with conventional therapy, intensive therapy was associated with a reduction in the mean estimated GFR of 1.7 ml per minute per 1.73 m2 during the DCCT study but during the EDIC study was associated with a slower rate of reduction in the GFR and an increase in the mean estimated GFR of 2.5 ml per minute per 1.73 m2 (P<0.001 for both comparisons). The beneficial effect of intensive therapy on the risk of an impaired GFR was fully attenuated after adjustment for glycated hemoglobin levels or albumin excretion rates. The long-term risk of an impaired GFR was significantly lower among persons treated early in the course of type 1 diabetes with intensive diabetes therapy than among those treated with conventional diabetes therapy. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; DCCT/EDIC ClinicalTrials.gov numbers, NCT00360815 and NCT00360893.)