本文選題：高血壓 + 糖尿病　； 參考：《第三軍醫(yī)大學(xué)》2016年碩士論文

【摘要】：背景和目的:隨著人們的生活方式發(fā)生巨大轉(zhuǎn)變,人類的疾病譜也悄然發(fā)生變化。流行病學(xué)研究發(fā)現(xiàn),腫瘤、糖尿病、心血管疾病、呼吸系統(tǒng)疾病等非傳染性疾病已成為全球死亡率增高的主要病因。糖尿病、高血壓是導(dǎo)致心、腦、腎等一系列靶器官功能衰竭的重要病因;早期發(fā)現(xiàn)靶器官損害及其危險(xiǎn)因素,并進(jìn)行積極的早期干預(yù)能有效預(yù)防和延緩靶器官衰竭。因此,糖尿病和高血壓早期管理就顯得尤其重要。我國(guó)糖尿病、高血壓患病率高,知曉率低,控制率低,兩者常常合并存在,在疾病進(jìn)展過(guò)程中相互影響,導(dǎo)致靶器官損害的加重。如何有效防控疾病的進(jìn)展,避免并發(fā)癥發(fā)生已成為糖尿病、高血壓防治工作中亟待解決的問(wèn)題。糖尿病合并高血壓發(fā)病機(jī)制復(fù)雜,是遺傳與環(huán)境相互作用的結(jié)果,其中不健康的生活方式是其重要原因。既往流行病學(xué)調(diào)查顯示,高鹽攝入與心血管疾病發(fā)病率的增高明確相關(guān),相關(guān)研究報(bào)道高鹽膳食與血壓升高有著密不可分的聯(lián)系,且日均攝鹽量與血壓存在一定劑量效應(yīng)關(guān)系。根據(jù)24小時(shí)鈉鹽排泄量評(píng)估日均攝鹽量是目前世界上公認(rèn)最準(zhǔn)確的方法,因此臨床研究通常選用24小時(shí)尿鈉排泄總量進(jìn)行換算后計(jì)算日均攝鹽量。臨床上尿微量白蛋白、血肌酐與腎小球?yàn)V過(guò)率是評(píng)估腎臟損害的指標(biāo),而24小時(shí)尿微量蛋白定量作為評(píng)估早期糖尿病腎病的有效指標(biāo),同時(shí)也是早期腎損害與影響心血管病預(yù)后的重要標(biāo)志物。既往眾多臨床研究發(fā)現(xiàn)高鹽增加糖尿病腎病及高血壓腎損害風(fēng)險(xiǎn),但針對(duì)高鹽是否引起糖尿病合并高血壓早期腎損害風(fēng)險(xiǎn),研究報(bào)道尚不多。故本研究以24小時(shí)尿鈉排泄作為評(píng)估日均攝鹽量標(biāo)準(zhǔn),并觀察糖尿病患者合并高血壓時(shí)攝鹽量(24小時(shí)尿鈉)與尿蛋白排泄量(早期腎損害)是否具有相關(guān)性,用以評(píng)估糖尿病合并高血壓早期腎損害的潛在危險(xiǎn)因素。研究對(duì)象:入選人群為第三軍醫(yī)大學(xué)大坪醫(yī)院高血壓內(nèi)分泌科住院2014年1月~2016年1月在2型糖尿病合并原發(fā)性高血壓患者345例,其中男性188例,女性157例;2型糖尿病患者159例(男性91例,女性68例);原發(fā)性高血壓患者373例(男性183例,女性190例)。所有患者年齡20~75歲。2型糖尿病的診斷標(biāo)準(zhǔn):依照2013年版《中國(guó)2型糖尿病防治指南》的定義:排除1型糖尿病、特殊類型糖尿病及妊娠糖尿病。原發(fā)性高血壓的診斷標(biāo)準(zhǔn):依據(jù)2010年《中國(guó)高血壓防治指南》的定義:排除繼發(fā)性高血壓。本研究的排除標(biāo)準(zhǔn):腎小球?yàn)V過(guò)率(e GFR)小于60ml/min/1.73m2患者,e GFR計(jì)算公式采用2006年全國(guó)e G FR課題協(xié)作組的改良MDRD方程(e GFR=175×[Scr(μmol/L)/88.4]-1.234×Age-0.179×(0.79女性)。方法:采集入選患者年齡、用藥史、家族史、糖尿病病程、高血壓病程、性別、既往疾病等一般資料;測(cè)量身高、體重、計(jì)算體重指數(shù)[BMI=體重(kg)/身高2(m2)],腰圍、收縮壓(SBP),舒張壓(DBP),收集24小時(shí)尿液。檢測(cè)總膽固醇(Total cholesterol,TC)、血清鈉、低密度脂蛋白膽固醇(Low-density lipoprotein cholesterol,LDL-c)、糖化血紅蛋白(Hb A1c)、甘油三酯(Triglyceride,TG)、空腹血糖、血肌酐、高密度脂蛋白膽固醇(High-density lipoprotein cholesterol,HDL-c)、尿微量白蛋白(Microalbumin)、24小時(shí)尿量、尿鈉、尿鉀、尿肌酐。根據(jù)24小時(shí)尿鈉排泄量換算為攝鹽量的計(jì)算公式為:日均食鹽攝入量(g/d)=(24h尿鈉排泄量(mmol/d)×58.5/103)。根據(jù)攝鹽量的四分位數(shù)將入選人群345例糖尿病合并高血壓患者分為4組,分別為:低攝鹽組(1.92 g/d≤攝鹽量≤7.11g/d)、中攝鹽組(7.12 g/d≤攝鹽量≤10.05g/d)、中高攝鹽組(10.07 g/d≤攝鹽量≤12.93 g/d)與高攝鹽組(12.95 g/d≤攝鹽量≤23.46g/d)。將所有數(shù)據(jù)利用SPSS 17.0軟件分析,四分位分組的組間計(jì)量資料采用單因素方差分析,卡方檢驗(yàn)用以分析組間計(jì)數(shù)資料。兩變量的線性相關(guān)性采用Pearson相關(guān)分析。多元線性回歸分析影響尿微量白蛋白的危險(xiǎn)因素。P0.05為差異具有統(tǒng)計(jì)學(xué)意義。結(jié)果:1.糖尿病合并高血壓患者高攝鹽組、中高攝鹽組、中攝鹽組及低攝鹽組患者的BMI、腰圍、尿酸、尿微量白蛋白、腎小球?yàn)V過(guò)率組間比較有統(tǒng)計(jì)學(xué)意義(P0.05)。高攝鹽組腰圍顯著高于低攝鹽組(P0.05),血尿酸水平顯著高于低攝鹽組和中低攝鹽組(P0.05),24h尿微量白蛋白顯著高于低攝鹽組((P0.05),體重指數(shù)顯著高于低攝鹽組((P0.05)。2.糖尿病合并高血壓患者收縮壓、尿酸、24h尿鈉、腰圍、總膽固醇和低密度脂蛋白膽固醇與24 h尿微量白蛋白呈正相關(guān)。3.糖尿病合并高血壓患者日均攝鹽量、收縮壓、糖化血紅蛋白及尿酸是24h尿微量白蛋白增高的危險(xiǎn)因素。4.原發(fā)性高血壓患者日均攝鹽量與24 h尿微量白蛋白呈正相關(guān)。5.糖尿病合并高血壓患者的日均攝鹽量顯著低于、而24 h尿微量白蛋白顯著高于單純2型糖尿病組與原發(fā)性高血壓組。結(jié)論:1.糖尿病合并高血壓患者高鹽攝入是早期腎臟損害的危險(xiǎn)因素,且日均攝鹽量越高早期腎臟損害越重。2.收縮壓、糖化血紅蛋白及尿酸是糖尿病合并高血壓患者早期腎臟損害的獨(dú)立危險(xiǎn)因素。3.高鹽攝入與原發(fā)性高血壓患者24 h尿微量白蛋白呈劑量相關(guān)性。4.糖尿病合并高血壓患者比2型糖尿病或原發(fā)性高血壓患者更容易出現(xiàn)早期腎臟損害。
