儿童暴发性1型糖尿病临床诊治特点

doi:10.12372/jcp.2023.22e1428

摘要/Abstract

摘要：

目的探讨儿科暴发性1型糖尿病（FT1DM）的临床诊治特点。方法回顾性分析2015年1月至2022年6月儿科重症监护室收治的初发糖尿病合并酮症酸中毒（DKA）患儿的临床资料，将研究对象分为FT1DM组和经典型1型糖尿病（TT1DM）合并DKA组，比较两组患儿临床特点和治疗情况。结果共纳入初发T1DM合并DKA患儿90例，男42例、女48例，中位年龄87.0（39.0~125.0）月，其中TT1DM合并DKA组85例，FT1DM组5例。所有入组患儿均无死亡及急性胰腺炎发生。FT1DM组的发病时间明显短于TT1DM合并DKA组，差异有统计学意义（P<0.05）。FT1DM组存在更显著的脱水、流感样症状、胸闷乏力、嗜睡，发生心动过速和呼吸增快的比例显著高于TT1DM合并DKA组，差异有统计学意义（P<0.05）。与TT1DM合并DKA组相比，FT1DM组血钠、糖化血红蛋白（HbAlc）、空腹C肽、血钠×HbAlc、抗谷氨酸脱羧酶抗体（GADA）和蛋白酪氨酸磷酸酶抗体（IA-2A）阳性比例较低，血钾、空腹血糖、入院时肌酐、血糖/HbAlc、血钾/HbAlc较高，差异有统计学意义（P<0.05）。与TT1DM合并DKA组相比，FT1DM组患儿入院24/48小时的液体复苏剂量、胰岛素总治疗剂量较高，酮症纠正时间较长，差异有统计学意义（P<0.05）。结论 FT1DM在儿科初发糖尿病患者中较少见，起病急骤，糖代谢紊乱更严重，并可影响多个系统。FT1DM患儿需要更长的治疗时间、输注更多的外源性胰岛素以及复苏扩容的液体。

关键词: 暴发性1型糖尿病, 经典1型糖尿病, 糖尿病酮症酸中毒, 糖化血红蛋白

Abstract:

Objective To investigate the clinical diagnosis and treatment of fulminant type 1 diabetes mellitus (FT1DM) in pediatrcis. Methods The clinical data of children with newly diagnosed diabetes mellitus complicated with ketoacidosis (DKA) admitted to the pediatric intensive care unit from January 2015 to June 2022 were retrospectively analyzed. The subjects were divided into FT1DM group and typical type 1 diabetes mellitus (TT1DM) combined with DKA group, and the clinical characteristics and treatment of the two groups were compared. Results A total of 90 children (42 boys and 48 girls) with initial T1DM complicated with DKA were included, and the median age was 87.0 (39.0-125.0) months. There were 85 children in TT1DM combined with DKA group and 5 in FT1DM group. None of the enrolled children died or had acute pancreatitis. The onset time of children in FT1DM group was significantly shorter than that of TT1DM combined with DKA group, and the difference was statistically significant (P<0.05). FT1DM group had more significant dehydration, influenza-like symptoms, chest tightness, fatigue and lethargy, and the proportion of tachycardia and tachypnea was significantly higher than that of TT1DM combined with DKA group, and the difference was statistically significant (P<0.05). Compared with TT1DM combined with DKA group, FT1DM group had lower levels of serum sodium, glycosylated hemoglobin (HbAlc), fasting C-peptide, sodium×HbAlc, and lower positive proportions of anti-glutamic acid decarboxylase antibody (GADA) and protein tyrosine phosphatase antibody (IA-2A); serum potassium, fasting blood glucose, creatinine, blood glucose/HbAlc and potassium/HbAlc were higher in FT1DM group, and the differences were statistically significant (P<0.05). Compared with TT1DM combined with DKA group, the fluid resuscitation dose and total therapeutic dose of insulin in FT1DM group were higher and the time to correct ketosis was longer at 24/48 hours after admission, and the difference was statistically significant (P<0.05). Conclusions FT1DM is rare in pediatric patients with newly diagnosed diabetes mellitus, has a sudden onset of disease, has a more severe disorder of glucose metabolism, and can affect multiple systems. Children with FT1DM require longer treatment periods, more exogenous insulin injections, and fluid for resuscitation and expansion.

Key words: fulminant type 1 diabetes mellitus, typical type 1 diabetes mellitus, diabetic ketoacidosis, glycosylated hemoglobin

李继如, 马朱圣颖, 钱雯, 邱慧楠, 许莉莉, 朱晓东. 儿童暴发性1型糖尿病临床诊治特点[J]. 临床儿科杂志, 2023, 41(6): 417-423.

LI Jiru, MA Zhushengying, QIAN Wen, QIU Huinan, XU Lili, ZHU Xiaodong. The clinical treatment characteristics of fulminant type 1 diabetes mellitus[J]. Journal of Clinical Pediatrics, 2023, 41(6): 417-423.

