儿童初发1型糖尿病伴不同程度糖尿病酮症酸中毒与甲状腺功能相关性研究

doi:10.12372/jcp.2022.21e1315

摘要/Abstract

摘要：

目的分析初发1型糖尿病（T1DM）患儿伴发糖尿病酮症酸中毒（DKA）的严重程度与甲状腺功能状态的相关性。方法回顾性分析2015年1月至2020年12月内分泌遗传代谢科收治的167例初发T1DM患儿临床资料,比较T1DM患儿中非DKA,轻度、中度、重度DKA四组临床特点、实验室指标、甲状腺功能状态差异,分析血清游离三碘甲状腺原氨酸（FT₃）水平的影响因素。结果 167例初发T1DM患儿中,男81例、女86例,中位年龄6.5（4.0~9.9）岁,中位病程14.0（7.0~28.0）d,非DKA组104例、轻度DKA组20例、中度DKA组16例、重度DKA组27例。各DKA组（FT₃）、总三碘甲状腺原氨酸（TT₃）、总甲状腺素（TT₄）、pH值及HCO^-₃显著低于非DKA组,而阴离子间隙（AG）、血糖水平显著高于非DKA组;重度DKA组的白细胞计数、中性粒细胞百分比显著高于其他三组,差异均有统计学意义（P<0.05）。167例初发T1DM儿童中,甲状腺功能正常92例,非甲状腺疾病综合征（NTIS）52例,亚临床甲状腺功能减退症10例,亚临床甲状腺功能亢进症6例,甲状腺功能减退症3例,甲状腺功能亢进症4例。不同严重程度DKA组之间的甲状腺功能状态分布差异有统计学意义（P<0.01）,非DKA组甲状腺功能正常患儿比例较高,NTIS比例较低。多元线性逐步回归分析结果显示,AG、血糖与FT₃水平存在显著负相关性（P<0.01）。结论初发T1DM伴DKA患儿的FT₃、TT₃及TT₄明显降低,有较高的NTIS发生率,测定甲状腺激素水平对排除甲状腺疾病及评估糖尿病病情有十分重要的临床意义。

关键词: 1型糖尿病, 酮症酸中毒, 甲状腺激素, 甲状腺功能, 儿童

Abstract:

Objective To explore the correlation between serum thyroid hormone and diabetic ketoacidosis (DKA) severity of children in type 1 diabetes mellitus (T1DM). Methods We retrospectively analyzed 167 T1DM children who were diagnosed with T1DM from January 2015 to December 2020. The clinical characteristics, laboratory indicators and thyroid function status of the four groups including non DKA, mild, moderate and severe DKA in T1DM were compared, and the related factors affecting serum free triiodothyronine (FT₃） level were analyzed. Results Among 167 patients with newly diagnosed T1DM, there were 81 males and 86 females, with a median age of 6.5 (4.0-9.9) years and a median course of disease of 14 (7-28) days. There were 104 cases in non DKA group, 20 cases in mild DKA group, 16 cases in moderate DKA group and 27 cases in severe DKA group. The FT₃, total triiodothyronine (TT₃), total thyroxine (TT₄), pH and HCO^-₃ in DKA groups were significantly lower than those in non DKA group, while the levels of anion gap and blood glucose were significantly higher than those in non DKA group, and the levels of WBC and the percentage of neutrophil in severe DKA group were significantly higher than those in other groups (P<0.05). There were 92 cases of normal thyroid function, 52 cases of non-thyroidal illness syndrome (NTIS), 10 cases of subclinical hypothyroidism, 6 cases of subclinical hyperthyroidism, 3 cases of hypothyroidism and 4 cases of hyperthyroidism. The severity of diabetes with DKA is associated with different thyroid function (P<0.01). The incidence of normal thyroid function in non DKA group was higher and the incidence of NTIS was lower. The multivariate regression analysis showed that FT₃ was negatively correlated with anion gap, blood glucose (P<0.01). Conclusions FT₃, TT₃ and TT₄ in DKA groups were lower than those in non DKA group. The incidence of NTIS in DKA group was significantly higher than that in non DKA group. Determination of thyroid hormone levels can provide a reliable basis for clinical judgment of thyroid diseases and diabetes mellitus.

Key words: type 1 diabetes, diabetic ketoacidosis, thyroid hormone, thyroid function, child

蒋明玉, 尹小琴, 李嫔. 儿童初发1型糖尿病伴不同程度糖尿病酮症酸中毒与甲状腺功能相关性研究[J]. 临床儿科杂志, 2022, 40(5): 339-344.

JIANG Mingyu, YIN Xiaoqin, LI Pin. Correlation analyses between thyroids function and diabetic ketoacidosis severity in T1DM children[J]. Journal of Clinical Pediatrics, 2022, 40(5): 339-344.

