第一临床医学院知识库

目的:本研究了解老年2型糖尿病（T2DM）患者在不同骨密度严重程度时，血糖、胰岛素、血脂、甲状腺功能、血尿酸、同型半胱氨酸、骨转换标志物等检验结果的变化，探讨老年T2DM患者发生骨代谢异常的危险因素及相关性关系。
方法:收集兰州大学第一医院2016年6月-2017年12月住院的老年（年龄≥60岁）T2DM患者524例，通过排除标准后入组老年（年龄≥60岁）T2DM患者362例，根据骨密度所得T值水平，分为老年T2DM合并骨量正常（94例）、骨量减少（132例）、骨质疏松（OP）（136例）三组。采用酶联免疫、双能X线（EXA-3000）检测等方法，比较三组患者的性别、年龄、民族、职业、体重指数（BMI）、病程、吸烟史、饮酒史、高血压史、糖尿病病史、常见并发症患病情况、空腹血糖（FPG）、餐后2小时血糖（2hPBG）、空腹胰岛素（FINS）、餐后2h胰岛素（2hINS）、糖化血红蛋白（HbAlc）、血尿酸（UA）、血清钙、血清磷、血清碱性磷酸酶（ALP）、总胆固醇（TC）、甘油三酯（TG）、低密度脂蛋白胆固醇（LDL-C）、高密度脂蛋白胆固醇（HDL-C）、同型半胱氨酸（HCY）、尿蛋白排泄率（uAER）、尿微量白蛋白（尿Alb）、甲状腺功能、叶酸、维生素B12、氨基端中和段骨钙素（N-MIDBGP）、骨特异性碱性磷酸酶（BAP）、25-羟维生素D3（25-OH-D3）。应用SPSS 21.0软件进行统计，分析老年T2DM患者影响骨代谢的危险因素及其相关性。
结果:（1）研究对象共362例，其中骨量正常组94例，骨量减少组132例，OP组136例。其中，骨量正常组年龄60～76岁，平均（67.27±6.09）岁；骨量减少组年龄60～80岁，平均（68.61±6.20）岁；OP组年龄60～84岁，平均（70.69±6.90）岁；
（2）老年T2DM合并骨量减少、OP组的患者，女性患病率（分别为54.55％、75.00％）明显高于男性（分别为45.45％、25.00％），且具有统计学差异（P＜0.05）；随着年龄增长患病率明显升高，且具有统计学意义（P＜0.05）；与糖尿病病程无关，数据无统计学差异（P＞0.05）；（3）老年T2DM合并OP的患者随着BMI升高患病率低于骨量正常、骨量减少组的患者，且具有统计学意义（P＜0.001）；
（4）老年T2DM合并骨量正常、骨量减少、OP的患者，在民族、职业中均无统计学差异（P＞0.05）；与胰岛素使用史、高血压史无明显统计学差异（P＞0.05）；在吸烟史、吸烟指数、饮酒史上均具有统计学差异（P＜0.05）；（5）老年T2DM合并OP的患者在视网膜病变、肾病、周围神经病变上有统计学差异（P＜0.05）；（6）老年T2DM合并骨量减少、OP组患者的UA水平明显低于老年T2DM合并骨量正常组，而ALP、HDL-C水平明显高于老年T2DM合并骨量正常组，且OP组与骨量正常组组间均具有统计学差异（P＜0.05）；老年T2DM合并OP组患者中HCY水平较骨量正常组明显升高，骨转化标志物中N-MIDBGP、BAP、25-OH-D3虽无明显统计学意义，但N-MIDBGP、BAP、25-OH-D3水平较骨量正常组有所下降；（7）采用相关性分析，结果显示，老年T2DM合并OP组患者的BMD的T值与年龄、吸烟指数、ALP、HDL-C、T4呈负相关，与BMI、UA呈正相关，差异均具有统计学意义（P＜0.05）；（8）采用有序多分类Logistic回归分析，校正混杂因素后，结果显示，年龄、吸烟指数、ALP、HCY为危险因素，BMI、UA则为保护因素。
结论:老年T2DM患者OP发病率较高，呈增龄性改变，女性尤为突出；BMI越低会增加OP的患病风险；老年T2DM合并OP患者糖尿病并发症发病率的升高，引起骨质流失的几率明显升高；吸烟、饮酒等不良生活方式是老年T2DM合并OP的危险因素之一；且年龄、BMI、UA、ALP、HCY、HDL-C、T4为老年T2DM影响骨代谢的因素；骨转换标志物中N-MIDBGP、BAP、25-OH-D3与骨代谢无明显统计学差异。探讨T值的危险因素，对提早发现骨折的风险，并及时进行危险因素预防和综合治疗具有重要的临床意义。

Objective:This study was to investigate the changes of blood glucose, insulin, blood lipids, thyroid function, blood uric acid, homocysteine, bone turnover markers, and other test results in elderly patients with type 2 diabetes mellitus (T2DM) at different bone mineral density. To explore the related risk factors and related relationship of bone metabolic abnormalities in elderly patients with T2DM.
