糖尿病核心更新 - 2025年12月

我是尼尔·斯科尔尼克医生，与约翰·拉塞尔医生共同带来本月精彩内容。我们将首先探讨《糖尿病护理》期刊的一篇重要文章：关于通过筛查利钠肽水平预测无已知心力衰竭的1型及2型糖尿病患者发生心衰和死亡风险的研究。

I'm doctor Neil Skolnick, and doctor John Russell and I have another great issue this month going over some really important articles beginning with an article from Diabetes Care on screening natriuretic peptide levels predicting heart failure and mortality in individuals with type one and type two diabetes without known heart failure at baseline.

接下来是《糖尿病护理》的另一篇文章：关于2型糖尿病患者在开始使用基于肠促胰岛素的药物后，发生急性胰腺炎和胆道事件风险的研究。

Next, there'll be an article from Diabetes Care on the risk of acute pancreatitis and biliary events after initiation of incretin based medications in patients with type two diabetes.

随后是《JAMA Network Open》的重要文章：探讨2型糖尿病患者持续血糖监测频率与血糖控制的关系。还有一篇既令人困扰又引人入胜的《JAMA》文章：比较AI驱动的生活方式干预与人工指导在糖尿病预防计划中的效果——这是两种强大力量的随机临床试验。

Following that, there will be an important article from JAMA Network Open on CGM frequency and glycemic control in people with type two diabetes, and then a, kind of bothersome and fascinating article from JAMA on AI powered lifestyle interventions versus, you guessed it, human coaching in the diabetes prevention program, a randomized clinical trial of these two powerful forces.

然后来自《糖尿病、肥胖与代谢》期刊的研究：针对门诊2型糖尿病患者采用两级筛查法进行肝纤维化分层评估。最后是《BMJ Open糖尿病研究与护理》的文章：关于CKD合并2型糖尿病患者尿白蛋白肌酐比值变化与临床结局的关联。

Then, from diabetes obesity metabolism, a two tier screening approach for liver fibrosis stratification in outpatients with type two diabetes, and finally, change in urine albumin to creatinine ratio and clinical outcomes in patients with CKD and type two diabetes from BMJ Open Diabetes Research and Care.

让我们开始吧。

Let's jump in.

我们的首篇文章来自《糖尿病护理》，该研究通过筛查利钠肽水平来预测无已知心力衰竭的1型及2型糖尿病患者发生心衰和死亡的风险。

Our first article is from Diabetes Care, and it looked at screening natriuretic peptide levels predicting heart failure and death in individuals with type one and type two diabetes without known heart failure.

本研究筛选了2017至2023年间接受门诊利钠肽检测、年龄超过18岁且无已知心力衰竭的1型或2型糖尿病成年患者。

So this study queried adults who were over the age of 18 with type one or type two diabetes without known heart failure who had received an outpatient natriuretic peptide test between twenty seventeen twenty three.

研究人员采用多变量Cox比例风险模型评估了利钠肽水平与新发心衰或死亡事件之间的关联。

The associations between the natriuretic peptides and incident heart failure or death were assessed using multivariable Cox proportional hazard models.

该研究调查了超过116,000名符合条件的受试者。

So the study looked at over 116,000 eligible individuals.

约3,000人患1型糖尿病，约113,000人患2型糖尿病。

Roughly 3,000 had type one diabetes, roughly one hundred and thirteen thousand had type two diabetes.

对患者进行了长达7年的随访。

The patients were followed up to seven years.

54%为女性患者。

Fifty four percent were female.

中位年龄为64岁。

The median age was 64 years of age.

基线中位糖化血红蛋白值为7.1%。

The median A1C was 7.1 at baseline.

约39.6%的1型糖尿病患者和42.3%的2型糖尿病患者BNP值超过50或proBNP值超过125。

Approximately 39.6% of individuals with type one and forty two point three percent of individuals with type two diabetes had a BNP greater than 50 or a proBNP greater than 125.

在调整后的Cox模型中，NT-proBNP水平升高与1型糖尿病患者心衰发病率或死亡率增加显著相关。

In adjusted Cox models, increased NT proBNP level was significantly associated with increased risk of incident heart failure or mortality among individuals with type one diabetes.

因此，如果proBNP水平在125到130之间，风险比为2.04。

So if there was a proBNP level 125 to 130, that hazard ratio was 2.04.

对于NT-proBNP大于300的情况，风险比为4.48。

For the NT proBNP greater than 300, it had a 4.48 hazard ratio.

这是针对1型糖尿病患者的数据。

So this is patients with type one diabetes.

对于2型糖尿病患者，当水平在125到300之间时风险比为1.85，大于300时风险比为3.58。

Patients with type two diabetes, there was a hazard ratio of 1.85 for a level between one hundred twenty five and three hundred, and greater than 300, a hazard ratio of 3.58.

尼尔？

Neil?

约翰，这是一篇重要文章。

John, this is an important article.

记得吗，大约一年半前我们讨论过相关建议，并在今年一月的护理标准中正式确立：所有糖尿病患者都应每年接受基础利钠肽筛查。

Remember, you and I went over the recommendations that came out about a year and a half ago and were codified in the standards of care this past January, that everyone with diabetes should be screened with a basic natriuretic peptide annually.

