【作者】 张娜；

【导师】 袁鹰；

【作者基本信息】 青岛大学 ， 内科学（内分泌与代谢病）（专业学位）， 2021， 硕士

【摘要】 目的:探讨老年女性2型糖尿病（T2DM）患者骨密度减低/骨质酥松与肌量减少的患病情况及其内在联系。方法:采用横断面研究,选取2019年1月至2019年12月于青岛大学附属医院内分泌科住院的病人,研究共纳入老年女性2型糖尿病患者158例,根据双能X线骨密度仪（DXA）测定的T值,采用WHO骨质疏松诊断标准,将研究人群分为三组:骨密度正常组、骨密度减低组和骨质疏松组,比较不同骨密度分组之间各相关指标和肌量减少检出率的统计学差异。根据2019年亚洲肌少症工作组（AWGS）肌量减少的诊断标准将研究对象分为肌量正常组与肌量减少组,比较两组间各相关指标和骨密度减低/骨质疏松检出率的统计学差异,并进一步分析骨密度与肌量减少之间的相关关系。结果:（1）在老年女性T2DM不同骨密度分组的患者中,随着骨密度T值的减低,肌量减少检出率逐渐增加,分别为25.0%（11/44）、46.6%（27/58）、55.4%（31/56）,各组间差异性显著（χ²=9.540,P=0.008）。骨质疏松组的年龄（H=8.724,P=0.013）、HOMA-IR（H=6.992,P=0.030）最高,空腹血糖（H=7.170,P=0.028）、尿酸（F=3.597,P=0.030）、老年营养风险指数（F=8.894,P=0.022）、四肢骨骼肌质量指数（F=6.182,P=0.003）最低。各组间糖尿病病程、体重指数（BMI）、收缩压、空腹胰岛素、空腹C肽、糖化血红蛋白(HbA_1c)、甘油三酯、总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇、谷草转氨酶、谷丙转氨酶、尿素氮、血肌酐、25羟维生素D3、骨钙素、甲状旁腺激素、握力、体脂量、步速、C反应蛋白、脂肪肝史、高血压史、冠心病史、糖尿病周围神经病变、糖尿病周围血管病变、糖尿病肾病无明显统计学差异。（2）在老年女性T2DM患者中,肌量正常组的骨密度减低/骨质疏松的检出率为62.9%（56/89）,肌量减少组的检出率为84.1%（58/69）,两组间差异有统计学意义（χ²=8.642,P=0.003）。肌量减少组体重指数（t=1.995,P=0.048）、空腹血糖（Z=-2.156,P=0.031）、HOMA-IR（Z=-1.982,P=0.047）、谷草转氨酶（Z=-2.177,P=0.029）、尿素氮（Z=-2.039,P=0.041）、腰椎T值（Z=-2.254,P=0.024）、脂肪肝史（χ²=6.692,P=0.010）较肌量正常组减低,高密度脂蛋白胆固醇（Z=-2.817,P=0.005）较肌量正常组增高。（3）二元logistic回归分析:以有无骨密度减低/骨质疏松为因变量,进行肌量减少单因素回归分析结果显示肌量减少是老年女性T2DM患者骨密度减低/骨质疏松发生的独立危险因素[OR=3.107,95%CI（1.432-6.744）,P=0.004],当校正年龄、空腹血糖、HOMA-IR、尿酸、GNRI混杂因素后,肌量减少与骨密度减低/骨质疏松的相关性仍存在[OR=3.178,95%CI（1.394-7.246）,P=0.006],且年龄是发生骨密度减低/骨质疏松的危险因素[OR=1.068,95%CI（1.001-1.139）,P=0.045],尿酸是发生骨密度减低/骨质疏松的保护因素[OR=0.995,95%CI（0.990-1.000）,P=0.041]。（4）年龄、尿酸分层后与骨密度及骨代谢指标的Spearman相关分析:年龄与左股骨颈T值呈负相关;尿酸与甲状旁腺激素、腰椎T值呈正相关。（5）骨密度减低/骨质疏松症合并肌少症检出率:158例受试者中共发现33例患有骨密度减低/骨质疏松症合并肌少症,检出率为20.9%。结论:（1）老年女性T2DM患者的骨密度与肌量呈正相关,肌量减少者骨密度减低/骨质疏松检出率增高,骨密度减低/骨质疏松者肌量减少检出率增高。（2）老年女性T2DM患者骨密度与肌量相互影响,在临床工作中我们应同时监测患者骨质量及骨骼肌质量,以期能早发现骨密度和/或肌量异常者,进而早期干预。（3）增龄是老年女性T2DM患者骨密度下降的危险因素,尿酸水平是骨密度下降的保护因素。因此对于高龄女性T2DM患者需早期检测骨密度,同时应合理控制尿酸水平。更多还原

