Objective To make individualized evidence-based treatment for patients with diabetic nephropathy with albuminuria. Methods Based on the clinical questions we raised, evidence was collected and critically assessed. Patients’ willingness was also taken into consideration in the decision-making treatment Results Seventy studies were retrieved and finally 14 randomized controlled trials, 2 systematic reviews, 2 meta-analyses and 41 clinical guidelines were considered eligible. The evidence indicated that albuminuria was an independent cardiovascular risk factor of diabetic patients; angiotensin receptor antagonists might decrease the level of urinary albumin excretion in patients with type 2 diabetic nephropathy; and such patients might benefit from blood glucose and blood pressure control. The individualized treatment plans were developed based on the available evidence. After 1 month of treatment, the serum creatinine returned to normal and albuminuria became negative. Conclusion The individualized treatment plans based on the high quality evidence were optimal in reducing cardiovascular complications and urinary albumin excretion. However, long-term prognostic benefits need to be confirmed by further follow-up.
【摘要】 目的 老年综合评估法筛查75岁以上2型糖尿病（type 2 diabetes mellitus，T2DM）合并老年综合征的情况，并观察以甘精胰岛素为基础的治疗方法对老年综合征、血糖、低血糖事件、治疗满意度等的影响。 方法 应用老年综合评估中的日常生活能力、工具性日程生活能力、简易智能量表、老年抑郁量表、微型营养评定法，分别评估2005年12月—2009年12月老年门诊及病房住院的日常生活能力、认知功能状态、情绪障碍和营养状态，对其合并功能障碍、痴呆、抑郁、营养障碍、伤害性跌倒等老年综合征的患病情况进行横断面调查；筛选至少合并一种老年综合征和一个其他合并疾病，血糖控制差、预期寿命有限的患者进行以甘精胰岛素为基础的降糖治疗，采用自身前后对照的方法了解对糖化血红蛋白（hemoglobin A1c， HbA1c）、低血糖事件、治疗满意度的影响，并观察甘精胰岛素治疗方案对上述老年综合征的影响。 结果 132例老年门诊及病房住院的75岁以上T2DM患者功能障碍者高达50.0%（66例），罹患包括轻度认知功能障碍在内的痴呆比例为39.4%（52例）；合并抑郁症28.0%（37例）；营养失衡30.0%（39例）。33例患者符合甘精胰岛素治疗纳入标准，经过2年的随访发现，以甘精胰岛素为基础的治疗方案在适当降低HbA1c水平时，不增加老年综合征的患病率，但可以减少胰岛素多次皮下注射的次数，降低低血糖事件发生次数（由1.58次/例降为0.81次/例），提高患者治疗满意度。 结论 75岁以上T2DM患者合并老年综合征的比例高，老年综合评估能及时发现老年综合征；以甘精胰岛素为基础的治疗方案不增加老年综合征的发生，并能显著降低低血糖事件数、改善营养状态、提高患者对治疗的满意度。【Abstract】 Objective To screen geriatric syndrome in patients older than 75 years with type 2 diabetes mellitus (T2DM) by the method of comprehensive geriatric assessment, and observe the impact of glargin-based therapy on geriatric syndrome, blood glucose level, the event of hypoglycemia and treatment satisfaction degree in patients older than 75 years with T2DM who suffered at least one kind of Geriatric syndromes. Methods From December 2005 to December 2009, activity of daily living (ADL), instrument activity of daily living (IADL), mini-mental state examination, geriatric depression scale and mini-nutritional assessment in comprehensive geriatric assessment were used to assess daily living ability, cognitive function status, emotional disorder and nutritional status of out/in-patients older than 75 years with T2DM in the Department of Geriatrics. Cross-sectional study was carried out to investigate geriatric syndromes such as combined functional disorder, dementia, depression, nutritional disorder and impairment falls in those patients, and patients with T2DM combined with at least one kind of geriatric syndrome and another kind of combined disease were screened out. A glargin-based anti-hyperglycemic therapy was carried out for those patients with poor blood glucose control limited remaining life time. The effects of this therapy on hemoglobin A1c (HbA1c), the event of hypoglycemia and treatment satisfaction degree of the patients were studied through a self-comparison method. Then, its effect on the above-mentioned geriatric syndromes was observed. Results Among all the 132 out/in patients older than 75 years with T2DM, the prevalence rates of functional disorder (including ADL and IADL), dementia including mild cognitive disorder, depression, and malnutrition were respectively 50.0% (66), 39.4% (52), 28.0% (37), and 30.0% (39). Only 33 patients met the criteria of glargin-based treatment. After 2 years of follow-up, we found that the glargin-based treatment could properly decrease the level of HbA1c without increasing the prevalence rate of geriatric syndrome. Moreover, it could reduce the frequency of insulin injection and the events of hypoglycemia, and treatment satisfaction degree was also significantly improved. Conclusions Geriatric syndrome has a relatively high prevalence rate in patients older than 75 years with T2DM. Comprehensive geriatric assessment is beneficial in finding out the geriatric syndrome, and glargin-based hypoglycemic therapy can significantly reduce the events of hypoglycemia, improve nutritional status, and increase treatment satisfaction degree without increasing the rate of geriatric syndrome .