这项大规模队列研究涵盖1型和2型糖尿病患者，有力支持了该建议，并表明无论是1型还是2型糖尿病患者，心力衰竭及其高风险都非常普遍。

Well, this is a huge cohort of individuals, both with type one and type two, really supporting that recommendation and showing that in both people with type one and type two diabetes, heart failure and high risk for heart failure is very common.

先前数据显示，约22%的2型糖尿病患者存在心力衰竭。

Now previous data has shown us that about twenty two percent of people with type two have heart failure.

这项数据表明实际比例可能更高，或这些人患有目前称为'心力衰竭前期'的病症。

This data suggests that it might even be higher or these people have what's now called pre heart failure.

为什么这很重要？

Why is that important?

目前我们有三类药物：SGLT2抑制剂、GLP-1受体激动剂和非甾体MRA类药物（如苯吡酮），能有效预防心力衰竭住院。

Well, we now have three classes of medicines, the SGLT2s, the GLP-1s, and the nonsteroidal MRAs, phenyrinone, that have efficacy in preventing heart failure hospitalization.

三年前《糖尿病护理》期刊有篇有趣的文章，通过观察性试验对150万人群进行研究，发现SGLT2和GLP-1类药物能使心力衰竭首发率降低10%至30%（具体取决于药物种类）。

And there was an interesting article three years ago in diabetes care, looking at a large cohort over a million and a half people in an observational trial of SGLT twos and GLP ones showing that they decreased the instance of first appearance of heart failure by between ten and thirty percent depending on the medicine.

此外我要说，我敢打赌这些筛查中发现BNP升高的患者中，很多人并非无症状——因为当我与50岁肥胖糖尿病患者交谈时，很少有人在运动时不气短或没有某种程度的疲劳。

In addition, I'll tell you, I would bet you a lot of these people with high BNP's found on screening actually are not asymptomatic because when I talk to people who are 50, who have obesity, who have diabetes, very few of them are not getting short of breath with exertion or suffering from some degree of fatigue.

我们通常认为这只是身体机能退化的表现。

And we usually think it is just life for deconditioning.

我敢说其中相当比例的患者，如果进行超声心动图检查，将会被发现患有心力衰竭。

A significant proportion of them on then checking an echo, I'll bet you, will be found to have heart failure.

关键要点是什么？

What's the take home point?

这进一步支持了已纳入指南的建议：每年检查一次BNP或NT-proBNP。

This is further support for what is already embedded in the recommendations to check, either BNP or an NT proBNP on an annual basis.

我们的下一篇文章来自《糖尿病护理》，标题为《二型糖尿病患者开始使用基于肠促胰岛素的药物后发生急性胰腺炎和胆道事件的风险》。

Our next article is from Diabetes Care titled Risk of Acute Pancreatitis and Biliary Events after initiation of incretin based medications in patients with type two diabetes.

我们知道二型糖尿病患者发生急性胰腺炎和胆道事件的风险更高，但关于肠促胰岛素疗法（即GLP-1类药物和DPP-4抑制剂）与这些结局之间的关联，证据仍存在分歧。

Patients with type two diabetes we know are at increased risk of acute pancreatitis as well as biliary events but the evidence remains mixed regarding the association between incretin based therapies, that is GLP ones and DPP fours, and those outcomes.

因此，作者们利用美国医疗保险付费服务数据库和两个商业索赔数据库对此进行了研究。

So the authors here sought to look at that using the Medicare fee for service in two US commercial claims databases.

他们通过配对队列和倾向评分分层，筛选出既往无胰腺炎或胆道疾病的二型糖尿病成人患者，这些患者分别开始接受GLP-1类药物对比SGLT2抑制剂、DPP-4抑制剂对比SGLT2抑制剂，或GLP-1类药物对比DPP-4抑制剂的治疗。

They identified pairwise cohorts and propensity scored stratification of adults who had, type two diabetes without out prior pancreatitis or biliary disease, who initiated treatment with either a GLP-one versus an SGLT2 or a DPP-four versus an SGLT2 or a GLP one versus a DPP four.

他们发现，与SGLT2抑制剂相比，GLP-1类药物和DPP-4抑制剂使用者的急性胰腺炎风险相似，风险比为1.01。

What they found was that GLP ones and DPP four initiators had similar risk of acute pancreatitis compared with SGLT2 initiators, and that was a hazard ratio of one point zero one.

因此两者风险基本相当。

So that was essentially the same.

然而，GLP-1受体激动剂和DPP-4抑制剂在开始使用并随访后，与SGLT2抑制剂相比，均显示出胆道疾病风险略有增加。

However, both GLP-1s and DPP-4s, when initiated and followed showed a modestly increased risk of biliary disease compared with the SGLT2 initiators.

其风险比分别为1.15（即15%的增幅）和1.2222的增幅，相当于每千人年发生不足一例事件。

And that was a hazard ratio of 1.15, So a 15% increase and a hazard ratio of 1.2222 increase respectively, equivalent to fewer though than one event per thousand person years.

约翰？

John?

尼尔，我觉得这个发现总是特别有意思。

So Neil, I find this to be always kind of very fascinating.

就是关于胰腺炎风险这部分。

So kind of this pancreatitis risk.