Methods:Collected a total of 524 elderly patients (age≥60 years) with T2DM from the First Hospital of Lanzhou University from June 2016 to December 2017. After exclusion of the criteria, 362 elderly patients (age≥60 years) with T2DM were enrolled. According to the T value of bone mineral density，elderly T2DM patients were divided into three groups, such as normal (94 cases), osteopenia (132 cases) and osteoporosis (136 cases). Using enzyme-linked immunosorbent assay (ELISA) and dual-energy X-ray (EXA-3000) detection methods, the gender, age, ethnicity, occupation, body mass index (BMI), duration of illness, smoking history, drinking history, hypertension history, diabetes history, common complications, fasting blood glucose (FPG), 2 hours postprandial blood glucose (2hPBG), fasting insulin (FINS), 2h postprandial insulin (2hINS), glycated hemoglobin (HbAlc), blood uric acid (UA), serum calcium, serum phosphorus, serum alkaline phosphatase (ALP), total cholesterol (TC), triglyceride Ester (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), homocysteine (HCY), urinary protein excretion rate (uAER), urine microalbumin (urine Alb), thyroid function, folic acid, vitamin B12, amino-terminal neutral segment osteocalcin (N-MIDBGP), bone-specific alkaline phosphatase (BAP), 25-hydroxyvitamin D3 (25-OH-D3). SPSS21.0 software was used for statistical analysis to analyze the risk factors and related factors of bone metabolism in elderly patients with T2DM.
Result:(1) A total of 362 subjects were studied, including 94 patients with normal, 132 patients with osteopenia, and 136 patients with OP. Among them, normal was 60-76 years old, with an average of (67.27±6.09) years old; osteopenia was 60-80 years old, with an average (68.61±6.20) years old; OP was 60-84 years old ; with an average of (70.69± 6.90) years old;(2) In elderly T2DM patients with osteopenia and OP, the incidence of females (54.55% and 75.00%) was significantly higher (P<0.05) than that of males (45.45% and 25.00%); The incidence of age increase was significantly increased and statistically significant (P<0.05). No correlation was found between the duration of diabetes and the duration of diabetes (P>0.05);(3) The prevalence of BMI in elderly T2DM patients with OP was statistically lower than that in patients with normal and osteopenia (P<0.001);(4) Elderly T2DM patients with normal, osteopenia, and OP had no significant difference in national and occupational status (P>0.05); there were no significant difference between insulin therapy history and hypertension history (P>0.05); there were statistical differences in drinking history, smoking history and smoking index (P<0.05);(5) The elderly T2DM patients with OP had statistical significance in retinopathy, nephropathy, and peripheral neuropathy (P<0.05);(6) The UA levels in elderly T2DM patients with osteopenia and OP were significantly lower than those in elderly T2DM patients with normal，but the levels of ALP and HDL-C were significantly higher than those in elderly T2DM with normal，and there was a statistical difference between the OP group and the normal (P<0.05). The HCY levels in elderly T2DM patients with OP were significantly higher than those in normal. There were no significant difference in N-MIDBGP, BAP and 25-OH-D3 in bone turnover markers, but N-MIDBGP, BAP and 25-OH-D3 levels decreased compared with the normal;(7) Using correlation analysis, the results showed that the T value of BMD in elderly T2DM patients with OP were negatively correlated with age, smoking index, ALP, HDL-C and T4, and positively correlated with BMI and UA. The differences were statistically significant (P< 0.05);(8) Using sequential multi-classified Logistic regression analysis, after adjusting for confounding factors, the results showed that age, smoking index, ALP and HCY were risk factors, and BMI, UA were protective factors.
Conclusions:The incidence of OP in elderly patients with T2DM is relatively high, showing ageing changes, especially in women. The lower the BMI, the higher the risk of OP; the higher the incidence of diabetic complications in older T2DM patients with OP, leading to bone loss. The odds were significantly higher; smoking, drinking and other unhealthy lifestyles were among the risk factors for elderly T2DM with OP; and age, BMI, UA, ALP, HCY, TC, HDL-C, T4 were the factors affecting bone metabolism in elderly T2DM; bone turnover markers were N-MIDBGP, BAP, 25-OH-D3 and bone metabolism had no significant difference. To explore the risk factors of T value has important clinical significance for early detection of fracture risk and timely prevention and comprehensive treatment of risk factors.