[Abstract]:Background and purpose: as people's lifestyle changes dramatically, the spectrum of human disease has also changed. Epidemiological studies have found that noncommunicable diseases, such as cancer, diabetes, cardiovascular disease, respiratory diseases, have become the main cause of global mortality. Diabetes, high blood pressure is a series of targets for heart, brain, kidney and so on. The early detection of target organ damage and its risk factors and active early intervention can effectively prevent and delay target organ failure. Therefore, the early management of diabetes and hypertension is especially important. In the course of the disease, the mutual influence of the disease causes the aggravation of the target organ damage. How to prevent and control the progress of the disease and avoid the complications has become the urgent problem in the prevention and treatment of hypertension. The pathogenesis of diabetes complicated with hypertension is complex, which is the result of the interaction between the heredity and the environment, and the unhealthy life is in it. The previous epidemiological survey showed that high salt intake was clearly associated with the increase in the incidence of cardiovascular diseases. The related studies reported that the high salt diet had an inseparable relationship with the increase of blood pressure, and the daily average salt intake and blood pressure had a certain dose effect relationship. The daily salt intake was assessed according to the 24 hour sodium salt excretion. It is currently recognized as the most accurate method in the world. Therefore, clinical studies usually use the total amount of sodium excretion in 24 hours to calculate daily average daily salt intake. Clinical urine microalbuminuria, serum creatinine and glomerular filtration rate are the indicators for evaluating renal damage, and the 24 hour urine microamount of egg white determination is effective as an effective assessment of early diabetic nephropathy. The index is also an important marker for early renal damage and the prognosis of cardiovascular disease. Many previous clinical studies have found that high salinity increases the risk of diabetic nephropathy and hypertensive renal damage. However, there are not many studies on whether high salt causes the risk of early renal damage in diabetes with hypertension. Therefore, the 24 hour urine sodium excretion is used in this study. To assess the daily salt uptake standard, and to observe the correlation between the amount of salt intake (24 hours urine sodium) and urine protein excretion (early renal damage) in diabetic patients with hypertension, to assess the potential risk factors for early renal damage in diabetes combined with hypertension. Subjects were selected as hypertension in Daping Hospital of Third Military Medical University. The Department of endocrinology was hospitalized in 345 cases of type 2 diabetes with primary hypertension in January ~2016 January 2014, including 188 males and 157 females, 159 cases of type 2 diabetes (91 males and 68 females); 373 cases of primary hypertension (183 males and 190 females). The diagnostic criteria of type.2 diabetes in all patients aged 20~75 years: according to 20 13 year edition of China's guidelines for the prevention and control of type 2 diabetes: excluding type 1 diabetes, special type diabetes and gestational diabetes. Diagnostic criteria for essential hypertension: according to the definition of Chinese hypertension prevention guide in 2010: exclusion of secondary hypertension. The exclusion criteria of this study: glomerular filtration rate (e GFR) less than 60ml/min/1.73m2 patients The e GFR formula uses the modified MDRD equation (E GFR=175 x [Scr (mu mol/L) /88.4]-1.234 x Age-0.179 x (0.79 women) of the 2006 National e G FR project cooperation group. Methods: collect the general data of patients' age, history of medicine, family history, the course of diabetes, the course of diabetes, the course of hypertension, the sex, and the past diseases; measure the height, weight, and calculate