關於這個主題,之前我也曾寫過兩篇文章:
1. 洗腎患者的紅血球壽命較短,可能會影響醣化血色素的數值。
2. 洗腎患者的醣化血色素高低,與預後可能關係不大。原因可能就是上面那一篇。
這個月在Kidney international期刊中發表的最新文章,是由日本的腎臟科專家們,利用他們自己國內的資料庫,收集了2300位患者的資料,所統計出來的結果。結果令歐美專家們大吃一驚:
死亡率(風險)最低的那一組,他們醣化血色素是控制在 6%-7%之間。小於 6或大於 7者,風險上升。
這和以往歐美所作的實驗大不相同,上一篇提到,有些觀察性的歐美研究指出:控制在 7-9%之間的腎友,預後最佳,然而,日本的研究卻告訴我們,要嚴格控制在 6-7%之間,風險最低,這提醒了我們人種之間的差異,當我們要用歐美國家的研究,套用在亞洲人,或者台灣人的身上時,都要謹慎,最好是有自己的研究結果,否則很可能是錯誤的。
這篇研究的討論裡提到,亞洲人種的胰島素抗性,比歐美人種來的低,或許是因為如此,醣化血色素的目標數值也應該不同。
從治療上也可以看出這個趨勢,日本糖尿病腎友需要使用胰島素的比例,明顯低於歐美糖尿病腎友,而日本糖尿病腎友使用口服血糖藥的比例較高,這表示兩個可能,一個是兩個種族的飲食習慣不同,使得日本腎友控制血糖比較容易,另一個可能就是剛剛所說的,亞洲人種的胰島素抗性沒那麼高,因此用口服藥就足以控制達標。
從我們自己臨床上的經驗,和這個統計結果十分類似,有不少糖尿病患開始洗腎之後,胰島素也停了,口服藥也減少了,甚至都不用吃了,需要用到胰島素的比例真的不多,而醣化血色素都還是能夠保持在 7%以下。
另外一個有趣的結果是:日本糖尿病的腎友,醣化血色素低於 6%的比例,居然超過一半。而且,居然也沒有增加低血糖發生的情況,真是驚人。
這會不會是日本洗腎患者的存活率能夠保持在世界中數一數二的原因之一呢?
不管如何,看了這篇研究統計之後,我們對於糖尿病腎友的照護,要在不發生低血糖的情形下,將醣化血色素控制在 7%以下,對預後才是最佳。
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