GLP-1类药物和DPP-4抑制剂问世时，总会伴随着关于胰腺炎的讨论。

So the GLP-1s come on the scene, the DP fours come on the scene and kind of this talk of pancreatitis.

如果你查看药品说明书，会看到对曾有胰腺炎病史或存在胰腺炎风险的患者需谨慎使用的警示。

And if you looked in the package insert, it would talk about caution in someone who ever had pancreatitis or caution for someone at risk for pancreatitis.

那么，哪些人属于胰腺炎高危人群呢？

Well, who's at risk for pancreatitis?

糖尿病患者。

People with diabetes.

如果你查阅过去二十年的多篇论文，糖尿病患者与非糖尿病患者相比，急性胰腺炎的风险比大约为1.74。

So if you look at multiple papers over the last twenty years, the hazard ratio roughly for acute pancreatitis in someone who has diabetes versus someone who doesn't have diabetes is about one point seven four.

仅仅是患有糖尿病就会增加你患胰腺炎的风险。

So just having diabetes puts you at increased risk for pancreatitis.

所以问题是，这篇论文并没有真正支持将DPP4抑制剂与SGLT2抑制剂进行比较，但也许它们都有一点影响。

So the question is, this paper really doesn't support this really comparing, you know, the DPP4s to the SGLT2s, but maybe they all do a little bit.

对吧？

Right?

你在进行比较时，这项研究中并没有真正的对照组。

And you're comparing it, you're not necessarily there's not a control group there in this study.

所以我们并不完全清楚，对于不使用这些药物的糖尿病患者，比如使用胰岛素的患者，他们的风险会是多少？

So, you know, we don't completely know that someone with diabetes who is on none of those drugs, someone who's on insulin or whatever, what would that kind of risk be?

因此，我会放心在胰腺炎高风险患者中使用这些药物，因为在这些研究中，糖尿病患者本身就比非糖尿病患者有高出75%的风险。

So, I would feel okay using these medicines in someone at risk for pancreatitis because I would use these in someone who has diabetes, who has a seventy five percent higher risk than someone without diabetes in these studies.

因此我对这个风险感到放心。

So I would feel good in that risk.

有胰腺炎病史的人要具体看情况，对吧？

The person with a history of pancreatitis kinda depends on what it was, right?

是有人得过坏死性胰腺炎住过ICU上过呼吸机这些，还是有人只是腹痛加上脂肪酶略高15个点，CT看起来基本正常。

Did someone have a necrotizing pancreatitis that was in the ICU and was on a vent and all this other things, or someone who had some abdominal pain and had a lipase that was 15 points above normal and had a pretty normal looking CAT scan.

我不确定会永远将其列为禁忌症，虽然我们的电子病历系统会标注该患者有过急性胰腺炎病史并可能弹出提示。

I'm not sure I would make that a contraindication forever, although in our EMR, it's gonna say that person had acute pancreatitis and it's probably gonna pop something up.

所以我觉得这个现象很有意思。

So, I think that that's interesting.

胆道疾病发生率增加每千患者年一例看起来并不算多，对吧？

The increased case of biliary disease one per thousand patient years doesn't seem like a whole lot, right?

假设100个患者用药十年，其中可能多一例胆道疾病，而这类疾病通常不会造成特别严重的终末期后果。

So you have a 100 patients who are on these medicines for ten years, one more of them will have some biliary disease, which for the most part doesn't tend to have horrible end of life kind of consequences and things like that.

因此我会感到比较安心。

So I would be reassured.

不过如果你查阅一些关于胰腺炎的早期文献，可能会发现胰腺炎患者使用胰岛素效果稍好一些。

If you look at some of the older articles though around pancreatitis, it might say that people with pancreatitis do a little better with insulin.

而对于胆道疾病患者，使用SGLT2抑制剂可能略胜一筹，约有15%的患者效果更好。

And in this with the biliary disease, maybe it's a pinch better, fifteen percent lower in someone, an SGLT2, and someone with some biliary disease.

因此我认为这两方面都应该是令人安心的。

So I think this should be kind of reassuring on both fronts.

我们的下一篇文章来自《JAMA开放网络》的糖尿病与内分泌学栏目，研究了2型糖尿病患者持续血糖监测频率与血糖控制的关系。

Our next article is from JAMA Open Network in Diabetes and Endocrinology and looked at continuous glucose monitoring frequency and glycemic control in patients with type two diabetes.

这项研究旨在比较12个月内使用CGM的频率与不使用CGM对血糖状态的关联。

So this study was to look at the association of CGM frequency with glycemic status over a twelve month period versus no CGM use.

这是一项回顾性倾向评分匹配的横断面研究，使用了2019年1月1日至2023年12月31日期间Optum市场数据库的数据，包含每位参与者索引日期前六个月和后续十二个月的跟踪数据。

So it was a retrospective propensity scored matched cross sectional study that used Optum defined market clarity data obtained between 01/01/2019 and 12/31/2023, including data from six months prior to each participant's index date with twelve months follow-up.

研究对象为18岁以上、基线糖化血红蛋白在7%至15%之间的2型糖尿病患者。

They were participants with type two diabetes who were over the age of 18 and had a hemoglobin A1C between seven and fifteen at baseline.

