社区糖尿病患者慢性肾脏病的发病率及其危险因素

目的：利用中国鄞州电子健康档案研究项目（Chinese Electronic health Records Research in Yinzhou, CHERRY）中构建的队列人群，估算其中糖尿病患者的慢性肾脏病（chronic kidney disease, CKD）发病率及其危险因素的效应大小，为选择筛查CKD发病风险较高的的重点人群及CKD的预防提供依据。 方法：从基于区域卫生信息系统的CHERRY研究中，纳入2009年1月至2016年12月间18岁以上基线无肾疾病的糖尿病患者组成队列，提取该队列人群的基线报卡、随访和医疗机构的体检数据，根据体检数据中提供的估计的肾小球滤过率（estimated glomerular filtration rate, eGFR）＜60 mL/(min×1.73 m2)或尿白蛋白与尿肌酐比值(urine albumin/creatinine ratio, ACR)≥3 mg/mmol定义为CKD结局事件，采用2010年第六次全国人口普查数据计算CKD标准化发病率，并在Cox比例风险模型中分析糖尿病患者CKD危险因素的效应大小。结果：在最终纳入的13 829名糖尿病患者中，中位随访时间为3.2年，随访期间新发CKD共1 087人，粗发病率为23.7/1 000人年（95%CI:22.3～25.2）， 标化发病率为14.8/1 000人年（95%CI:12.1～17.6），＞60岁的糖尿病患者发病率高于≤60岁的糖尿病患者(26.6/1 000人年对11.5/1 000人年，P＜0.05）。Cox比例风险模型显示与CKD关联的危险因素是＞60岁（HR=1.88，95%CI:1.51～2.35）、共患高血压（HR=1.81，95%CI:1.56～2.10）、总胆固醇（HR=1.07，95%CI:1.00～1.14）和糖尿病病程（每年HR=1.02，95%CI:1.00～1.03）, 高密度脂蛋白胆固醇水平为保护因素（HR=0.49，95%CI:0.40～0.61）。性别、吸烟、饮酒状况及空腹血糖随访均值与CKD发生的关联无统计学意义（P＞0.05）。根据性别、年龄是否≤60岁、总胆固醇是否控制达标（＜4.5 mmol/L）、高密度脂蛋白胆固醇是否控制达标（男＞1.0 mmol/L，女＞1.3 mmol/L）及糖尿病病程是否＜5年分组后进行亚组分析，结果显示即使总胆固醇或高密度脂蛋白胆固醇控制达标，共患高血压的糖尿病患者发生CKD的风险仍然较高。结论：宁波市鄞州区糖尿病患者的CKD发病率较高，年龄＞60岁和共患高血压是与CKD的发生关系最密切的危险因素，提示应将年龄＞60岁、共患高血压的糖尿病患者作为CKD的重点筛查人群。

Incidence and risk factors of chronic kidney disease in community-based patients with diabetes

Objective： To estimate the incidence rate and effects of risk factors on chronic kidney di-sease (CKD) in Chinese patients with diabetes, based on Electronic Health Records (EHRs) from the Chinese Electronic health Records Research in Yinzhou (CHERRY) Study. Methods: Using the CHERRY cohort study with the individual-level information on chronic disease management; and health administrative, clinical and laboratory databases, patients with diabetes without kidney disease at baseline were enrolled and followed up from January 2009 through December 2016. CKD was defined as the estimated glomerular filtration rate(eGFR) <60 mL/(min×1.73 m2) or urine albumin/creatinine ratio (ACR)≥3 mg/mmol. Standardized incidence rates of CKD in diabetic population were calculated according to the 2010 China census data. Cox proportional hazards models were used to explore the association of risk factors on CKD in patients with diabetes. Results: Over a median 3.2 years of follow-up, 13 829 patients with diabetes were included in this analysis and 1 087 developed CKD. The crude and standardized incidence rate was 23.7(95%CI: 22.3-25.2) and 14.8(95%CI:12.1-17.6) per 1 000 person years respectively. The incidence rate for developing CKD in patients with diabetes aged over 60 years was higher than those aged 60 and below(26.6 vs. 11.5 per 1 000 person-years, P<0.05).Cox proportional hazards models showed that age over 60 years(HR=1.88, 95%CI:1.51-2.35), hypertension(HR=1.81, 95%CI:1.56-2.10), total cholesterol (HR=1.07, 95% CI:1.00-1.14) and duration of diabetes (HR per year increment=1.02,95%CI:1.00-1.03)and the level of high density lipoprotein cholesterol (HDLC, HR=0.49,95%CI:0.40-0.61) were significantly associated with CKD. No statistical significance was found for sex, smoking status, alcohol use and average level of fasting glucose (All P>0.05).Subgroup analysis indicated that even when the lipid levels were well-controlled, comorbidity of hypertension was still associated with CKD in the patients with diabetes. Conclusion: Incidence rate of chronic kidney disease in this Chinese population with diabetes was high. Age and comorbidity of hypertension were the most important risk factors for CKD, suggesting the priority for CKD screening in patients with diabetes in China. Control of blood pressure and lipid were especially crucial to prevent CKD in patients with diabetes.