广西医学

目的探讨血清25⁃羟维生素D3［25（OH）D3］水平和骨密度与中老年2型糖尿病（T2DM）患者并发糖尿病足溃疡（DFU）的相关性。方法纳入T2DM住院患者240例，其中120例并发DFU（DFU组），120例未并发DFU（T2DM组）。根据Wagner分级将DFU组分为轻度DFU组（Wagner分级1~2级，n=60）和重度DFU组（Wagner分级3~5级，n=60）。比较各组的一般资料，采用Logistic回归模型分析中老年T2DM患者并发DFU的影响因素；采用受试者工作特征（ROC）曲线和决策曲线分析血清25（OH）D3水平和骨密度对中老年T2DM患者并发DFU的预测价值和净收益率；比较DFU各组中维生素D营养水平及骨量状态的分布情况；采用Spearman相关分析血清25（OH）D3水平、骨密度与Wagner 分级的相关性。结果 DFU组的糖尿病病程、空腹血糖、HbA1c、脂蛋白a水平长于或高于T2DM组，而舒张压、体质指数、血清25（OH）D3、骨密度、总胆汁酸、总蛋白、血清白蛋白、ALT、AST、尿酸、总胆固醇、甘油三酯、HDL⁃C、LDL⁃C、极低密度脂蛋白胆固醇水平低于T2DM组（P<0.05）。多因素Logistic回归分析结果显示，血清25（OH）D3水平、骨密度是中老年T2DM患者并发DFU的影响因素（P<0.05）；ROC曲线分析结果显示，血清25（OH）D3水平、骨密度预测中老年T2DM患者并发DFU的曲线下面积（AUC）为0.725、0.698（P<0.05），敏感度和特异度分别为45.0%、78.3%和88.3%、52.5%，上述二者联合预测中老年T2DM患者并发DFU的AUC为0.775（P<0.05），敏感度和特异度分别为72.5%和74.2%，两个指标联合预测的效能和总体净收益优于单一指标。重度DFU组患者的血清25（OH）D3水平、骨密度低于轻度DFU组，维生素D缺乏比例和骨质疏松比例高于轻度DFU组（P<0.05）；Spearman相关分析结果显示，血清25（OH）D3水平、骨密度与Wagner 分级呈负相关（P<0.05）。结论血清25（OH）D3水平、骨密度是中老年T2DM患者并发DFU的影响因素，并与DFU的Wagner 分级呈负相关，二者联合对于中老年T2DM患者并发DFU的预测效能更佳。

Objective To investigate the correlation of serum 25⁃hydroxy vitamin D3 ［25(OH)D3］ level and bone mineral density with concomitant diabetic foot ulcers (DFU) in middle⁃aged and elderly patients with type 2 diabetes mellitus (T2DM). Methods A total of 240 hospitalized T2DM patients were enrolled, including 120 cases with concomitant DFU (the DFU group) and 120 cases without concomitant DFU (the T2DM group). The DFU group was further divided into mild DFU (Wagner grade 1-2, n=60) or severe DFU (Wagner grade 3-5, n=60) according to Wagner grade. General data were compared between various groups. The Logistic regression model was used to analyze influencing factors for concomitant DFU in middle⁃aged and elderly patients with T2DM. The receiver operating characteristic (ROC) curve and decision curve were adopted to analyze the predictive value and net income ratio of serum 25(OH)D3 level and bone mineral density for concomitant DFU in middle⁃age and elderly patients with T2DM. The distribution of vitamin D nutritional level and bone mass status was compared between DFU various groups. The Spearman correlation was used to analyze the correlation of serum 25(OH)D3 level and bone mineral density with Wagner grade. Results Compared with the T2DM group, the DFU group exhibited longer diabetes duration, and higher levels of fasting blood glucose, HbA1c, and lipoprotein a, whereas lower diastolic blood pressure, body mass index, bone mineral density, and lower levels of serum 25(OH)D3, total bile acids, total protein, serum albumin, ALT, AST, uric acid, total cholesterol, triglyceride, HDL⁃C, LDL⁃C, and very⁃low⁃density lipoprotein cholesterol (P<0.05). The multivariate Logistic regression analysis revealed that serum 25(OH)D3 level and bone mineral density were the influencing factors for concomitant DFU in middle⁃aged and elderly patients with T2DM (P<0.05). ROC curve analysis indicated that areas under the curve (AUC) of serum 25(OH)D3 level and bone mineral density for predicting middle⁃aged and elderly patients with T2DM and concomitant DFU were 0.725 and 0.698, respectively (P<0.05), with sensitivities and specificities of 45.0%, 78.3% and 88.3%, 52.5%, respectively. AUC of the combined prediction of the two mentioned as above for predicting middle⁃aged and elderly patients with T2DM and concomitant DFU was 0.775 (P<0.05), with sensitivity and specificity of 72.5% and 74.2%, respectively, demonstrating superior predictive performance and overall net income over individual indicators. The severe DFU group yielded lower serum 25(OH)D3 level and bone mineral density, higher proportions of vitamin D deficiency, and of osteoporosis as compared with the mild DFU group (P<0.05). The results of Spearman correlation analysis indicated that serum 25(OH)D3 level and bone mineral density negatively correlated with Wagner grade (P<0.05). Conclusion Serum 25(OH)D3 level and bone mineral density are influencing factors for concomitant DFU in middle⁃aged and elderly T2DM patients, and negatively correlate with Wagner grade of DFU. The combination of the two mentioned as above exerts superior predictive performance on concomitant DFU in middle⁃aged and elderly patients with T2DM.