他们统计了索引后12个月内使用CGM的天数情况。

So they looked at the number of days using the CGM during the twelve month post index period.

使用频率分为：第一组少于90天，第二组90至180天，第三组180至270天，第四组超过270天。

And the frequency was one, greater to one than less than ninety days, frequency two, greater than 90 to less than 180, frequency three, one hundred eighty to two seventy, frequency four, greater than two seventy.

另外还设有对照组。

And then there was the control group.

主要观察指标是相对于不同CGM使用频率组与未使用组之间的A1C变化。

The primary outcome was change in A1C relative to the frequency of CGM versus no CGM.

该分析共纳入9,200多名患者，其中4,200名为女性。

So the analysis included over 9,200 patients, of which four thousand two hundred were female.

平均年龄为55.9岁，对照组有4,600多名患者。

The mean age was 55.9 years and there were four thousand six hundred plus patients in the control group.

各组人数分布为：第一组1,081人，第二组1,523人，第三组2,540人，第四组2,485人。

There were ten eighty one in frequency one, fifteen twenty three in frequency two, 2,540 in frequency three, and two thousand four hundred and eighty five in frequency four.

高频使用组（第四组）与A1C显著降低相关，较未使用组下降1.52%。

High CGM use, which would frequency four, was associated with greater reduction in A1C, a decrease in 1.52 versus no CGM use.

对照组也有下降，但降幅为0.63个百分点。

That also had a decrease, but 0.63 percentage points.

使用CGM的患者在大约三个月时出现最大降幅

CGM users experienced the greatest reduction approximately three months.

因此频率1组下降了0.5个百分点，频率2组下降0.57，频率3组0.79，频率4组0.91，均与对照组患者相比

So frequency one had a decrease of 0.5 percentage points, frequency two decreased in 0.57, frequency three zero point seven nine, and frequency four, zero point nine one compared with control patients.

在六个月后，频率2和3组未观察到进一步的血糖改善

No further glycemic improvement was observed with frequency in two and three after six months.

频率1和4组患者的改善效果在整个观察期内持续存在

Improvements in patients with frequency one and four groups sustained for the duration of the post index period.

在频率4组中加用GLP-1受体激动剂，与对照组相比在约12个月时出现1.13个百分点的A1C治疗差异

The addition of a GLP-one receptor agonist in the frequency four group was associated with an A1C treatment difference of a decrease in 1.13 percentage points versus controls at approximately twelve months.

尼尔？

Neil?

约翰，这项研究很有意思，虽然结果并不意外，但我认为很有意义

John, this is an interesting study and that not that it's surprising, but I think it is interesting.

那么它究竟告诉我们什么？

And basically what does it tell us?

这告诉我们使用CGM（持续血糖监测）很重要。

It tells us that using CGM matters.

它帮助人们更好地控制血糖。

It helps people get better control.

而且与我们某些人有时认为的不同——觉得偶尔使用一下，获得动力、了解自己的糖尿病就够了。

And unlike what some of us, I think sometimes think that if you use it now and then, so you get motivated, understand your diabetes, that's enough.

这项研究表明，持续使用、一年中大部分时间使用比偶尔使用效果更好。

What this says is that continuous use, using it for much of the year is better than using it now and then.

至于为什么有效，接下来就是推测了。

And after that it's speculation, why does it help?

我认为有两个原因：第一，它能根据定期更新的数据更频繁地调整药物。

Well, I think the two reasons are one, it allows more regular changes of medicine based on regular updating of data.

你不必再等三个月或更久，通过糖化血红蛋白看到足够变化才调整用药。

You don't have to wait that three months or more for your a one c to see a sufficient change to to change a medicine.

第二，它形成了患者能立即获得的内部反馈循环——当他们饮食不当时，会很快看到血糖变化的影响。

And two, it creates an internal feedback loop that patients get when they eat wrong, they see the effect very quickly on their blood sugar.

如果他们运动，就会看到血糖下降，我们都会对这种与行为时间相近的自然反馈做出反应。

If they exercise, they see that blood sugar going down, and we all respond to natural feedback that is close in time to the behavior that caused that feedback to occur.

我们在其他播客中也讨论过这个话题。

And we've talked about that on other podcasts.

所以，关键结论是：持续血糖监测（CGM）很有价值，值得更多使用。

So, take home point here, CGM, good, worth using, more.

下一篇来自JAMA的文章题为《人工智能驱动的生活方式干预与人类辅导在糖尿病预防计划中的对比：一项随机临床试验》。

Next article from JAMA is titled an AI powered lifestyle intervention versus human coaching in the diabetes prevention program, a randomized clinical trial.

哈，我知道这场较量中我支持的是哪一方。

Oh boy, I know who I was rooting for in this one.

我们知道糖尿病前期很常见。

So we know prediabetes is common.

我们知道糖尿病预防计划是有史以来最伟大的试验之一，它证明生活方式干预能减少从糖尿病前期发展为糖尿病的概率，但这个计划需要大量资源。

We know the diabetes prevention program is one of the great trials of all time showing lifestyle intervention decreases progression from prediabetes to diabetes, but it is a resource intensive program.