图/表 3

表1

T1DM伴不同程度DKA组各项观察指标比较"

项目	非DKA组(n=104)	轻度DKA组(n=20)	中度DKA组(n=16)	重度DKA组(n=27)	统计量	P
性别(男/女)	53/51	7/13	6/10	15/12	χ²=3.02	0.388
年龄[M(P₂₅~P₇₅)]/岁	6.4(4.0~9.8)	5.6(4.1~9.9)	7.8(3.3~10.0)	7.4(4.4~9.4)	H=0.31	0.958
病程[M(P₂₅~P₇₅)]/d	20.0(10.0~28.0)	14.0(7.0~21.0)	14.0(7.0~28.0)	14.0(5.0~56.0)	H=4.65	0.199
HtSDS[M(P₂₅~P₇₅)]	0.4(-0.4~1.1)	0.6(-0.3~0.8)	0.2(-0.4~2.2)	0.0(-0.8~1.4)	H=1.25	0.741
WtSDS[M(P₂₅~P₇₅)]	0.0(-0.6~0.8)	0.0(-0.3~0.2)	-0.4(-1.1~1.0)	0.0(-0.6~0.3)	H=0.50	0.920
BMI(x±s)/kg·m^-2	15.4±2.0	15.3±1.9	15.5±3.0	15.7±2.0	F=0.22	0.884
FT₃(x±s)/pmol·L^-1	5.0±1.2	4.3±1.1¹⁾	4.3±0.9¹⁾	4.0±1.2¹⁾	F=6.96	<0.001
FT₄(x±s)/pmol·L^-1	13.0±4.0	12.0±3.8	9.6±3.2	10.3±3.4	F=6.31	0.195
TT₃[M(P₂₅~P₇₅)]/nmol·L^-1	1.1(0.8~1.3)	0.6(0.4~0.9)¹⁾	0.6(0.3~0.9)¹⁾	0.6(0.3~0.9)¹⁾	H=36.80	<0.001
TT₄[M(P₂₅~P₇₅)]/nmol·L^-1	92.9(81.6~107.5)	74.5(63.8~93.2)¹⁾	57.0(39.4~85.4)¹⁾	75.4(44.1~83.7)¹⁾	H=36.47	<0.001
TSH[M(P₂₅~P₇₅)]/uIU·mL^-1	1.9(1.4~2.6)	1.9(0.5~3.1)	1.4(0.8~2.5)	1.1(0.8~2.1)	H=5.03	0.118
WBC[M(P₂₅~P₇₅)]/×10⁹·L^-1	7.0(4.1~8.6)	8.0(6.1~9.1)	9.1(7.0~11.9)	16.6(6.5~22.3)¹⁾²⁾³⁾	H=26.60	<0.001
NE(x±s)/%	45.8±13.0	55.3±13.2	57.4±16.2	67.2±19.5¹⁾²⁾³⁾	F=17.13	<0.001
HCT(x±s)/%	38.0±3.3	37.5±4.0	40.4±4.0	39.6±4.6	F=3.40	0.276
pH值(x±s)	7.4±0.1	7.3±0.1¹⁾	7.2±0.1¹⁾	7.0±0.1¹⁾	F=396.32	<0.001
HCO^-₃(x±s)/mmol·L^-1	21.4±5.2	12.8±2.1¹⁾	7.4±2.2¹⁾	3.6±1.4¹⁾	F=156.04	<0.001
AG[M(P₂₅~P₇₅)]/mmol·L^-1	13.5(9.7~17.6)	26.0(22.0~27.7)¹⁾	23.6(20.9~28.6)¹⁾	28.4(26.0~30.0)¹⁾	H=90.68	<0.001
BG(x±s)/mmol·L^-1	20.5±7.1	23.7±5.5¹⁾	25.3±3.6¹⁾	25.3±4.9¹⁾	F=6.14	0.001
HbA1c(x±s)/%	12.4±2.7	13.4±2.9	12.9±2.0	12.9±2.3	F=1.04	0.375
空腹C肽[M(P₂₅~P₇₅)]/nmol·L^-1	0.1(0.0~0.1)	0.1(0.0~0.1)	0.1(0.0~0.1)	0.1(0.0~0.1)	H=2.56	0.465
三酰甘油[M(P₂₅~P₇₅)]/mmol·L^-1	1.3(0.9~2.2)	2.8(1.2~5.3)	1.5(1.0~6.0)	2.1(1.4~3.0)	H=4.19	0.112
胆固醇(x±s)/mmol·L^-1	5.1±1.4	5.2±1.5	5.8±1.3	5.3±1.7	F=1.41	0.243
HDL-C[M(P₂₅~P₇₅)]/mmol·L^-1	1.2(1.0~1.5)	0.9(0.6~1.2)	1.3(0.9~1.4)	1.0(0.7~1.5)	H=5.58	0.132
LDL-C[M(P₂₅~P₇₅)]/mmol·L^-1	3.0(2.2~3.7)	2.9(1.9~3.9)	3.5(2.5~3.9)	2.5(1.9~3.4)	H=3.75	0.289

表1

表2

表3

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组别	例数	甲状腺功能正常	NTIS	亚临床甲状腺功能减退症	亚临床甲状腺功能亢进症	甲状腺功能减退症	甲状腺功能亢进症
非DKA组	104	70(67.3)	19(18.3)	6(5.8)	3(2.9)	3(2.9)	3(2.9)
轻度DKA组	20	7(35.0)	9(45.0)	2(10.0)	1(5.0)	0(0.0)	1(5.0)
中度DKA组	16	5(31.3)	10(62.5)	1(6.3)	0(0.0)	0(0.0)	0(0.0)
重度DKA组	27	10(37.0)	14(51.9)	1(3.7)	2(7.4)	0(0.0)	0(0.0)

因素	回归系数	标准误	标准化回归系数	t值	P	95%CI
AG	-0.03	0.01	-0.31	-3.96	<0.001	-0.05~-0.02
血糖	-0.03	0.02	-0.16	-2.12	0.036	-0.06~-0.00
常量	6.02	0.33	-	18.04	<0.001	5.36~6.68