Page 22 - 2022-36-中国全科医学

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3.Department of Endocrinology，Sun Yat-sen Memorial Hospital，Sun Yat-sen University，Guangzhou 510120，China
*
Corresponding authors：LIU Dan，Chief physician；E-mail：liudan2@mail.sysu.edu.cn
YAN Li，Chief physician；E-mail：hfxyl@163.net
WU Wenxia and CHEN Guishan are co-first authors
【Abstract】 Background Patients with diabetic foot undergoing endovascular therapy for lower extremity arterial
disease exhibit poor outcomes and a high mortality rate. It is unclear whether malnutrition assessed by geriatric nutritional risk
index（GNRI）is associated with clinical outcomes in these patients. Objective To investigate the association of baseline
malnutrition assessed by GNRI and clinical outcomes of endovascular therapy for lower extremity arterial disease in patients
with diabetic foot. Methods Ninety-five patients who were admitted in Department of Endocrinology，Sun Yat-sen Memorial
Hospital due to diabetic foot and lower extremity arterial disease were included from January 2011 to December 2016. All
of them received endovascular therapy and followed up for two years. Baseline GNRI was assessed，and divided into three
levels：normal nutrition （43 cases），mild malnutrition （31 cases） and moderate to severe malnutrition （21 cases）.
Clinical characteristics were collected，including sex，age，diabetes duration，smoking，body mass index，prevalence of
cardiovascular and cerebrovascular diseases，diabetic foot classification，systolic and diastolic blood pressure，and blood test
results containing white blood cell count，platelet count，lymphocyte count，neutrophil count，neutrophil-to-lymphocyte
ratio，hemoglobin，fasting blood glucose，glycosylated hemoglobin，total cholesterol，triglyceride，high-density lipoprotein
cholesterol and low-density lipoprotein cholesterol，albumin，creatinine，and estimated glomerular filtration rate. The primary
endpoint was all-cause mortality，and the secondary endpoint was major lower extremity amputation. The Kaplan-Meier curve was
used for survival analysis. Univariate and multivariate Cox proportional hazards regression analysis were analyzed to evaluate the
risk factors of all-cause mortality. Results Fifty-two cases（54.7%）were assessed with malnutrition（GNRI ≤ 98）. Normal
nutrition，mild malnutrition，and moderate to severe malnutrition patients had significant differences in average body mass
index，leukocyte count，neutrophil count，neutrophil-to-lymphocyte ratio，hemoglobin，triglyceride and albumin （P<0.05）.
During the follow-up，16 patients died，10 of whom were due to cardiovascular or cerebrovascular diseases；five patients
underwent major lower extremity amputation. The two-year survival rate was 92.1%，75.6% and 50.1% in normal nutrition，
mild malnutrition，and moderate to severe malnutrition patients，respectively，showing statistically significant difference（Log-
2
rank test：χ =10.812，P=0.004）. GNRI ≤ 98〔HR=3.937，95%CI（1.070，13.942），P=0.037〕 was an independent
risk factor for all-cause mortality. Conclusion The two-year survival rate of patients in normal nutrition group（GNRI>98）was
higher than that in malnutrition group（GNRI ≤ 98）. Baseline GNRI-assessed malnutrition may be an independent risk factor
for all-cause mortality in diabetic foot patients with lower extremity arterial disease treated by endovascular therapy，so assessing
and improving the nutritional status may better improve the clinical outcome of these patients.
【Key words】 Diabetic foot；Geriatric nutritional risk index；Malnutrition；Lower extremity arterial disease；
Endovascular therapy；Clinical outcome；Survival rate；Risk factors

糖尿病的发病率在世界范围内不断上升。据国际 术后 1 年的死亡率达 13%，术后 2 年达 29%（19%~48%），
糖尿病联合会（IDF）估计，2021 年全球约有 5.37 亿 而术后 5 年更是高达 47%（39%~71%） ［8］ 。就临床上
20~79 岁的成年人患有糖尿病，而到 2045 年这一数字 所见，即使解决了患者下肢血供问题，并同时积极控制
预计将增长 46%，达到 7.83 亿 ［1］ 。糖尿病足是 2 型糖 血糖、血压、血脂及抗血小板治疗，患者的总体生存率
尿病主要的慢性并发症之一，也是非创伤性下肢截肢最 仍较低。这提示在此类患者中，除了常规危险因素，可
主要的原因 ［2］ 。糖尿病足溃疡显著增加了患者死亡率， 能还存在一些未被识别的危险因素影响临床预后。
给患者造成了巨大的医疗负担，50% 以上的糖尿病足溃 营养状态是多种疾病临床预后差的危险因素 ［9-10］ 。
疡患者存在下肢动脉病变 ［3］ 。同时糖尿病下肢动脉病 既往研究表明糖尿病足溃疡患者营养不良的比例高，这
变作为全身动脉粥样硬化性疾病的一部分，经常合并心 可能是影响临床预后的因素之一 ［11］ 。近年来，基于血
脑血管疾病，因此患者长期临床预后较差 ［4-6］ 。下肢血 清白蛋白和体质量指标的老年营养风险指数（Geriatric
运重建可以改善糖尿病足溃疡预后、降低截肢率。血管 Nutritional Risk Index，GNRI）作为一种简便的营养状
腔内治疗作为一种常见的血运重建策略，由于其可行性、 况评估工具，在各种疾病的评估中得到了广泛应用。研
安全性、有效性、可重复性和微创性的相对优势，已成 究表明，利用 GNRI 评估的营养不良是心力衰竭 ［12］ 和
为糖尿病足患者的主要治疗方法 ［7］ 。虽然下肢血管腔 血液透析患者 ［13］ 临床预后较差的预测因素。目前，利
内治疗可以提高保肢率，但患者总体死亡率仍然较高， 用 GNRI 评估的营养不良对接受血管腔内治疗的糖尿病