为了确定完全由人工智能（AI）主导的、基于DPP-4计划的生活方式干预在达到推荐体重减轻和糖化血红蛋白降低阈值方面是否不劣于人类主导的DPP计划，作者开展了一项随机试验。

So determine whether referral to an exclusively artificial intelligence, AI led lifestyle intervention based on the DPP-four program was non inferior to referral to a human led DPP in achieving recommended thresholds for weight loss and A1C reduction, as well as weekly physical activity among adults with prediabetes and overweight or obesity, the authors developed a randomized trial.

这是一项三期平行组实用性非劣效性随机临床试验，于2021年10月1日至2024年12月16日在美国两个临床中心进行。

It was a phase three parallel group pragmatic non inferiority randomized clinical trial conducted from 10/01/2021 to 12/16/2024 at two US clinical sites.

这两个中心分别位于巴尔的摩和雷丁。

That was in Baltimore and Reading.

值得花点时间讨论下参与者按1:1比例随机分配到的干预措施。

It is worth talking a moment about the interventions to which participants were randomized in a one to one ratio.

他们要么被分配到AI驱动的DPP四型生活方式干预组（通过移动应用配合蓝牙电子秤实施），要么被分配到人工教练指导的生活方式干预组——两组都使用了计步器。

They either got referral to an AI powered DPP four lifestyle intervention delivered by a by a mobile app with Bluetooth enabled digital scale, and they also used, some step counters or referral to a human coach led lifestyle intervention.

需要明确的是，人工教练组也是远程实施的。

It's important to understand that human coach was delivered remotely.

这项研究启动于新冠疫情期间，因此决定采用远程方式进行生活方式干预。

This was started during part of the COVID pandemic, and the decision was made to deliver the lifestyle interventions in a remote manner.

有必要讨论下AI程序的具体形式，因为我们对这类事物还不太熟悉。

It's worth discussing what the AI based program looked like because we're not real familiar with that sort of thing.

参与者在注册后8-12天内会收到一个数字健康工具包。

They were the participants received a digital health kit, within eight to twelve days of signing up.

这套设备包含一个能与应用程序连接的蓝牙体重秤。

It had a Bluetooth scale that connected with an app.

最令人着迷的是，该应用程序会根据收集的数据（包括饮食记录、体重测量以及地理位置等手机追踪信息）推送个性化的体重管理、运动锻炼和营养建议通知。

And what was fascinating here is the app delivered personalized push notifications for weight management, physical activity, and nutrition, and it was informed by the data that it collected, meal logging, weight measurements, as well as things like geolocation, which was fascinating that was tracked through the phone.

举个例子，当你走进超市时，会收到一条消息说：'让我们在购物时做出些健康的选择吧'。

So for instance, if you were walking into the supermarket, you would get a text saying, let's make some good choices while we're shopping here.

这些消息会根据你的饮食记录为你提供个性化建议。

And those texts would give you the choices based on what your eating has been so that it was personalized to you.

比如如果你在某天没有按计划运动，就会收到提醒：'今天运动可能是个好主意'。

If you hadn't, for instance, exercised on a day where you had planned to, You would get a text saying, might be a good idea to exercise today.

即使你无法完成全部运动计划，只完成部分也是进步。

And even if you can't do your full exercise program, even if you do part of that program, it's a win.

这样你就能了解他们的运作方式。

So you have a sense of what they were doing.

研究共纳入了368名参与者。

A total of 368 participants were included.

71%为女性。

Seventy one percent were female.

中位BMI值为32。

The median BMI was thirty two.

转诊后，93%的人启动了AI主导的项目，82%启动了人工主导的项目。

After referral, ninety three percent of the people initiated the AI led program, and eighty two percent initiated the human led program.

所以AI从一开始就领先了。

So AI was winning right out of the starting gate.

主要结果指标显示，AI组31%和人工组31%达到了非劣效性标准。

The primary outcome was achieved by thirty one percent in the AI group and thirty one percent in the human group meeting the criteria for noninferiority.

两组的结果基本相当。

They were about equal in their outcomes.

哦，天哪。

Oh, boy.

约翰？

John?

你知道吗，尼尔，这真的挺让人意外的。

You know, Neil, that surprising, really.

所以三月份《新英格兰医学杂志》上有篇关于心理治疗的文章。

So in March, article in the New England Journal looking at psychotherapy.

对吧？

Right?

如果有人被转介到Therabot，接受AI驱动的心理治疗，结果显示效果还不错。

If someone could be referred to Therabot and could get kind of AI driven psychotherapy and it showed it did okay.

但最近一期《今日心理学》对此提出了一些注意事项，AI在处理流程化事务时表现更好。

But some of the caveats kind of written up in a recent edition of Psychology Today about that, the AI did better with protocol driven type things.

所以对于未分化的病例——我们在初级诊疗中经常讨论这个——资深临床医生的优势就在于他们能处理这类未分化的病例并逐步剖析。

So the undifferentiated, and you and I kind of talk about this in primary care is really that seasoned clinician really what differentiates them from a protocol driven system is someone who can kind of take that undifferentiated patient and kind of unpack it.

所以糖尿病预防计划的辅导，我认为应该是相当结构化的，对吧？

So the DPP for coaching, think is probably pretty structured, right?

如果A，那么B；如果B，那么C。

If A, then B, if B, then C.

