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目的 在超重或肥胖的2型糖尿病患者中探讨夜间血清皮质醇水平和糖尿病微血管并发症的相关关系.方法 检测316例超重或肥胖的2型糖尿病患者的夜间0点血清皮质醇,按照不同的皮质醇水平分组,比较各组间糖尿病微血管并发症的状况.所有夜间血清皮质醇>50 nmol/L者行过夜小剂量地塞米松抑制试验,排除亚临床库欣综合征.用化学发光免疫法检测血清皮质醇,同时检查患者发生糖尿病肾病(Diabetic nephropathy,DN)、糖尿病视网膜病变(Diabetic retinopathy,DR)、糖尿病周围神经病变(Diabetic peripheral neuropathy,DPN)的情况.结果 (1)在超重或肥胖的2型糖尿病患者中,DN发生比例在低、中、高皮质醇组逐渐升高,分别为13.3％、27.7％、44.2％,3组比较差异有统计学意义(P<0.05).与低皮质醇组相比,中、高皮质醇组发生DR的比例升高(40.6％和47.7％对22.7％,均P<0.01).高皮质醇组发生DPN的比例高于低皮质醇水平组(60.5％对38.7％,P<0.01);(2)有糖尿病微血管并发症的患者夜间血清皮质醇水平较无并发症者高[(136.87±105.78对97.55±93.48)nmol/L,P<0.01];与仅合并单个并发症者相比,合并有多个并发症的患者夜间皮质醇水平较高[(151.66±114.54对117.69±90.26)nmol/L,P<0.05];(3)单因素相关分析显示,除了女性、年龄、糖尿病病程、空腹血糖以外,高皮质醇水平也是发生2型糖尿病微血管并发症的危险因素.多因素相关分析显示,经过校正病程、空腹血糖、HbA1C、使用胰岛素治疗等因素后,夜间0点皮质醇水平仍是发生糖尿病微血管并发症的危险因素(P=0.013).结论 在超重或肥胖的2型糖尿病患者中,夜间皮质醇水平升高可能是糖尿病伴发微血管并发症的危险因素.

Objective To explore the association of nocturnal serum cortisol levels with diabetic microvascular complications in overweight or obese patients with type 2 diabetes mellitus. Methods Serum cortisol levels of 316 overweight or obese type 2 diabetic patients were tested at midnight by the method of chemiluminescence. Diabetic microvascular complications were compared among various groups according to nocturnal serum cortisol levels. All the patients with nocturnal serum cortisol level > 50 nmol/L were asked to undergo overnight low-dose dexamethasone suppression test to rule out the possibility of subclincal Cushing's syndrome. The incidences of diabetic nephropathy ( DN ) , diabetic retinopathy ( DR ) , and diabetic peripheral neuropathy ( DPN ) were examined in all the patients. Results (1)The incidence of DN was gradually increased from 13.3％to 27.7％and 44.2％in patients with low, medium, and high cortisol level groups, showing a statistical difference among 3 groups ( P<0.05) . The incidences of DR in medium and high cortisol level groups were higher than that in low cortisol level group (40.6％and 47.7％vs 22.7％, both P<0.01). The incidence of DPN in high cortisol level group was higher as compared with low cortisol level group (60.5％ vs 38.7％, P<0.01). (2) Nocturnal serum cortisol level in patients with diabetic microvascular complications was higher than that in patients without complications [ (136.87 ± 105.78 vs 97.55 ± 93.48) nmol/L, P<0.01]. Nocturnal serum cortisol level in patients with multiple diabetic microvascular complications was higher than that in patients with single diabetic microvascular complication [ (151.66±114.54vs117.69±90.26)nmol/L,P<0.05].(3)Singlefactorlogisticregressionanalysisshowedthat higher nocturnal serum cortisol level was a risk factor for diabetic microvascular complications in addition to female, age, longer diabetic duration, higher fasting plasma glucose ( FPG ) . Multivariate logistic regression analysis showed that higher nocturnal serum cortisol level was still a risk factor for diabetic microvascular complications after adjusted by diabetic duration, FPG, HbA1C, and the use of insulin (P=0.013). Conclusion Nocturnal serum cortisol level seems to be a risk factor for diabetic microvascular complications in overweight or obese patients with type 2 diabetes mellitus.