閻燕　尹紅軍　劉紅珍

(新疆兵團(tuán)第七師醫(yī)院預(yù)防保健科，新疆 奎屯 833200)

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·論著·

老年Ⅱ型糖尿病患者并發(fā)骨質(zhì)疏松的危險(xiǎn)因素研究*

閻燕尹紅軍劉紅珍

(新疆兵團(tuán)第七師醫(yī)院預(yù)防保健科，新疆 奎屯 833200)

【摘要】目的探討老年Ⅱ型糖尿病(T2DM)并發(fā)骨質(zhì)疏松癥(OP)的危險(xiǎn)因素，為老年T2DM患者防治骨質(zhì)疏松提供理論參考。方法分析2010年4月～2013年7月來(lái)院接受治療的老年T2DM并發(fā)OP患者77例的臨床資料進(jìn)行分析。根據(jù)骨密度(BMD)值將患者分為骨質(zhì)疏松組(OP組)45例和非骨質(zhì)疏松組(NOP組)32例。另選正常體檢30例作為對(duì)照組，比較三組患者在性別、年齡、BMI、病程、HbAlc、24h mAlb、mAlb、ISI以及BMD等指標(biāo)上的差異。結(jié)果OP組和NOP組在FPG、血磷及血鈣組間比較均無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05)；但在性別、年齡、BMI、病程、HbAlc、24h mAlb、mAlb、ISI及BMD組間比較，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)；OP與NOP組患者的FPG、HbAlc、24h mAlb、mAlb均顯著高于正常組，而ISI、BMD水平則低于正常組。病程、年齡、24h mAlb、mAlb以及HbAlc與BMD呈負(fù)相關(guān)關(guān)系；而ISI、BMI與BMD呈正相關(guān)關(guān)系(P<0.05)；血磷、血鈣、FPG與BMD的相關(guān)性不顯著(P>0.05)。結(jié)論老年T2DM患者發(fā)生OP與多種因素相關(guān)，女性、高齡、病程較長(zhǎng)、BMI低、血糖控制不佳、腎功能受損等均是發(fā)生OP的易患因素。

【關(guān)鍵詞】Ⅱ型糖尿病(T2DM)；骨質(zhì)疏松癥(OP)；老年；危險(xiǎn)因素

Ⅱ型糖尿病(T2DM)患者和老年人群均容易患骨質(zhì)疏松癥(OP)，易導(dǎo)致骨折，出現(xiàn)較高的致殘率，患者的生活自理能力喪失或降低，嚴(yán)重時(shí)會(huì)危及生命，使患者經(jīng)濟(jì)負(fù)擔(dān)加重。糖尿病患者的糖代謝表現(xiàn)異常，能通過(guò)各種途徑對(duì)骨代謝形成影響，進(jìn)而引發(fā)OP，且T2DM的骨量降低[1]。老年T2DM合并OP患者早期可無(wú)臨床癥狀，因此往往容易被忽略，直至中后期才會(huì)有骨折、畸形、骨骼疼痛等癥狀出現(xiàn)，一旦發(fā)生骨質(zhì)疏松，無(wú)法逆轉(zhuǎn)，故早期預(yù)防尤為關(guān)鍵[2]。本文旨在通過(guò)老年T2DM并發(fā)OP患者的發(fā)生率，以及OP與性別、年齡、體質(zhì)量(BMI)等相關(guān)性因素的分析，為早期臨床診治提供參考。

1資料與方法

1.1研究對(duì)象分析2010年4月～2013年7月接受治療的老年T2DM 77例患者的臨床資料。入選患者年齡均>60歲，參照世界衛(wèi)生組織(WHO)1999年制定的關(guān)于糖尿病診斷的相關(guān)標(biāo)準(zhǔn)[3]。入組患者不包括在最近3個(gè)月內(nèi)曾服用激素類(lèi)藥物和鈣劑、維生素D、二磷酸鹽等對(duì)骨代謝有影響的藥物等的患者。年齡平均73.1歲；女性35例，男性42例；病程平均12.5年。排除繼發(fā)性O(shè)P(如肝臟腎臟疾病、結(jié)締組織病、血液病等)、其它急性并發(fā)癥及糖尿病酮癥。

1.2研究方法骨密度(BMD)的測(cè)定：股骨頸和腰椎BMD的測(cè)量采用雙能X線BMD儀，參照WHO于2003年制定的關(guān)于骨質(zhì)疏松的相關(guān)診斷標(biāo)準(zhǔn)[4]，將患者分為OP組(骨質(zhì)疏松組，骨密度(BMD)：T-Score≤-2.5SD者)45例和NOP組(非骨質(zhì)疏松組)32例，并選取正常體檢者30例作為正常對(duì)照組。