与其将其视为洪水猛兽，或许这将成为我们和患者（尤其是那些需要改善饮食、增加运动的大众）的强大工具。

And instead of kind of viewing this as the boogeyman, maybe this becomes kind of a great kind of tool for us, for our patients, which is multitudes who kind of fall in that, boy, need to eat a little better, I need to exercise a little bit more.

也许如果我手机上能收到些信息会更好，毕竟人们现在基于手机推送做了太多愚蠢的事情。

And maybe if I got something to my phone, would be, because people are doing an awful lot of stupid stuff based on what's coming across their phone.

或许手机上能推送些真正智能有用的内容。

Maybe something coming smart and helpful coming across their phone.

这难道不是革命性的改变吗？总比又刷个抖音或浪费时间的玩意强吧？

Wouldn't that be revolutionary instead of another TikTok or whatever people are wasting?

所以我觉得这很有意思。

So I find this to be interesting.

我并不希望它完全取代其他方式，但建立标准化流程很有必要——毕竟我们现在是在糖尿病主题播客里。

I don't think I would want this to kind of replace, you know, kind of everything else, but I think instituting a protocol and we're on a diabetes podcast right now.

可以预见未来几年，胰岛素剂量推荐将通过人工智能来完成。

You could imagine that in the years ahead that insulin dosing recommendations will go through some artificial intelligence.

你甚至能想象华法林剂量调整也会接入某种人工智能系统来指导患者用药。

You could imagine that warfarin dosing and kind of something that kind of loops in with some artificial intelligence to tell people to adjust their dose.

我们刚刚讨论了充血性心力衰竭，如果患者体重增加，你可以看到很多这类非常依赖标准化流程的内容正运用这种AI技术。

We just talked about congestive heart failure, if someone's weight goes up, you could see a lot of this stuff that is very protocol driven kind of using this AI technology.

所以我不觉得惊讶，但觉得很有意思。

So I don't find it surprising, find it interesting.

这项研究来自《糖尿病、肥胖与代谢》期刊，采用了两阶段筛查方法对门诊2型糖尿病患者进行肝纤维化分层评估，是一项多中心横断面研究。

Came from diabetes and obesity and metabolism, and it looked at two tier screening approach for liver fibrosis stratification in outpatients with type two diabetes, a multicenter cross sectional study.

该研究回顾性纳入了1200多名意大利老年门诊2型糖尿病患者，他们接受了振动控制瞬时弹性成像检查（后文简称VCTE），包括肝脏硬度测量和受控衰减参数检测。

So this study retrospectively enrolled over 1,200 older Italian outpatients who had type two diabetes, who underwent a vibration controlled transient elastography, which we will refer to as VCTE with liver stiffness measurement and controlled attenuation parameter.

代谢性肝病患者的定义为CAP值大于248。

People with metabolic liver disease was defined as having a CAP greater than two forty eight.

显著肝纤维化的定义为大于8kPa。

Significant liver fibrosis was defined as having greater than eight kPa.

代偿期进展性慢性肝病的定义为肝脏硬度测量值大于10。

Compensated advanced chronic liver disease as liver stiffness measurement greater than 10.

临床显著性门静脉高压的定义为数值大于25kPa，或肝脏硬度测量值大于20且血小板计数低于150。

And clinically significant portal hypertension that number being greater than 25 kPa or LSM greater than 20 and platelet count under 150.

所有参与者都计算了纤维化指数。

And a fib index was calculated in all participants.

代谢功能障碍相关肝病、显著肝纤维化、晚期慢性肝病或慢性系统性门脉高压的患病率分别为71.3%、21.1%、11.7%和1.7%。

The prevalence of having metabolic dysfunction associated liver disease, significant liver fibrosis, advanced chronic liver disease, or chronic systemic portal hypertension were seventy one point three, twenty one point one, eleven point seven and one point seven respectively.

采用纤维化-4指数和VCTE的两阶段筛查策略显示，在纤维化-4指数正常的患者中，83.3%的患者肝硬度值低于8，126名患者高于8。

A two tiered screening strategy for fibrosis using the fib four index and the VCTE showed that among patients with a normal Fib-four index, 83.3 had stiffness under eight and one hundred and twenty six had it greater than eight.

纤维化-4指数检测肝硬度值>8的敏感性为50.4%，特异性66.3%，阴性预测值83.3%，阳性预测值28.6%。

Sensitivity specificity negative and positive predictive value of the four index for detecting a level greater than eight was 50.4, 66.3, eighty three point three and twenty eight point six respectively.

体重增加（调整后比值比3.34）和AST水平升高（调整后比值比1.54）是显著肝纤维化的最强预测因素。

Increased body weight, adjusted odds ratio of 3.34 and elevated AST levels, adjusted odds ratio 1.54 were the strongest predictors of significant liver fibrosis.

尼尔？

Neil?

约翰，让我来解读这篇文章的背景。

John, let me put this article into context.

作者表示这支持了指南推荐方案，即我们应该对所有糖尿病和肥胖患者进行纤维化-4指数筛查。

The author said that this supported the guideline approach, and the guideline approach is that we should be screening everyone with diabetes and obesity with a fib four.

如果他们的评分低于1.3，就无需进行进一步评估。

And if they have a score less than 1.3, they fall out of the need to do any further evaluation.

