The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
권호 표지

The Association between Albuminuria and Peripheral Arterial Disease in Patientswith Type 2 Diabetes Mellitus

제2형 당뇨병 환자에서 알부민뇨와 말초동맥 질환과의 관계

  • Park, Seong-Hwan (Department of Internal Medicine, Chonnam National University Medical School) ;
  • Chung, Jin-Ook (Department of Internal Medicine, Chonnam National University Medical School) ;
  • Cho, Dong-Hyeok (Department of Internal Medicine, Chonnam National University Medical School) ;
  • Chung, Dong-Jin (Department of Internal Medicine, Chonnam National University Medical School) ;
  • Chung, Min-Young (Department of Internal Medicine, Chonnam National University Medical School)
  • 박승환 (전남대학교 의과대학 내과학교실) ;
  • 정진욱 (전남대학교 의과대학 내과학교실) ;
  • 조동혁 (전남대학교 의과대학 내과학교실) ;
  • 정동진 (전남대학교 의과대학 내과학교실) ;
  • 정민영 (전남대학교 의과대학 내과학교실)
  • Published : 2011.07.01
⟨ Previous Next ⟩

Abstract

Background/Aims: Albuminuria is an early indicator of renal damage in type 2 diabetes mellitus, and has been recognized as a risk factor for peripheral arterial disease (PAD). The aim of this study was to assess the association between albuminuria and PAD in Korean type 2 diabetes patients. Methods: Our retrospective study included 390 consecutive patients with type 2 diabetes mellitus. The ankle-brachial index (ABI) and toe-brachial index (TBI) were used to assess PAD. The urinary albumin-creatinine excretion ratio (UAE) was evaluated by determining the albumin/creatinine ratio (ACR) in the first voided morning urine sample. Results: Duration of diabetes, serum creatinine levels, and UAE were significantly higher in patients with low ABI scores (< 0.9) than in those with normal ABI scores (${\geq}$ 0.9). Age, duration of diabetes, and UAE were significantly higher in patients with low TBI scores (< 0.6) than in those with normal TBI scores (${\geq}$ 0.6). Albuminuria was independently associated with low ABI (OR = 1.980, 95% CI = 1.001-3.918). It was also independently associated with low TBI and normal ABI (OR = 3.149, 95% CI = 1.260-7.871). Conclusions: The results of this study suggest that albuminuria may be associated with PAD, including in arteries distal to the ankle joint.

목적: 제2형 당뇨병 환자에서 알부민뇨는 신장 손상의 지표일 뿐만 아니라 심혈관 질환의 이환과 사망을 증가시키는 위험요인으로 알려져 있다. 알부민뇨는 동맥경화증에 의해 발생하는 말초동맥 질환의 중요한 위험인자로 보고된다. 이 연구는 제2형 당뇨병 환자를 대상으로 알부민뇨와 ankle-brachial index (ABI)와 toe-brachial index (TBI)와의 관련성을 알아보고 알부민뇨가 말초동맥 질환에 미치는 영향을 분석하고자 하였다. 방법: 제2형 당뇨병 환자를 대상으로 신체계측, 생화학검사, 알부민뇨 측정을 하였으며 말초동맥 질환 검사를 위해 ABI 및 TBI를 측정하였다. 결과: 총 390명의 환자를 대상으로 하였으며 평균 나이는 $60.9\;{\pm}\;12.2$세, 당뇨병 이환기간의 중앙값은 5년이었고 당화 혈색소는 7.9%였다. ABI 0.9 미만인 군에서 0.9 이상인 군에 비해 당뇨병 이환기간, 혈청 크레아티닌, 사구체 여과율 및 알부민뇨의 정도가 유의하게 높았다. 또한 ABI 0.9 미만인 군에서 미세 알부민뇨 또는 현성 단백뇨의 빈도가 유의하게 더 높았다. TBI 0.6 미만인 군에서 0.6 이상인 군에 비해 연령, 당뇨병 이환기간, 알부민뇨의 정도가 유의하게 높았고 고밀도 지단백 콜레스테롤은 유의하게 낮았다. 또한 TBI 0.6미만인 군에서 미세 알부민뇨 또는 현성 단백뇨가 빈도가 유의하게 더 높았다. 발목 근위 동맥(between the aorta and the ankle joint)에서의 말초동맥 질환과의 연관성을 알아보기 위해 다중회귀분석을 하였을 때 알부민뇨는 발목 근위 동맥의 말초동맥 질환과 밀접한 연관성이 있었다(OR = 1.980, 95% CI = 1.001-3.918). 발목 원위 동맥(distal to the ankle joint)에서의 말초동맥 질환과의 관계를 알아보기 위해 다중회귀분석을 하였을 때 알부민뇨는 발목 원위 동맥의 말초동맥 질환과 유의한 관계를 보였다(OR = 3.149, 95% CI = 1.260-7.871). 결론: 본 연구에서 알부민뇨는 제2형 당뇨병 환자에서 발목 근위 동맥뿐만 아니라 발목 원위 동맥의 협착성 병변과 밀접한 관련이 있으며 이는 알부민뇨가 혈관의 전반적인 동맥경화성 병변과 관련이 있음을 보였다.