測(cè)定生化指標(biāo)：采用TBA120FR型全自動(dòng)生化分析儀對(duì)血磷、血鈣、糖化血紅蛋白(HbAlc)和空腹血糖(FPG)進(jìn)行測(cè)定；采用放射免疫法對(duì)空腹胰島素(FINS)和C-肽進(jìn)行測(cè)定，依據(jù)胰島素敏感性指數(shù)(ISI)=1/[FPG(mmol/l)×FPI(空腹血漿胰島素)(IU/L)]；24小時(shí)尿蛋白定量(24h mAlb)用磺胺水楊酸法測(cè)定；將晨尿留取，使用放射免疫法對(duì)尿白蛋白定量(mAlb)進(jìn)行測(cè)定。

2結(jié)果

2.1三組患者各項(xiàng)指標(biāo)比較結(jié)果提示，OP組和NOP組患者在FPG、血磷及血鈣方面的組間比較均無(wú)統(tǒng)計(jì)學(xué)差異(P>0.05)；但在性別、年齡、BMI、病程、HbAlc、24h mAlb、mAlb、ISI以及BMD方面兩組的組間比較，差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)；OP與NOP患者的FPG、HbAlc、24h mAlb、mAlb均顯著高于對(duì)照組，而ISI、BMD水平則低于對(duì)照組，見(jiàn)表1。

表1　三組患者各項(xiàng)指標(biāo)的比較

注：與NOP組比較①P<0.05,與對(duì)照組比較②P<0.05

2.2OP的相關(guān)因素分析結(jié)果提示病程、年齡、24h mAlb、mAlb以及HbAlc與BMD呈負(fù)相關(guān)關(guān)系；ISI、BMI與BMD呈正相關(guān)關(guān)系(P<0.05)；血磷、血鈣、FPG與BMD的相關(guān)性不顯著(P>0.05)，見(jiàn)表2。

3討論

老年人發(fā)生骨質(zhì)疏松的幾率約為55%[5]。本文提示老年T2DM并發(fā)OP患者的發(fā)生率可達(dá)58.44%，也證實(shí)了糖尿病會(huì)使骨質(zhì)疏松發(fā)生率顯著增加[6]。本實(shí)驗(yàn)針對(duì)老年T2DM并發(fā)OP的相關(guān)因素的分析結(jié)果發(fā)現(xiàn)，病程、年齡、24h mAlb、mAlb以及HbAlc與BMD呈負(fù)相關(guān)關(guān)系；ISI、BMI與BMD呈正相關(guān)關(guān)系；血磷、血鈣、FPG與BMD的相關(guān)性不顯著。糖尿病致使BMD降低的機(jī)制較為復(fù)雜，通常是多種因素的共同作用結(jié)果：高血糖會(huì)引發(fā)滲透性利尿，增加鈣、磷的排出量，而高尿糖阻斷了腎小管重吸收鈣、磷的可能性，使鈣、磷的丟失量增加；低血鈣對(duì)甲狀旁腺激素進(jìn)行刺激，使其分泌量增加，加快了骨質(zhì)的吸收，進(jìn)一步使BMD降低[7]；患者長(zhǎng)時(shí)間的高血糖會(huì)讓糖尿病者機(jī)體內(nèi)形成大量的糖基化的終末產(chǎn)物，進(jìn)而使破骨細(xì)胞對(duì)骨吸收的誘導(dǎo)作用增強(qiáng)[8]；并發(fā)糖尿病腎病的同時(shí)，腎小管減少了對(duì)鈣的重吸收量，繼發(fā)性甲狀旁腺功能亢進(jìn)和腎1-a羥化酶活性降低，生產(chǎn)1,25(OH)2D3量降低，腸道吸收鈣的量也相對(duì)降低，同時(shí)血磷上升，從腸道排泄的磷會(huì)結(jié)合鈣，對(duì)鈣吸收形成影響，使血鈣對(duì)甲狀旁腺素(PTH)分泌的刺激降低，進(jìn)而使破骨細(xì)胞相應(yīng)的骨吸收能力得到了促進(jìn)[9]。