但这项研究明确指出的问题是，FIB-4指数远未达到完美的阴性预测值。

The issue though that this study really nicely delineates is that the fib four doesn't have anywhere near a perfect negative predictive value.

事实上，这将漏诊约17%存在显著肝纤维化的患者。

In fact, that would miss about seventeen percent of people with significant liver fibrosis.

我想特别关注这个问题，因为临床上我们现在重点关注F2和F3级纤维化患者——这些患者目前有资格接受FDA批准的NASH治疗（现阶段包括罗美司他和司美格鲁肽）。

And I just wanna focus on that particular issue because clinically that's what we're looking for now, people with F2 and F3 fibrosis, because those are the people who are eligible for the FDA approved treatments for NASH, being rosmederon and semaglutide at this point.

还有更多药物正在研发中。

There are plenty more in the pipeline.

这意味着如果仅依赖FIB-4指数而不采取额外措施，你将漏诊约17%本有资格接受治疗的NASH患者。

But it means that you'd be missing about seventeen percent of the people who have NASH that would be eligible for treatment if you did nothing in addition to the fib four.

我觉得这有点令人担忧。

And I find that a bit concerning.

本研究中MASLD和MASH的患病率与其他研究结果一致，这也是造成上述情况的原因。

And the reason for that in this study, the prevalence of mass old and mesh was the same as we see in other studies.

71%的人患有脂肪肝，约21%存在显著肝纤维化。

Seventy one percent of the people had mass old, about twenty one percent had significant liver fibrosis.

那么我们该如何利用这些信息？

So what do we do with this information?

因为我们不想对所有人都立即进行弹性成像检查。

Because we wouldn't wanna jump and do elastography on everybody.

我的理解是——这里我引用你最后说的部分——体重明显增加的人群纤维化风险更高，ALT水平升高者同样如此。

So what what I take from this, and here I'm I'm using the part that you said last, that people who had particularly increased body weight were at higher risk of fibrosis, same with high l f ALT levels.

我们会做FIB-4检测，但不会完全拘泥于其结果。

Well, we do the fib four, but we don't adhere to it religiously.

对于患有三级肥胖或肝功能异常但FIB-4低于1.3的患者，我们可能会进一步做瞬时弹性成像检查。

We then think, and if someone has, class three obesity or elevated LFTs and they have a fib four less than 1.3, maybe we go on and do that transient elastography as well.

另一个我担心的群体是年轻患者。

The other group I worry about are people who are younger.

因为要记住，FIB-4指数受年龄因素驱动。

Because remember, the fib four is driven by age.

年龄越大，你得到的数值就越高，这与我们的ASCVD计算器非常相似。

You get a higher number the higher your age is in a way that's very similar to our ASCVD calculator.

如果其他因素不变，年龄增长十岁，你的分数就会上升。

And if nothing else changes, you're a decade older, your score goes up.

所以如果有人分数接近临界值，而他们才30或40岁，我可能还是会继续检查他们。

So if someone has a score near that borderline score and they were, say, 30 or 40, I might go ahead and check them anyway.

我认为这是一篇重要文章，很可能会影响未来的指南。

I think this is an important article and, will likely influence future guidelines.

我们本期的最后一篇文章来自《BMJ开放糖尿病研究与护理》，标题是《慢性肾病合并2型糖尿病患者尿白蛋白与肌酐比值变化对临床结局的影响》。

Our final article of this issue is from BMJ Open Diabetes Research and Care and is titled Change in Urine Albumin to Cranion Ratio in Clinical Outcomes in Patients with Chronic Kidney Disease and Type two Diabetes.

该研究旨在探讨尿白蛋白与肌酐比值变化与慢性肾病合并2型糖尿病患者临床结局之间的关联。

The study aimed to investigate the association between the change in urine albumin and creatinine ratio and clinical outcomes in patients with chronic kidney disease and type two diabetes.

他们观察了成年患者在确诊2型糖尿病和慢性肾病后初始检测中UACR（尿白蛋白/肌酐比值）大于30的情况。

They looked at adult patients with an elevated UACR greater than 30 in initial testing after the diagnosis of type two diabetes and CKD.

这些数据来自Optum电子健康记录数据库。

And it was identified from an Optum electronic health records database.

我们经常听到这个数据集，因为它包含了大约七千万人的信息。

We're hearing about this dataset a lot because it is one that encompasses somewhere around seventy million people's information.

UACR从初始测试到最后一次测试（6至24个月期间）的变化被分为三类：下降超过30%、稳定、或上升超过30%。

A UACR change from initial to last test from six to twenty four months was categorized as either a greater than 30% decrease, stable, or a greater than 30% increase in UACR.

他们发现，与UACR稳定的患者（共35,000人）相比，UACR下降超过30%的患者（共89,000人）全因死亡率风险更低（低7%），同时复合心血管结局和CKD进展风险也更低。

And what they found was that compared with patients who had a stable UACR, there were thirty five thousand of them, those who had greater than a 30% decrease in their UACR, eighty nine thousand people, had a lower risk of all cause mortality, seven percent lower risk, and a lower risk of composite cardiovascular outcomes as well as CKD progression.

而UACR上升超过30%的患者，上述各项终点的风险都更高。

And patients who had an increase UACR of greater than 30% had a higher risk of each of those endpoints.

