目的:老年人易发生脆性骨折,尤其是那些患有2型糖尿病(T2DM)合并骨质疏松症的患者。尽管有研究证实了GNRI与骨质疏松症患病率之间的关联,GNRI与脆性骨折风险之间的关系以及FRAX估计的骨质疏松性脆性骨折的个体化10年概率之间的关系尚不清楚.这项研究旨在探讨GNRI与脆性骨折之间的关系以及FRAX评估的老年T2DM髋部骨折(HF)和严重骨质疏松性骨折(MOF)的10年概率。
方法:2014年至2023年共纳入580例年龄≥60岁的T2DM患者。本研究是一项双向纵向队列研究。所有参与者每6个月随访一次,为期9年,通过门诊服务的中位数为3.8年,医疗记录,和家庭固定电话采访。根据GNRI的三元语,所有受试者分为三组:低水平(59.72-94.56,n=194),中等水平(94.56-100.22,n=193),和高水平(100.22-116.45,n=193)。通过接收器工作特性(ROC)分析评估了GNRI与脆性骨折之间的关系以及通过FRAX计算的HF和MOF的10年概率,斯皮尔曼相关分析,受限三次样条(RCS)分析,多变量Cox回归分析,分层分析,和Kaplan-Meier生存分析。
结果:在580名参与者中,102例发生脆性骨折事件(17.59%)。ROC分析表明,最佳GNRI临界值为98.58,灵敏度为75.49%,特异性为47.49%,分别。Spearman偏相关分析显示GNRI与25-羟基维生素D[25-(OH)D](r=0.165,P<0.001)和骨密度(BMD)[腰椎(LS)呈正相关,r=0.088,P=0.034;股骨颈(FN),r=0.167,P<0.001;全髋关节(TH),r=0.171,P<0.001];与MOF(r=-0.105,P=0.012)和HF(r=-0.154,P<0.001)呈负相关。RCS分析表明,GNRI与脆性骨折事件呈反向S形剂量依赖性(P<0.001),与FRAX评估的10年MOF(P=0.03)和HF(P=0.01)风险呈Z形,分别。多因素Cox回归分析表明,与高水平GNRI相比,中等水平[风险比(HR)=1.950;95%置信区间(CI)=1.076~3.535;P=0.028]和低水平水平(HR=2.538;95%CI=1.378~4.672;P=0.003)脆性骨折的风险增加.分层分析显示GNRI与脆性骨折风险呈负相关,其中林区存在的分层因素不是混杂因素,也不影响GNRI对该总体队列人群脆性骨折事件的预测作用(P为交互作用>0.05),尽管年龄≥70岁的老年女性,体重指数(BMI)≥24,高血压,伴或不伴贫血(均P<0.05)。Kaplan-Meier生存分析发现,较低水平的GNRI组有较高的脆性骨折累积发生率(log-rank,所有P<0.001)。
结论:这项研究首次证实,GNRI与脆性骨折呈负相关,并且通过FRAX评估的骨质疏松性脆性骨折的10年概率呈反向S形和Z形剂量依赖性模式老年T2DM患者,分别。GNRI可作为老年T2DM患者脆性骨折风险的一个有价值的预测指标。因此,在常规临床实践中,关注老年T2DM患者的营养状况并给予适当的饮食指导可能有助于预防脆性骨折事件。
OBJECTIVE: The elderly are prone to fragility fractures, especially those suffering from type 2 diabetes mellitus (T2DM) combined with osteoporosis. Although studies have confirmed the association between GNRI and the prevalence of osteoporosis, the relationship between GNRI and fragility fracture risk and the individualized 10-year probability of osteoporotic fragility fractures estimated by FRAX remains unclear. This
study aims to delve into the association between the GNRI and a fragility fracture and the 10-year probability of hip fracture (HF) and major osteoporotic fracture (MOF) evaluated by FRAX in elderly with T2DM.
METHODS: A total of 580 patients with T2DM aged ≥60 were recruited in the
study from 2014 to 2023. This research is an ambispective longitudinal cohort
study. All participants were followed up every 6 months for 9 years with a median of 3.8 years through outpatient services, medical records, and home fixed-line telephone interviews. According to the tertiles of GNRI, all subjects were divided into three groups: low-level (59.72-94.56, n = 194), moderate-level (94.56-100.22, n = 193), and high-level (100.22-116.45, n = 193). The relationship between GNRI and a fragility fracture and the 10-year probability of HF and MOF calculated by FRAX was assessed by receiver operating characteristic (ROC) analysis, Spearman correlation analyses, restricted cubic spline (RCS) analyses, multivariable Cox regression analyses, stratified analyses, and Kaplan-Meier survival analysis.
RESULTS: Of 580 participants, 102 experienced fragile fracture events (17.59%). ROC analysis demonstrated that the optimal GNRI cut-off value was 98.58 with a sensitivity of 75.49% and a specificity of 47.49%, respectively. Spearman partial correlation analyses revealed that GNRI was positively related to 25-hydroxy vitamin D [25-(OH) D] (r = 0.165, P < 0.001) and bone mineral density (BMD) [lumbar spine (LS), r = 0.088, P = 0.034; femoral neck (FN), r = 0.167, P < 0.001; total hip (TH), r = 0.171, P < 0.001]; negatively correlated with MOF (r = -0.105, P = 0.012) and HF (r = -0.154, P < 0.001). RCS analyses showed that GNRI was inversely S-shaped dose-dependent with a fragility fracture event (P < 0.001) and was Z-shaped with the 10-year MOF (P = 0.03) and HF (P = 0.01) risk assessed by FRAX, respectively. Multivariate Cox regression analysis demonstrated that compared with high-level GNRI, moderate-level [hazard ratio (HR) = 1.950; 95% confidence interval (CI) = 1.076-3.535; P = 0.028] and low-level (HR = 2.538; 95% CI = 1.378-4.672; P = 0.003) had an increased risk of fragility fracture. Stratified analysis exhibited that GNRI was negatively correlated with the risk of fragility fracture, which the stratification factors presented in the forest plot were not confounding factors and did not affect the prediction effect of GNRI on the fragility fracture events in this overall cohort population (P for interaction > 0.05), despite elderly females aged ≥70, with body mass index (BMI) ≥24, hypertension, and with or without anemia (all P < 0.05). Kaplan-Meier survival analysis identified that the lower-level GNRI group had a higher cumulative incidence of fragility fractures (log-rank, all P < 0.001).
CONCLUSIONS: This
study confirms for the first time that GNRI is negatively related to a fragility fracture and the 10-year probability of osteoporotic fragility fractures assessed by FRAX in an inverse S-shaped and Z-shaped dose-dependent pattern in elderly with T2DM, respectively. GNRI may serve as a valuable predictor for fragility fracture risk in elderly with T2DM. Therefore, in routine clinical practice, paying attention to the nutritional status of the elderly with T2DM and giving appropriate dietary guidance may help prevent a fragility fracture event.