Keywords

References

  1. Borch-Johnsen K, Feldt-Rasmussen B, Strandgaard S, Schroll M, Jensen JS. Urinary albumin excretion: an independent predictor of ischemic heart disease. Arterioscler Thromb Vasc Biol 1999;19:1992-1997. https://doi.org/10.1161/01.ATV.19.8.1992
  2. Hillege HL, Fidler V, Diercks GF, et al. Urinary albumin excretion predicts cardiovascular and noncardiovascular mortality in general population. Circulation 2002;106:1777-1782. https://doi.org/10.1161/01.CIR.0000031732.78052.81
  3. Naidoo DP. The link between microalbuminuria, endothelial dysfunction and cardiovascular disease in diabetes. Cardiovasc J S Afr 2002;13:194-199.
  4. Dart AM, Kingwell BA. Pulse pressure: a review of mechanisms and clinical relevance. J Am Coll Cardiol 2001;37:975-984. https://doi.org/10.1016/S0735-1097(01)01108-1
  5. Al Zahrani HA, Al Bar HM, Bahnassi A, Abdulaal AA. The distribution of peripheral arterial disease in a defined population of elderly high-risk Saudi patients. Int Angiol 1997;16:123-128.
  6. Katsilambros NL, Tsapogas PC, Arvanitis MP, Tritos NA, Alexiou ZP, Rigas KL. Risk factors for lower extremity arterial disease in non-insulin-dependent diabetic persons. Diabet Med 1996;13:243-246. https://doi.org/10.1002/(SICI)1096-9136(199603)13:3<243::AID-DIA69>3.0.CO;2-U
  7. O'Hare AM, Glidden DV, Fox CS, Hsu CY. High prevalence of peripheral arterial disease in persons with renal insufficiency: results from the National Health and Nutrition Examination Survey 1999-2000. Circulation 2004;109:320-323. https://doi.org/10.1161/01.CIR.0000114519.75433.DD
  8. Aboyans V, Criqui MH, Denenberg JO, Knoke JD, Ridker PM, Fronek A. Risk factors for progression of peripheral arterial disease in large and small vessels. Circulation 2006;113:2623-2629. https://doi.org/10.1161/CIRCULATIONAHA.105.608679
  9. Wattanakit K, Folsom AR, Criqui MH, et al. Albuminuria and peripheral arterial disease: results from the multi-ethnic study of atherosclerosis (MESA). Atherosclerosis 2008;201:212-216. https://doi.org/10.1016/j.atherosclerosis.2007.12.044
  10. Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976;16:31-41. https://doi.org/10.1159/000180580
  11. Pan CR, Staessen JA, Li Y, Wang JG. Comparison of three measures of the ankle-brachial blood pressure index in a general population. Hypertens Res 2007;30:555-561. https://doi.org/10.1291/hypres.30.555
  12. Stoffers HE, Kester AD, Kaiser V, Rinkens PE, Kitslaar PJ, Knottnerus JA. The diagnostic value of the measurement of the ankle-brachial systolic pressure index in primary health care. J Clin Epidemiol 1996;49:1401-1405. https://doi.org/10.1016/S0895-4356(96)00275-2
  13. 고보람, 김연경, 안상미 등. 당뇨병성 말초혈관질환과 ankle-brachial index의 상관관계. 대한내분비학회지 2006;21:382-388.
  14. Morimoto S, Nakajima F, Yurugi T, et al. Risk factors of normal ankle-brachial index and low toe-brachial index in hemodialysis patients. Ther Apher Dia 2009;13:103-107. https://doi.org/10.1111/j.1744-9987.2009.00663.x
  15. Orchard TJ, Strandness DE Jr. Assessment of peripheral vascular disease in diabetes: report and recommendations of an international workshop sponsored by the American Diabetes Association and the American Heart Association September 18-20, 1992: New Orleans, Louisiana. Circulation 1993;88:819-828. https://doi.org/10.1161/01.CIR.88.2.819
  16. Carter SA. Indirect systolic pressures and pulse waves in arterial occlusive diseases of the lower extremities. Circulation 1968;37:624-637. https://doi.org/10.1161/01.CIR.37.4.624
