在上一篇討論“血糖與糖化血色素”的文章中,我們瞭解糖化血色素(以下用HbA1C來表示)的數值,必須小心解讀,尤其是如果患者的紅血球比較夭壽(短命),那麼HbA1C的數值,就可能會偏低。那麼,洗腎患者也經常會貧血,那他們的HbA1C,會不會也受到影響呢?如果會受影響,那麼該用多少當成控制的目標呢?
關鍵字:洗腎 & 糖化血色素
先找到一篇2010年發表在美國腎臟學會臨床雜誌(Clinical Journal of the American Society of Nephrology, CJASN),總共收集了24751個糖尿病洗腎患者的研究,結果指出,HbA1C和預後關係非常微弱。
天啊!怎麼會?
似乎很多控制指標,遇到洗腎患者時,都要被顛覆了,對於一般糖尿病患者,HbA1C一向是非常重要的血糖指標,而且糖尿病腎病變的患者(還沒進展到洗腎者)的建議目標,也會建議將HbA1C控制在7%以下(當然,除了那些有低血糖風險的患者以外),這樣的好處是,能夠減緩腎臟功能下降的速度,保護腎臟,減少蛋白尿的進展等等。
但是洗腎患者的HbA1C控制目標,似乎仍缺乏共識,因為各家研究結果都不一樣,有的說在7-9%中間最好,有的研究就如前面那一篇的結果,HbA1C和預後的關聯很弱。
居然有研究說沒差?為什麼會這樣?
我不用控制血糖了嗎?
嘿嘿!這是個邏輯問題,HbA1C和預後無關,但是血糖控制和預後有沒有關係呢?那就要看HbA1C,能不能等於血糖控制了啊!在看過之前一篇文章之後,再深入看看專家們的討論,有個呼之欲出的答案,很可能就是:用的工具(HbA1C)不大準確,以至於對於預後的預測就不精準。
Freedman教授的研究指出,如果改用另一個指標工具(糖化白蛋白)來判斷患者的血糖控制,還是能準確預測洗腎患者的住院率、以及死亡率。所以囉,血糖控制還是很重要!只是單用HbA1C,來評估每個洗腎患者的血糖控制,有可能會誤判喔,平日使用血糖機來監測血糖,更能精準控制血糖,HbA1C作為參考用,但不是絕對的標準,而或許“糖化白蛋白”,會是將來用來評估洗腎患者血糖控制更好的工具。
KDOQI治療指引怎麼說
針對腎臟病的KDOQI治療指引,對糖尿病腎臟病患者的建議,於2012年也作出更新,其中針對HbA1C指出幾點要注意的(p.867):
1. 洗腎患者的HbA1C會比實際的平均血糖低。
2. 洗腎患者的HbA1C每增加1%,平均血糖增加約20 mg/dL,而一般人是30 mg/dL。
3. 洗腎患者的HbA1C與平均血糖的相關性,比一般人的低。
4. 慢性腎臟病患者(第三、四期)的HbA1C可能會比實際的平均血糖低。
5. 有補充紅血球生成素(EPO)者,或有在補充鐵劑者,HbA1C會降低0.5-0.7%。
6. 洗腎患者的HbA1C數值,若搭配自我血糖監測(血糖機),可獲得更準確的血糖資料。
講結論
將洗腎患者血糖控制好十分重要,目的是降低其他糖尿病的併發症,如:眼睛視網膜病變(眼睛看不見)、週邊神經病變(手麻腳麻)、或足部傷口問題(壞死截肢),控制這些併發症非常重要,這點無庸置疑。至於HbA1C的目標,不可全部患者都使用一樣的標準,目標得要個別化,因為受到太多因素影響,可能會使HbA1C比實際平均血糖來的低,至於臨床醫師,應該要搭配平日血糖機的數值,來判讀血糖是否得宜。
Reference:
KDOQI Clinical Practice Guideline For Diabetes: Update 2012
(PDF檔下載,引用P.864以及P.867之資料)
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