约翰？

John?

所以这里有很多

So there are a lot of things

从方法论角度来说，我很欣赏这项研究的设计。

methodologically I liked about this study.

首先明确'好转'或'恶化'必须超过30%的变化阈值。

And starting off that better or worse had to be more than thirty percent.

所以，这些仅相差几点的变化，如果简单地说变好或变坏，我挺喜欢他们用明确的方式定义了'更好'或'更差'。

So, these changes that are just a couple points that would be say, well, it's better or it's worse, I kind of liked that it really defined better or worse in a nice way.

不过在这项研究中，我认为微量白蛋白检测的平均间隔时间是18个月。

One of the things though, in this particular study, I think that the average time between microabumins was eighteen months.

也许这才是真实、完整的现实世界数据，反映了实际情况。

And maybe this is real, complete real world data, and that's what's going on out there.

我想这再次提醒我们，未来会越来越多地听到这类心肾关联的研究。

I think this is just yet another reminder to us as we are gonna hear more and more and more and more and more about this kind of cardio renal link.

因此，如果我们能在糖尿病背景下改善患者的肾功能，很可能也会降低他们患心血管疾病的风险。

So if we can make people's kidneys better in the setting of diabetes here, we're probably gonna decrease their chance of having cardiovascular disease.

因为实际上，如果观察那些微量白蛋白恶化30%但肌酐或GFR未变化的患者，他们最终需要透析的相对风险变化可能不大，或需要移植的可能性也不高，但这确实会显著增加患心血管疾病的风险。

Because really, if you look at the difference for that person whose microalbumin 30% worse, but maybe their creatinine has not changed or their GFR hasn't changed, their chance of ending up on dialysis is the relative change in those numbers might not be huge, or their need for being on a transplant list or whatever might not be huge, but it clearly accelerates the risk of having cardiovascular disease.

而这正是导致大多数肾病患者死亡的原因。

And that is what kills most people with renal disease.

所以，这可能是电子病历系统很容易追踪的一个指标。

So one of the things, this is probably something very easy for electronic records to follow.

我记得在初级诊疗时，我们曾以患者是否进行微量白蛋白检测作为评判标准。

And I think once upon a time, you and I in primary care, we were judged that our patient have a microalbumin.

但我从未真正见过有人会追问'你对那个微量白蛋白结果采取了什么措施？'这样的评判。

But I really didn't see ever really that kind of judgment for what did you do about that microalbumin?

即使有追问，最多也就是问'你用的是ACE抑制剂还是ARB类药物？'

Or maybe if it did, did you start an ACE or did you start an ARB?

仅此而已。

And that was it.

我想很多人可能只是做了检测却未采取任何措施，但愿事实并非如此。

And I think a lot of people might just check it and not do anything about it, and I hope not.

但如果检测值升高，首先应该让患者服用ACE或ARB类药物，并逐步加大剂量以力求达到30%的降幅。

But if it is elevated, starting off with putting someone on an ACE or an ARB, but pushing the dose of that ACE or ARB to really try to get that 30% reduction.

我认为这应该是我们的职责——当患者出现微量白蛋白升高时，通过使用ACE或ARB类药物使其指标下降30%。

And I think that really should be a little bit of our charge if you have that person with some increased microalbumin and I started an ACE or an ARB that I can get that down to 30.

如果这种方法无效，或许就需要考虑添加其他类别的药物。

And if that doesn't work, that maybe I'm adding on one of the other categories.

我会加用SGLT2抑制剂，或者MRA类药物来保护患者的肾脏功能。

I'm adding an SGLT2, I'm adding, you know, one of the MRA type medicines to kind of protect people's kidneys.

但我认为这对我们基层医疗工作者将是个越来越大的挑战——如何为CKD三期和四期患者做出改变，防止他们发展到五期。

But I think this is going be more and more of the challenge for those of us in primary care, for those people who are in that CKD three, that CKD four, to make those differences so someone never becomes CKD five.

约翰，在结束前我想和听众分享一个重要消息。

John, before we close, I wanna share some important news with our listeners.

如你所知，除了糖尿病外，我们一直涵盖所有心脏代谢疾病领域，因此节目名称将随之调整以契合这一定位。

As you know, in addition to diabetes, we've been covering the full range of cardiometabolic conditions, and so our name is gonna be changing to meet that consistent mission.

我们的播客将更名为《糖尿病、肥胖与心脏代谢动态》。

Our podcast will be rebranded as Diabetes, Obesity, and Cardiometabolic Update.

我知道，我知道你已经在想了——没错。

I know, I know, you're already thinking, and you're right.

新名称就叫《医学动态》。

The new name is Doc Update.

全称是《糖尿病、肥胖与心脏代谢动态》。

Diabetes, Obesity and Cardiometabolic Update.

当您的订阅源更新时，您会注意到这一变化。

You'll notice this when the change is made on your subscriber feed.

我们将采用新的标题和品牌标识。

We'll have a new title and branding.

同样优质的内容。

Same great information.

欲了解更多信息及本期讨论文章的链接，请访问diabetesjournal.org。

For more information and links to the articles that we discussed in this issue, just go to diabetesjournal.org.

下个月见，请继续收听

Until next month, keep listening

并持续学习。

and keep learning.