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参考文献 33

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项目	FT1DM(n=5)	TT1DM合并DKA(n=85)	统计量	P
年龄[M(P₂₅~P₇₅)]/月	60.0(16.0~86.0)	89.5(51.0~121.0)	Z=1.71	0.080
体重[M(P₂₅~P₇₅)]/kg	17.0(9.4~26.2)	24.0(15.5~32.5)	Z=1.48	0.130
男性[n(%)]	3(60.0)	39(45.9)	-	0.660¹⁾
家族史[n(%)]	1(20.0)	13(15.3)	-	0.580¹⁾
居住农村[n(%)]	3(60.0)	34(40.0)	-	0.390¹⁾
发病时间[M(P₂₅~P₇₅)]/d	4.0(3.0~5.0)	10.0(7.0~13.0)	Z=3.49	<0.001
临床表现
流感样症状[n(%)]	3(60.0)	10(11.8)	-	0.020¹⁾
嗜睡[n(%)]	3(60.0)	14(16.5)	-	0.040¹⁾
胸闷乏力[n(%)]	4(80.0)	18(21.2)	-	0.010¹⁾
呕吐/腹痛[n(%)]	3(60.0)	19(22.4)	-	0.090¹⁾
呼吸增快[n(%)]	4(80.0)	27(31.8)	-	0.040¹⁾
心动过速[n(%)]	3(60.0)	12(14.1)	-	0.030¹⁾
脱水[M(P₂₅~P₇₅)]/%	12.0(7.2~14.0)	9.0(7.8~10.0)	Z=2.21	0.030

项目	FT1DM(n=5)	TT1DM合并DKA(n=85)	统计量	P
钠[M(P₂₅~P₇₅)]/mmol·L^-1	129.0(128.0~130.0)	135.0(132.0~137.0)	Z=3.06	0.002
钾[M(P₂₅~P₇₅)]/mmol·L^-1	4.3(3.8~5.9)	3.8(3.4~4.4)	Z=2.06	0.040
空腹血糖[M(P₂₅~P₇₅))]/mmol·L^-1	29.3(28.9~33.4)	26(22.6~29.5)	Z=1.97	0.049
pH值[M(P₂₅~P₇₅)]	7.0(7.0~7.1)	7.1(7.0~7.2)	Z=0.42	0.960
BE[M(P₂₅~P₇₅)]/mmol·L^-1	-26.0(-27.0~-21.0)	-20.0(-26.0~-17.0)	Z=1.30	0.190
HCO^-₃[M(P₂₅~P₇₅)]/mmol·L^-1	4.2(3.6~6.1)	5.5(4.4~7.7)	Z=1.06	0.290
HbA1c[M(P₂₅~P₇₅)]/%	8.0(6.9~8.5)	12.5(11.0~14.4)	Z=3.47	0.001
空腹C-肽[M(P₂₅~P₇₅)]/nmol·L^-1	0.1(0.0~0.1)	0.2(0.1~0.5)	Z=2.66	0.008
胰岛素[M(P₂₅~P₇₅)]/pmol·L^-1	8.4(7.4~33.4)	14.1(8.1~36.0)	Z=0.57	0.570
入院时肌酐[M(P₂₅~P₇₅)]/μmol·L^-1	64.7(54.4~67.0)	40.6(32.5~56.3)	Z=2.36	0.020
出院时肌酐[M(P₂₅~P₇₅)]/μmol·L^-1	27.0(19.0~35.0)	21.0(18.0~27.0)	Z=1.58	0.510
ALT[M(P₂₅~P₇₅)]/U·L^-1	29.0(28.0~32.0)	23.0(18.0~27.0)	Z=1.61	0.110
TG[M(P₂₅~P₇₅)]/mmol·L^-1	4.5(3.2~12.5)	2.5(1.7~5.0)	Z=1.41	0.160
TC[M(P₂₅~P₇₅)]/mmol·L^-1	5.2(5.2~8.5)	4.8(4.1~6.4)	Z=0.17	0.240
尿比重(x±s)	1.0±0.0	1.0±0.0	t=0.21	0.830
尿酮体(x±s)/mg·dL^-1	148.0±2.0	140.0±5.0	t=0.43	0.670
GADA阳性[n(%)]	0(0)	46(54.1)	-	0.025¹⁾
IA-2A阳性[n(%)]	0(0)	52(61.2)	-	0.011¹⁾
FI
血糖/HbA1c[M(P₂₅~P₇₅)]/mmol·L^-1·%^-1	4.2(3.4~4.3)	2.1(1.8~2.6)	Z=3.47	0.001
血钾/HbA1c[M(P₂₅~P₇₅)]/mmol·L^-1·%^-1	0.6(0.5~0.7)	0.3(0.2~0.4)	Z=3.38	0.001
血钠×HbA1c[M(P₂₅~P₇₅)]/mmol·L^-1·%	1 032.0(875.0~1 088.0)	1 706.8(1 465.2~1 944.6)	Z=3.52	0.001

项目	FT1DM(n=5)	TT1DM合并DKA(n=85)	统计量	P
液体复苏剂量(x±s)/mL·kg^-1·h^-1
入院24 h	6.6±0.2	5.3±0.1	t=3.37	0.001
入院48 h	5.6±0.2	4.7±0.2	t=2.78	0.005
胰岛素剂量(x±s)/U·kg^-1·h^-1
入院24 h	0.092±0.008	0.079±0.002	t=3.27	0.001
入院48 h	0.128±0.003	0.102±0.005	t=2.79	0.005
治疗结局[M(P₂₅~P₇₅)]
酮症纠正时间/h	35.0(30.0~37.0)	21.5(17.0~28.0)	Z=2.79	0.005
PICU住院时间/d	3.5(3.0~4.0)	3.0(2.0~4.0)	Z=0.92	0.361
总住院时间/d	9.0(8.0~11.0)	9.5(8.0~12.0)	Z=0.96	0.340