the body mass index. MI= weight (kg) / height 2 (M2)], waist circumference, systolic pressure (SBP), diastolic pressure (DBP), collected 24 hours of urine. Test total cholesterol (Total cholesterol, TC), serum sodium, low density lipoprotein cholesterol (Low-density lipoprotein cholesterol, LDL-c), glycosylated hemoglobin, triglyceride, blood creatinine, high density fat High-density lipoprotein cholesterol (HDL-c), urine microalbuminuria (Microalbumin), 24 hour urine, urine sodium, urinary potassium, and urine creatinine. The formula for the conversion of 24 hour urine sodium excretion into salt intake is: daily average salt intake (g/d) = (24h urine sodium excretion (mmol/d) * 58.5/103). According to the four digits of salt intake 345 patients with diabetes combined with hypertension were divided into 4 groups: low salinity group (1.92 g/d or less 7.11g/d), medium salt group (7.12 g/d < < 10.05g/d), high salinity group (10.07 g/d < < 12.93 g/d) and high salinity group (12.95 g /d < /d < < 23.46g/d). All data were divided into SPSS 17 software. Analysis, the inter group measurement data of the four sub group were analyzed by one-way ANOVA, and the chi square test was used to analyze the inter group count data. The linear correlation of the two variables was analyzed by Pearson correlation analysis. The multivariate linear regression analysis of the risk factors for urinary microalbuminuria was of the difference of.P0.05. Results: 1. diabetes combined with hypertension The BMI, waist circumference, uric acid, urine microalbuminuria and glomerular filtration rate were statistically significant (P0.05) in the high intake salt group, middle high salt group and low salt intake group. The waist circumference of the high intake salt group was significantly higher than that of the low salinity group (P0.05). The serum uric acid level was significantly higher than the low salinity group and the low middle salt group (P0.05), and the 24h urine trace white eggs. The white show was higher than the low salinity group (P0.05), the body mass index was significantly higher than the low salinity group (P0.05).2. diabetes combined with hypertension, the uric acid, 24h urine sodium, waist circumference, total cholesterol and low density lipoprotein cholesterol were positively correlated with 24 h urine microalbuminuria,.3. glucurauria and hypertension patients with daily salt intake, systolic pressure, glycosylated blood red Protein and uric acid are the risk factors for the increase of 24h urine microalbuminuria in.4. primary hypertension patients, the daily average salt intake and 24 h urine microalbuminuria are positively correlated with the daily average salt intake in.5. diabetic patients with hypertension, while 24 h urine microalbuminuria is significantly higher than that of the simple type 2 glycan group and the primary hypertension group. High salt intake in patients with hypertension and hypertension is a risk factor for early renal damage, and the higher the daily salt intake is, the higher the early renal damage is.2. systolic pressure, glycated hemoglobin and uric acid are independent risk factors for early renal damage in patients with diabetes and hypertension,.3. high salt intake and 24 h urine trace white eggs in patients with essential hypertension White dose related.4. diabetes and hypertension patients are more prone to early renal damage than type 2 diabetes or essential hypertension.
【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R544.1;R587.2

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