Authors:Yang Yingrui, Xu Xun, Sun Jiali, Chen Yanyan, Zhang Mengyue, Huang Zixu, Fan Shuoning, Song Zongming
Corresponding authors: Fan Shuoning, Email: fanshuoning@126.com; Song Zongming, Email: szmeyes@126.com
Published:2026-09-10
DOI:10.3760/cma.j.cn115989-20251230-00459
ABSTRACT
Objective To explore the correlative factors for diabetic retinopathy (DR) in patients with type 2 diabetes mellitus (T2DM), so as to provide evidence for identifying high-risk populations in clinical practice.
Methods A single-center, retrospective cross-sectional real-world study was performed. A total of 960 T2DM patients admitted to Henan Provincial People’s Hospital from July 2023 to January 2025 were enrolled. Patients were divided into the DR group (326 cases) and non-DR group (634 cases) according to fundus photography. DR was further classified into non-proliferative DR (NPDR) and proliferative DR (PDR) based on the International Clinical Diabetic Retinopathy (ICDR) severity scale. Demographic data, diabetes duration, blood pressure, glycemic and lipid profiles, renal function indicators including urinary albumin-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR), liver function indicator aspartate aminotransferase-to-alanine aminotransferase ratio (AST/ALT), as well as serum protein and other laboratory parameters were collected. Correlation between DR severity and UACR stage and eGFR stage was evaluated by Spearman rank correlation. Binary and ordinal multinomial logistic regression were applied to identify independent correlative factors for DR prevalence and severity grading. Restricted cubic spline (RCS) was used to assess the non-linear relationship between UACR and DR. A discriminant model was constructed, and its performance was validated by receiver operating characteristic (ROC) curve and Bootstrap resampling. This study protocol was approved by the Ethics Committee of Henan Provincial People’s Hospital (No. HNEEC-2025[28]).
Results The overall prevalence of DR was 34.0%(326/960), including 19.4%(186/960) for NPDR and 14.6%(140/960) for PDR. Multivariate binary logistic regression showed that sex (female: OR=1.918, 95% CI: 1.374-2.676, P<0.001), diabetes duration ( OR=2.219, 95% CI: 1.580-3.117, P<0.001), glycated hemoglobin A1c (HbA1c) ( OR=1.073, 95% CI: 1.002-1.150, P=0.044), UACR stage (30-300 mg/g: OR=2.834, 95% CI: 1.901-4.225, P<0.001; >300 mg/g: OR=6.225, 95% CI: 3.220-12.034, P<0.001), AST/ALT ratio ( OR=0.566, 95% CI: 0.331-0.965, P=0.037), and eGFR stage 45-59 ml(min·1.73m 2): OR=0.387, 95% CI: 0.150-0.996, P=0.049; 30-44 ml(min·1.73m 2): OR=0.316, 95% CI: 0.107-0.932, P=0.037) were independent correlative factors for DR. DR severity grade was positively correlated with UACR stage ( r s=0.460, P<0.001) and negatively correlated with eGFR stage ( r s=-0.242, P<0.001). Ordinal multinomial logistic regression confirmed that elevated UACR was an independent correlative factor for worsening DR severity OR(95% CI)=3.648(2.912-4.568), and RCS analysis showed a significant non-linear dose-response association existed between UACR and DR. The area under the ROC curve (AUC) of the combined-indicator discriminant model reached 0.766, superior to any single indicator; among single indicators, UACR stage yielded higher AUC values than others.
Conclusions UACR stage, diabetes duration, sex, HbA1c, AST/ALT ratio and eGFR stage are independent correlative factors for DR in T2DM patients. UACR stage exerts the strongest effect on DR severity grading.
