精“英”克糖|2型糖尿病患者TIR与全因死亡和心血管死亡的关系

2022-10-16 10:13:14

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葡萄糖目标范围内时间（TIR）指24 h内葡萄糖在目标范围内的时间或其所占的百分比。2019年国际糖尿病先进技术和治疗联盟（ATTD）发布《TIR国际共识》，首次将TIR作为评价血糖控制的指标之一，标志着血糖精细化管理时代的开启。2020年美国糖尿病协会（ADA）《糖尿病医学诊疗标准》正式推荐应用TIR评估血糖管理。不久前，上海交通大学附属第六人民医院的周健教授牵头一项前瞻性队列研究，探讨了2型糖尿病患者TIR与全因死亡和心血管死亡的关系。该研究结果近期发表在Diabetes Care杂志（IF = 19.112）。美国阿宾顿-杰弗森健康中心的Neil Skolnik博士和John J. Russell博士对相关文献进行了播讲。

文章作者：

周健教授，

上海交通大学附属第六人民医院

中英文字幕

Taylor swift

第一篇文章来自Diabetes Care，是一项前瞻性队列研究，探讨了2型糖尿病患者葡萄糖目标范围内时间（TIR）与全因死亡和心血管死亡的关系。

So first article is from Diabetes Care, and it looked at time in range (TIR) in relation to all-cause mortality and cardiovascular mortality in patients with type 2 diabetes, a prospective cohort study.

研究纳入2005年1月至2015年12月来自中国上海单中心的成年2型糖尿病患者，共6225例。基线时，通过持续葡萄糖监测结果计算TIR，并根据TIR值将受试者分成四组：>85%组、71～85%组、51～70%组和≤50%组。使用Cox比例风险回归模型来估计不同TIR水平与全因和心血管疾病死亡风险间的关系。

So in this study, a total of 6,225 adult patients with type 2 diabetes were included from January 2005 to December 2015 from a single center in Shanghai, China. TIR was measured with continuous glucose monitoring at baseline, and the participants were stratified into four groups by TIR: >85%, 71～85%, 51～70%, and ≤50%. Cox proportional Hazards regression models were used to estimate the association between different levels of TIR and the risks of all-cause and cardiovascular disease mortality.

受试者基线时的平均年龄为61.7岁。在中位随访6.9年期间，共838例患者死亡，其中287例死于心血管疾病。多变量调整后的死亡HR与不同TIR水平相关：＞85%组（参照组）、71%～85%组、51%～70%组和≤50%组的全因死亡风险的HR分别为1.00、1.23、1.30和1.83，而四组的心血管死亡风险的HR分别为1.00、1.35、1.47和1.85。

The mean age of the participants was 61.7 years at baseline. During a median follow-up of 6.9 years. There were 838 deaths identified. 287 were due to cardiovascular disease. The multivariable-adjusted hazard ratios associated with different levels of TIR, so for >85% was 1.00; 71～85%, 1.23; 51～70%, 1.30; and≤50%, 1.83, for all-cause mortality. And for the same subgroups,1.00, 1.35 , 1.47, and 1.85 for cardiovascular mortality.

John，我认为这是一篇非常有趣且非常重要的文章。但它仍存在局限性，我一会儿会讲到。但首先介绍一下关于持续葡萄糖监测和TIR的背景知识。TIR已成为一个非常重要的血糖控制指标。随着扫描式葡萄糖监测的出现，初级保健医生可对2型糖尿病患者开出持续葡萄糖监测的处方。非常重要的是，监测时间只需几周，且患者无需长期佩戴该设备。

John, this is a very interesting article, and one that I would have thought would be a critically important one, except for what I think is a little bit of a fatal flaw that I'll get to in a minute or two. But first in background on continuous glucose monitoring and time in range. And time in range become an incredibly important thing. And for those of us in primary care with the advent of flash glucose monitoring where we can prescribe it for patients with type 2 diabetes. For just a couple of weeks now and then without them having to have a device all the time. It's become a very relevant issue for all of us.

TIR提供了糖化血红蛋白（HbA_1c）的补充信息。例如，一名患者总体血糖波动在100～200 mg/dl，其TIR为70%，HbA_1c为7.5%。我们将他与另一名HbA_1c为7.5%但血糖波动在50～250 mg/dl的患者进行比较。两位患者的平均葡萄糖水平相同，即有相同的HbA_1c。但很明显的是，血糖最低降至50 mg/dl的患者并不在安全范围内。所以，关注TIR，特别是关注低血糖及高血糖的发生，能让我们获得更多血糖信息从而更好地管理患者。

Remember that? It gives us complementary information to the A1c. For example, take a person who has a range from 100～200 in general and there in range 70% of the time, and with A1c of 7.5. And we compare that to another person who has A1c of 7.5, but there in ranges from 50～250. Their mean glucose is the same. They have the same A1c. But clearly, the person who's dipping down into the 50 is not in a safe area. So the ability to look at time in range, and specifically how often people are hypoglycemic, as well as significantly hyperglycemic. Let us get more knowledgeable and better control of our patients.

此外，既往研究已将TIR作为一个独立于HbA_1c的参数，与糖尿病视网膜病变、糖尿病肾病等结局指标相关联。我们期待看到的就是像这篇文章一样将TIR与死亡结局相关联的研究。乍一看，这篇文章研究的就是这方面，但我认为相关内容应在摘要部分就有所体现，而实际上研究者将其隐藏在方法部分。研究人员随访了一组糖尿病患者，所有患者均在住院期间评估了TIR水平。

In addition, there's early data that relates time in range as a separate parameter, separate from A1c to hard outcomes like retinopathy, nephropathy. So what we would love to see is results in an article like this showing its relation to mortality. At first blush, that's what this looks to do, but, and I really think it should have been in the abstract, but it was in essence hidden in the methods section. That they looked at a group of patients with diabetes all of whom were in the hospital when they assessed their blood glucose time in range.

我认为这篇文章传递了有趣而重要的信息，但也不能完全依赖该结果。因为住院患者和我们希望看到的病情更稳定的门诊患者会有所差异，其中可能会存在TIR的混杂因素。所以这篇有趣的文章提出了非常重要的观点，但我认为仍需要大型门诊随访患者的队列研究进行进一步证实。

And I'll tell you, I don't think, therefore, I think it's interesting information, it's important information, but it isn't an information we can hang our hat on. Because the different things that might be confounding time in range for a group of people who are inpatients is different than what we would expect when that same group of people may be stable and be treated as outpatients. So interesting article raises some really important points. But I think we still need to wait for the solid of data done on a large cohort of patients who were followed as outpatients.

相关单词学习

Word Study

Cox proportional Hazards regression models Cox

比例风险回归模型

multivariable-adjusted hazard ratios

多变量调整后的风险比

retinopathy /,retɪ'nɒpəθɪ/

视网膜病变

nephropathy /nɪˈfrɑːpəθi/

肾病，糖尿病肾病

Resource:

Lu et al. Diabetes Care 2021; 44(2): 549-555. DOI:10.2337/dc20-1862

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（来源：《国际糖尿病》编辑部）

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精“英”克糖|2型糖尿病患者TIR与全因死亡和心血管死亡的关系

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