  17. Criqui MH, Denenberg JO, Bird CE, Fronek A, Klauber MR, Langer RD. The correlation between symptoms and non-invasive test results in patients referred for peripheral arterial disease testing. Vasc Med 1996;1:65-71.
  18. Resnick HE, Lindsay RS, McDermott MM, et al. Relationship of high and low ankle brachial index to all-cause and cardiovascular disease mortality: the Strong Heart Study. Circulation 2004;109:733-739. https://doi.org/10.1161/01.CIR.0000112642.63927.54
  19. Meijer WT, Grobbee DE, Hunink MG, Hofman A, Hoes AW. Determinants of peripheral arterial disease in the elderly: the Rotterdam Study. Arch Intern Med 2000;160:2934-2938. https://doi.org/10.1001/archinte.160.19.2934
  20. Premalatha G, Shanthirani S, Deepa R, Markovitz J, Mohan V. Prevalence and risk factors of peripheral vascular disease in a selected South Indian population: the Chennai Urban Population Study. Diabetes Care 2000;23:1295-1300. https://doi.org/10.2337/diacare.23.9.1295
  21. 박준성, 강준구, 함준수 등. 제2형 당뇨병 환자의 말초 혈관 질환의 위험 인자에 관한 연구. 대한혈관외과학회지 2002;18:259-267.
  22. MacGregor AS, Price JF, Hau CM, Lee AJ, Carson MN, Fowkes FG. Role of systolic blood pressure and plasma triglycerides in diabetic peripheral arterial disease: the Edinburgh Artery Study. Diabetes Care 1999;22:453-458. https://doi.org/10.2337/diacare.22.3.453
  23. Kallio M, Forsblom C, Groop PH, Groop L, Lepäntalo M. Development of new peripheral arterial occlusive disease in patients with type 2 diabetes during a mean follow-up of 11 years. Diabetes Care 2003;26:1241-1245. https://doi.org/10.2337/diacare.26.4.1241
  24. Feldt-Rasmussen B. Microalbuminuria, endothelial dysfunction and cardiovascular risk. Diabetes Metab 2000;26:64-66.
  25. Hsieh MC, Tien KJ, Perng DS, et al. Diabetic nephropathy and risk factors for peripheral artery disease in Chinese with type 2 diabetes mellitus. Metabolism 2009;58:504-509. https://doi.org/10.1016/j.metabol.2008.11.008
  26. 정유선, 유형준, 서승오 등. Ankle-brachial index (ABI)로 말초혈관질환이 진단된 60세 이상 당뇨병 환자에 있어서 말초혈관질환의 위험인자와 영양상태와의 관계. 당뇨병 1999;23:814-821.
  27. Nosadini R, Velussi M, Brocco E, et al. Course of renal function in type 2 diabetic patients with abnormalities of albumin excretion rate. Diabetes 2000;49:476-484. https://doi.org/10.2337/diabetes.49.3.476
  28. Redon J, Morales-Olivas F, Galgo A, et al. Urinary albumin excretion and glomerular filtration rate across the spectrum of glucose abnormalities in essential hypertension. J Am Soc Nephrol 2006;17(12 Suppl 3):S236-S245.
  29. Murussi M, Gross JL, Silveiro SP. Glomerular filtration rate changes in normoalbuminuric and microalbuminuric type 2 diabetic patients and normal individuals A 10-year follow-up. J Diabetes Complications 2006;20:210-215. https://doi.org/10.1016/j.jdiacomp.2005.07.002
  30. Mogensen CE, Vestbo E, Poulsen PL, et al. Microalbuminuria and potential confounders: a review and some observations on variability of urinary albumin excretion. Diabetes Care 1995;18:572-581.
  31. Damsgaard EM, Froland A, Jorgensen OD, Mogensen CE. Microalbuminuria as predictor of increased mortality in elderly people. BMJ 1990;300:297-300. https://doi.org/10.1136/bmj.300.6720.297
  32. Cowell CT, Rogers S, Silink M. First morning urinary albumin concentration is a good predictor of 24-hour urinary albumin excretion in children with type 1 (insulin-dependent) diabetes. Diabetologia 1986;29:97-99. https://doi.org/10.1007/BF00456117