【Abstract】 Objective:To explore the prevalence of reduced bone mineral density/osteoporosis and muscle mass loss in elderly women patients with type 2 diabetes mellitus(T2DM),and their internal relationships.Method:A total of 158 elderly female patients with type 2 diabetes mellitus were enrolled in this cross-sectional study from the Department of Endocrinology,Affiliated Hospital of Qingdao University,from January to December 2019.According to the T-score measured by dual-energy X-ray bone density instrument(DXA)and WHO criteria for the diagnosis of osteoporosis,the study population was divided into three groups: Normal bone mineral density group,Reduced bone mineral density group and Osteoporosis group,the differences of the related indicators and the detection rate of muscle mass loss among different bone mineral density groups were compared.The subjects were divided into Normal muscle mass group and Muscle mass loss group according to the diagnostic criteria of sarcopenia set by the Asian Sarcopenia Working Group(AWGS)in 2019,and the statistical differences of related indicators and the detection rate of reduced bone mineral density/osteoporosis between the two groups were compared,and the correlation between bone mineral density and muscle mass loss was analyzed.Result:(1)In elderly female T2 DM patients with different bone mineral density,with the decrease of T-score,the detection rate of muscle mass loss gradually increased,which were 25.0%(11/44),46.6%(27/58),55.4%(31/56)respectively.There was a significant difference(χ~2=9.540,P=0.008).In this study population,osteoporosis group had the highest age(H=8.724,P=0.013)and HOMA-IR(H=6.992,P=0.030),the fasting blood glucose(H=7.170,P=0.028),uric acid(F = 3.597,P= 0.030),Geriatric Nutritional Risk Index(F=8.894,P=0.022)and Appendicular Skeletal Muscle Mass Index(F= 6.182,P= 0.003)were the lowest.Diabetes duration,body mass index(BMI),systolic blood pressure,fasting insulin,fasting C peptide,glycosylated hemoglobin(Hb Alc),triglyceride,total cholesterol,low-density lipoprotein cholesterol,high-density lipoprotein cholesterol,Aspartate aminotransferase,Alanine aminotransferase,urea nitrogen,serum creatinine,25 hydroxy vitamin D3,osteocalcin,parathyroid hormone,and grip strength,body fat,pace,C-reactive protein,history of fatty liver,history of hypertension,history of coronary heart disease,history of diabetic peripheral neuropathy,diabetic peripheral angiopathy,and diabetic nephropathy were not significantly different in each group.(2)In elderly female patients with T2 DM,the detection rate of reduced bone mineral density/osteoporosis was 62.9%(56/89)in the normal muscle mass group and 84.1%(58/69)in the muscle mass loss group,the difference between the two groups was statistically significant(χ~2=8.642,P=0.003).Body mass index(t=1.995,P=0.048),fasting blood glucose(Z=-2.156,P=0.031),HOMA-IR(Z=-1.982,P=0.047),aspartate aminotransferase(Z=-2.177,P=0.029),urea nitrogen(Z=-2.039,P=0.041),history of fatty liver(χ~2=6.692,P=0.010)and lumbar T-score(Z=-2.254,P=0.024)were lower than those in the normal muscle mass group,while high-density lipoprotein cholesterol(Z=-2.817,P=0.005)was higher.(3)Binary logistic regression analysis: With or without of reduced bone mineral density/osteoporosis as the dependent variable,univariate regression analysis of muscle mass loss showed that muscle mass loss was an independent risk factor for occurrence of reduced bone mineral density/osteoporosis in elderly female patients with T2DM[OR=3.107,95%CI(1.432-6.744),P=0.004].After adjusting for age,fasting blood glucose,HOMA-IR,uric acid and GNRI confounding factors,muscle mass loss was still associated with reduced bone mineral density/osteoporosis [OR=3.178,95%CI(1.394-7.246),P=0.006].Age was a risk factor for the reduced bone mineral density/osteoporosis [OR=1.068,95%CI(1.001-1.139),P=0.045],uric acid was a protective factor for the reduced bone mineral density /osteoporosis [OR=0.995,95%CI(0.990-1.000),P=0.041].(4)By age,uric acid stratification,with bone mineral density and bone metabolism indexes were conducted spearman correlation analysis: age was negatively correlated with T-score of left femoral neck;Uric acid was positively correlated with parathyroid hormone and T-score of lumbar spine.(5)Detection rate of osteosarcopenia : 33 patients with osteosarcopenia were found among 158 subjects,with a detection rate of 20.9%.Conclusion:(1)Bone mineral density(BMD)and muscle mass were positively correlated in elderly women patients with T2 DM,and the detection rate of reduced bone mineral density/osteoporosis was increased in patients with muscle mass loss,while the detection rate of muscle mass loss was increased in patients with reduced bone mineral density/osteoporosis.(2)The bone mineral density and muscle mass affect each other in elderly female patients with T2 DM,we should monitor both bone mass and skeletal muscle mass of patients in clinical work,in order to detect abnormal bone mineral density and muscle mass in this population,and then intervene early.(3)Aging is a risk factor for bone mineral density decline in elderly women with T2 DM,and uric acid level is a protective factor for bone mineral density decline.Therefore,early detection of bone mineral density and reasonable control of uric acid level in elderly female patients with T2 DM should be carried out.更多还原