减肥手术可持久改善糖尿病肾病

圣迭戈——一项单中心研究结果显示，减肥手术对糖尿病肾病的明显改善作用可维持至少5年。

主要研究者、克利夫兰医院减肥与代谢研究所的Helen M. Heneghan博士在美国代谢与减肥手术学会(ASMBS)年会上指出：“除了显著降低体重，减肥手术还能产生重要的代谢效应，包括改善血糖控制和胰岛素敏感性，降低心血管疾病风险和死亡风险。我们猜测减肥手术还可能防治糖尿病并发症，例如糖尿病肾病。”

Helen M. Heneghan博士

研究者对在该医院接受减肥手术的52例患者进行了5年随访。基线时，入组患者的平均年龄为51岁，75%为女性，术前平均体重指数(BMI)为49 kg/m2，84%合并高血压，71%合并高脂血症，平均糖尿病病程为8.6年，29%已开始使用胰岛素，平均糖化血红蛋白A1c水平为7.7%。38%的患者患有糖尿病肾病，诊断标准为微量白蛋白尿(30~299 mg白蛋白/1 g肌酐)或大量白蛋白尿(＞300 mg白蛋白/1 g肌酐)。22%的患者接受了ACEI或ARB处方。

69%的患者接受胃旁路术，25%接受腹腔镜胃束带术，6%接受袖套胃切除术。结果显示，术后5年时，44%的患者仍保持2型糖尿病治愈状态，33%有显著改善，23%的病情无变化或反而加重。研究者称，病情不变或加重的患者减重最少、术前糖尿病病程最长。

高血压治愈、改善和不变/加重的患者比例分别为16%、50%和34%，血脂异常治愈、改善和不变/加重的比例分别为39%、20%和41%。

在术前无糖尿病肾病的患者中，仅有25%术后发生这种并发症。在术前有大量白蛋白尿的患者中，42%在随访5年期间保持稳定，58%恢复至无蛋白尿状态。与此相似，在术前有微量白蛋白尿的患者中，50%保持稳定，50%恢复至无蛋白尿状态。

接受了与未接受保肾药物处方的患者，在术前平均尿白蛋白/肌酐比率(ACR)方面无差异。但未使用保肾药物的患者术后的尿ACR更低(P=0.039)。

Heneghan博士报告称无相关利益冲突。

爱思唯尔  版权所有

By: DOUG BRUNK, Clinical Endocrinology News Digital Network

SAN DIEGO – Bariatric surgery induced a significant and durable improvement in diabetic nephropathy after 5 years of follow-up, results from a single-center study showed.

"In addition to significant weight loss, [bariatric surgery] achieves profound metabolic effects, including improvements in glycemic control and insulin sensitivity, as well as a decrease in cardiovascular disease risk and mortality," lead author Dr. Helen M. Heneghan said at the annual meeting of the American Society for Metabolic and Bariatric Surgery. "We hypothesized that improving diabetic control with bariatric surgery may have positive effects on the end-organ complications of this disease, such as diabetic nephropathy. We also wanted to address one of the prevailing questions in this field: whether or not the effects of bariatric surgery on diabetes and its complications are durable."

Dr. Heneghan, a bariatric surgery fellow at the Cleveland Clinic Bariatric and Metabolic Institute, and her associates identified 52 patients who underwent bariatric surgery at the institute and had completed the 5-year follow-up. At baseline, the mean age of patients was 51 years, and 75% were women. Their preoperative mean body mass index was 49 kg/m2, 84% had hypertension, and 71% had hyperlipidemia. Preoperatively, the mean duration of diabetes was 8.6 years, and 29% were already taking insulin. Their mean hemoglobin A1c level was 7.7%, and 38% had diabetic nephropathy as indicated by microalbuminuria (30-299 mg of albumin per g of creatinine) or macroalbuminura (greater than 300 mg/g), and 22% of patients were prescribed an ACE inhibitor or angiotensin receptor blocker.

The majority of patients (69%) underwent gastric bypass; 25% had laparoscopic gastric banding and 6% had sleeve gastrectomy. Dr. Heneghan reported that 5 years after their surgery, 44% of patients had sustained remission of their type 2 diabetes, 33% had a significant improvement, and 23% had no change or worsening of their disease. This latter cohort "had the least amount of weight loss and were those who had the longest standing duration of diabetes preoperatively."

The rates of patients with remission, improvement, or change in hypertension were 16%, 50%, and 34%, respectively, whereas the rates for patients with dyslipidemia were 39%, 20%, and 41%.

Only 25% of patients who did not have diabetic nephropathy at the time of surgery went on to develop the condition. Among patients with preoperative microalbuminuria, 42% remained stable whereas 58% regressed and had no albuminuria 5 years after surgery. Similarly, among patients with preoperative microalbuminuria, 50% remained stable and 50% regressed and had no albuminuria at 5 years.

There were no preoperative differences in the mean urinary albumin to creatinine ratio (ACR) between patients who were and patients who were not prescribed a renoprotective agent. However, postoperatively, patients who were not on a renoprotective agent had a significantly lower urinary ACR, compared with those who remained on a renoprotective agent (P = .039). "This probably reflects the fact that patients who had improvement of their diabetes and regression or nonprogression of their nephropathy status also had a significant improvement in – or remission of – hypertension, and were no longer prescribed an antihypertensive medication," Dr. Heneghan explained.

She characterized the study’s overall findings as "remarkable, considering that diabetes is a chronic, progressive disease, and certainly warrant further investigation in the form of a prospective and larger study."

Dr. Heneghan said that she had no relevant financial conflicts to disclose.