Diabetes Care：青少年T2DM患者高血压和肾病患病率急剧上升

在青少年2型糖尿病患者中，关于高血压和微量白蛋白尿的发生和进展的研究资料十分有限。针对这种情况，来自美国华盛顿大学的Laura Pyle博士等人进行了一项研究，即TODAY临床研究。研究小组人员对TODAY临床试验的患者的高血压和微量白蛋白尿进行评估，并分析治疗方式、血糖控制、性别和民族/种族对二者的影响。研究发现，青少年2型糖尿病患者高血压和微量白蛋白尿患病率随时间推移逐渐增高。性别、高BMI和血糖控制是高血压和微量白蛋白尿发生的危险因素。研究结果在线发表于2013年6月的美国《糖尿病治疗》(Diabetes Care)杂志上。

这是一项队列研究，研究对象为699名青少年，年龄10-17岁，2型糖尿病病程<2年、BMI≥85%、二甲双胍治疗后HbA1c≤8%、血压(BP)可控、计算的肌酐清除率>70 mL/min。患者随机分配接受二甲双胍，二甲双胍联合罗格列酮或二甲双胍联合强化生活方式干预治疗。主要研究结果为6个月后血糖控制失败或代谢失调，需要注射胰岛素。采用标准疗法积极治疗高血压和微量白蛋白尿，以维持BP<130/80 或年龄、性别和高度小于第95百分位，以及微量白蛋白尿<30mg/mg。

结果显示，319名患者(45.6%)达到主要研究结果，基线高血压患病率为11.6%，研究结束时为33.8%(平均随访时间3.9年)。男性和高BMI显著增加高血压风险。基线微量白蛋白尿患病率为6.3%，研究结束时升高到16.6%。不同组别、性别和民族/种族间，诊断的微量白蛋白尿没有显著区别，但是高水平HbA1c与发生微量白蛋白尿的风险显著相关。

研究表明，尽管对糖尿病采取了治疗，但是随着时间推移，青少年2型糖尿病患者高血压和微量白蛋白尿患病率仍增高。高血压的最大危险因素是性别(男性发病率高)和高BMI。微量白蛋白尿的危险因素则与血糖控制更为密切相关。

Rapid Rise in Hypertension and Nephropathy in Youth With Type 2 Diabetes: The TODAY clinical trial.
OBJECTIVE
Among adolescents with type 2 diabetes, there is limited information regarding incidence and progression of hypertension and microalbuminuria. Hypertension and microalbuminuria assessments made during the TODAY clinical trial were analyzed for effect of treatment, glycemic control, sex, and race/ethnicity.
RESEARCH DESIGN AND METHODS
A cohort of 699 adolescents, 10-17 years of age, <2 years duration of type 2 diabetes, BMI ≥85%, HbA1c ≤8% on metformin therapy, controlled blood pressure (BP), and calculated creatinine clearance >70 mL/min, were randomized to metformin, metformin plus rosiglitazone, or metformin plus intensive lifestyle intervention. Primary study outcome was loss of glycemic control for 6 months or sustained metabolic decompensation requiring insulin. Hypertension and microalbuminuria were managed aggressively with standardized therapy to maintain BP <130/80 or <95th percentile for age, sex, and height and microalbuminuria <30 μg/mg.
RESULTS
In this cohort, 319 (45.6%) reached primary study outcome, and 11.6% were hypertensive at baseline and 33.8% by end of study (average follow-up 3.9 years). Male sex and higher BMI significantly increased the risk for hypertension. Microalbuminuria was found in 6.3% at baseline and rose to 16.6% by end of study. Diagnosis of microalbuminuria was not significantly different between treatment arms, sex, or race/ethnicity, but higher levels of HbA1c were significantly related to risk of developing microalbuminuria.
CONCLUSIONS
Prevalence of hypertension and microalbuminuria increased over time among adolescents with type 2 diabetes regardless of diabetes treatment. The greatest risk for hypertension was male sex and higher BMI. The risk for microalbuminuria was more closely related to glycemic control.