KEYWORDS：
Type 2 diabetes mellitus;Diabetic retinopathy;Associated factors;Real-world study
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Authors Info & Affiliations
Yang Yingrui
Henan Provincial People’s Hospital, Henan Eye Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
Xu Xun
Shanghai General Hospital, Shanghai 200080, China
Sun Jiali
Henan Provincial People’s Hospital, Henan Eye Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
Chen Yanyan
The Eye Hospital of Wenzhou Medical University, Wenzhou 325027, China
Zhang Mengyue
The Eye Hospital of Wenzhou Medical University, Wenzhou 325027, China
Huang Zixu
Henan Provincial People’s Hospital, Henan Eye Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
Fan Shuoning
Henan Provincial People’s Hospital, Henan Eye Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
Song Zongming
Henan Provincial People’s Hospital, Henan Eye Hospital, People’s Hospital of Zhengzhou University, Zhengzhou 450003, China
Figures & Tables
Table 1 Comparison of baseline characteristics between NDR group and DR group Note: (a: Independent samples t-test; b: χ 2 test; c: Mann-Whitney U test) NDR: no diabetic retinopathy; DR: diabetic retinopathy; BMI: body mass index; HbA1c: glycated hemoglobin; BUN: blood urea nitrogen; UPCR: urine protein-creatinine ratio; NEFA: Non-esterified fatty acid; Lpa: lipoprotein a; AST: aspartate aminotransferase; ALT: alanine aminotransferase; ALB: albumin; HDL: high-density lipoprotein cholesterol; LDL: low-density lipoprotein cholesterol; TC: total cholesterol; TG: triglyceride; eGFR: estimated glomerular filtration rate; UACR: urinary albumin creatinine ratio 1 mmHg=0.133 kPa
Table 2 Multivariate binary logistic regression analysis of factors associated with DR in patients with type 2 diabetes mellitus （n=960） Note: Reference group for sex was male (male=0, female=1); reference group for diabetes duration was duration <10 years (<10 years=0, ≥10 years=1); reference group for UACR categories was UACR <30 mg/g; reference group for eGFR categories was eGFR ≥120 ml(min·1.73 m 2). The model was adjusted for confounding factors including age, BMI, smoking history, drinking history, antihypertensive and lipid-lowering medication, and serum lipid indicators DR: diabetic retinopathy; SE: standard error; OR: odds ratio; CI: confidence interval; HbA1c: glycated hemoglobin; AST: aspartate aminotransferase; ALT: alanine aminotransferase; UACR: urinary albumin-creatinine ratio; eGFR: estimated glomerular filtration rate; BMI: body mass index
Table 3 Ordinal multinomial logistic regression analysis of DR severity with UACR stage and eGFR stage Note: UACR categories were coded as: <30 mg/g=1, 30-300 mg/g=2, >300 mg/g=3; eGFR categories were coded as: ≥120 ml(min·1.73 m 2)=1, 90-119 ml(min·1.73 m 2)=2, 60-89 ml(min·1.73 m 2)=3, 45-59 ml(min·1.73 m 2)=4, 30-44 ml(min·1.73 m 2)=5, <30 ml(min·1.73 m 2)=6 DR: diabetic retinopathy; UACR: urinary albumin-creatinine ratio; eGFR: estimated glomerular filtration rate; SE: standard error; OR: odds ratio; CI: confidence interval
Figure 1 Distribution of constituent ratios of DR grades in patients with different UACR stages UACR: urinary albumin-creatinine ratio; DR: diabetic retinopathy; NDR: no diabetic retinopathy; NPDR: non-proliferative diabetic retinopathy; PDR: proliferative diabetic retinopathy
Figure 2 Distribution of constituent ratios of DR grades in patients with different eGFR stages eGFR: estimated glomerular filtration rate; DR: diabetic retinopathy; NDR: no diabetic retinopathy; NPDR: non-proliferative diabetic retinopathy; PDR: proliferative diabetic retinopathy
Figure 3 Restricted cubic spline dose-response relationship between UACR and DR The solid line represented the fitted OR curve, and the shaded area indicated the 95% confidence interval OR: odds ratio; UACR: urinary albumin-creatinine ratio; DR: diabetic retinopathy
Figure 4 Comparison of ROC curves for each related factor ROC: receiver operating characteristic; UACR: urinary albumin-creatinine ratio; eGFR: estimated glomerular filtration rate; AST: aspartate aminotransferase; ALT: alanine aminotransferase; HbA1c: glycated hemoglobin
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