表2　患者OP的相關(guān)因素分析

老年人發(fā)生OP概率的上升，與胃腸吸收功能尤其是性激素分泌降低、運(yùn)動(dòng)減少、維生素D吸收合成少、鈣吸收量的減少以及骨代謝轉(zhuǎn)換率的降低等相關(guān)。有資料顯示，男性的雄激素水平降低，BMD也降低[10]。女性老年糖尿病患者發(fā)生OP的幾率明顯比老年男性糖尿病患者高[11]。女性骨架相對(duì)瘦小，絕經(jīng)后其雌激素缺乏顯著，此外高血糖會(huì)導(dǎo)致卵巢損傷，致使雌激素進(jìn)一步降低，致使骨吸收量上升，阻礙了骨形成，更易產(chǎn)生OP[12]。糖尿病較長(zhǎng)病程的患者，考慮可能是由于長(zhǎng)時(shí)間的高血糖，且慢性并發(fā)癥增加，同時(shí)糖尿病周?chē)纳窠?jīng)發(fā)生病變，尤其是感覺(jué)減退、麻木、下肢疼痛的患者，其運(yùn)動(dòng)量減少，其由運(yùn)動(dòng)激發(fā)的骨轉(zhuǎn)換的作用相對(duì)降低；同時(shí)存在糖尿病的微血管病變癥狀，進(jìn)而引發(fā)骨骼營(yíng)養(yǎng)不良[13]。

對(duì)BMD，BMI的主要影響是生物力學(xué)機(jī)制和激素，BMI高增加了骨組織對(duì)機(jī)械負(fù)荷的承受量，使骨吸收降低，對(duì)骨形成進(jìn)行刺激，體胖者在絕經(jīng)后，其雌激素水平相對(duì)較高，而消瘦者自身營(yíng)養(yǎng)不良，糖尿病患者并發(fā)神經(jīng)血管病變的時(shí)候，骨的營(yíng)養(yǎng)障礙加重了，影響了骨骼自身的新陳代謝[14]。相關(guān)研究資料結(jié)果顯示胰島素能加快骨形成、骨基質(zhì)的形成以及骨蛋白的合成、使鈣磷代謝維持正常[15]。老年T2DM患者可能由于存在白內(nèi)障和糖尿病的視網(wǎng)膜病變等影響視力的疾??；可能并有糖尿病足而有感覺(jué)減退、疼痛、麻木以及下肢周?chē)纳窠?jīng)病變等的情況而對(duì)患者的行走造成影響，容易摔倒，且有OP的患者非常容易出現(xiàn)骨折，其可致使畸形、活動(dòng)障礙、疼痛加重乃至臥床不起，對(duì)患者的生活質(zhì)量構(gòu)成嚴(yán)重影響。

4結(jié)論

老年T2DM患者需注重胰島素敏感性的提高和協(xié)調(diào)飲食結(jié)構(gòu)，盡可能維持理想的BMI和維生素D、鈣、磷的平衡。預(yù)防糖尿病并發(fā)癥的發(fā)生，適當(dāng)合理進(jìn)行鍛煉，對(duì)延緩和預(yù)防OP有重要的臨床意義。

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Discussion of risk factors of the occurrence of OP in T2DM gerontism patients

YAN Yan,YIN Hongjun,LIU Hongzhen

(DepartmentofPreventionandHealthCare,TheSeventhDivisionHospitalofXinjiangCorps,Kuitun833200,Xinjiang,China)

【Abstract】ObjectiveOur retrospective study was aimed to analyze the risk factors of T2DM gerontism patients combined with OP, which giving the theoretical direction for the prevention and cure of T2DM gerontism patients combined with OP. Methods Clinical data of T2DM gerontism patients combined with OP received treatment at our hospital from 2010 to 2013 were retrospectively analyzed. Patients included were divided into two groups according to the BMD values, OP group and non-OP group. The gender, age, BMI, course of disease, HbAlc, 24h mAlb, mAlb, ISI, BMD and other indexes between two groups were compared. Results 77 patients were retrospective analyzed, including 45 cases in OP group and 32 cases in non-OP group. The FPG, serum phosphorus and calcium of patients in two groups had no statistical difference (P>0.05). But the gender, age, BMI, course of disease, HbAlc, 24h mAlb, mAlb, ISI, BMD of patients in two groups had statistical differences (P<0.05). The levels of FPG, HbAlc, 24h mAlb, mAlb in OP and NOP group were significantly higher than those in normal group. The levels ISI and BMD in OP and NOP group were significantly lower than those in normal group. The course of disease, age, 24h mAlb, mAlb,HbAlc had negative correlation with BMD, and ISI, BMI had positive correlation with BMD (P<0.05). The correlation between FPG, serum phosphorus, calcium and BMD was not obvious (P>0.05). Conclusion The occurrence of OP in T2DM gerontism patients is correlated to many factors, such as female, old age, longer duration, low BMI, poor control of blood glucose, impaired renal function and so on are all the risk factors of OP.

【Key words】Type 2 diabetes mellitus; Osteoporosis; Gerontism; Risk factors

(收稿日期：2015-09-01； 編輯： 陳舟貴)

【中圖分類(lèi)號(hào)】R 587.1

【文獻(xiàn)標(biāo)志碼】A

doi：10.3969/j.issn.1672-3511.2016.04.009

基金項(xiàng)目：國(guó)家科技成果(20130177)