儿童糖尿病合并酮症酸中毒和高血糖高渗状态临床特征分析

目的了解儿童糖尿病合并酮症酸中毒(DKA)和高血糖高渗状态(HHS)的临床特征。方法依据诊断标准,从1995年1月至2009年12月新确诊的糖尿病患儿中筛选DKA和HHS患儿,比较糖尿病同时合并DKA和HHS(DKA-HHS)与单纯DKA患儿的临床特点。结果 1 065例新诊断儿童糖尿病患儿中有483例合并DKA,占45.35%;16例符合DKA-HHS,占1.50%;无单纯HHS糖尿病患儿。HHS在DKA患儿中的发生率为3.31%,其中1型糖尿病14例,2型糖尿病2例。HHS在年龄≥10岁的DKA患儿中的发生率明显高于小年龄患儿(χ2=6.05,P<0.05)。DKA-HHS患儿中重度脱水的比例、平均有效渗透压、血糖、三酰甘油及尿素氮水平均显著高于单纯DKA患儿,且酸中毒程度明显重于单纯DKA患儿,差异均有统计学意义(P均<0.05);DKA-HHS患儿的校正血清钠水平显著高于单纯DKA患儿,差异有统计学意义(P<0.05)。结论新诊断糖尿病患儿的HHS发生率较DKA低,且均与DKA合并存在;更常见于≥10岁患儿;DKA-HHS较单纯DKA患儿的代谢紊乱程度、脱水及酸中毒程度更严重,肾功能异常率更高。     

儿童1型糖尿病酮症酸中毒合并低磷血症临床研究

目的 总结儿童1型糖尿病酮症酸中毒（DKA）合并低磷血症的临床特点,探讨DKA治疗期间低磷血症的发生率及预后。方法 回顾性分析2016年1月至2020年6月于广州市妇女儿童医疗中心遗传与内分泌科住院治疗的133例合并DKA的1型糖尿病患儿临床资料,分析入院后4～24h血磷水平,并对影响儿童血磷变化的相关因素进行分析。结果 133例DKA患儿中男55例（41%）,女78例（59%）,年龄6月龄至15岁,平均年龄（6.7±3.9）岁,新发1型糖尿病占72%。75例（56%）患儿出现血磷降低,其中41例（31%）患儿血磷0.81～1.29 mmol/L,22例（16%）患儿血磷0.61～0.81mmol/L,10例（7.5%）患儿血磷0.38～0.61mmol/L,2例（1.5%）患儿血磷<0.38mmol/L。正常血磷组与低血磷组之间pH值、碳酸氢根（HCO3-）、碱剩余（BE-B）、血钾、血氯差异均有统计学意义。酸中毒、年龄≤5岁为影响儿童DKA时血磷降低严重程度的危险因素。75例低血磷患儿均未出现低磷血症相关临床症状,未补充磷酸盐治疗。34例血磷<0.81mmol/L的患儿...     

儿童青少年1型糖尿病患儿发生酮症酸中毒的危险因素分析及预测模型的建立

目的 研究儿童青少年1型糖尿病（type 1 diabetes mellitus, T1DM）发生糖尿病酮症酸中毒（diabetic ketoacidosis, DKA）的危险因素,并建立DKA风险预测模型,以期降低该类患儿DKA的发生率,提高患儿生存质量。方法 回顾性选择2018年1月—2021年12月宁夏医科大学总医院收治的217例T1DM患儿,其中169例发生DKA患儿为DKA组,48例未发生DKA患儿为非DKA组。分析T1DM患儿发生DKA的危险因素,并建立预测T1DM患儿发生DKA风险的列线图模型。结果 217例T1DM患儿中DKA发生率为77.9%(169/217)。多因素logistic回归分析显示,T1DM患儿入院随机血糖高、糖化血红蛋白高（hemoglobin A1c, HbA1c）、血酮高、甘油三酯高与发生DKA密切相关（分别OR=1.156、3.203×1015、20.131、9.519,P<0.05）。列线图预测模型C-统计量为0.95,列线图模型预测T1DM患儿发生DKA的风险与实际发生DKA的风险平均绝对误差为0.004,说明模型整体预测能力较好。结论...     

初发1型糖尿病患儿酮症酸中毒的调查

目的调查初发1型糖尿病患儿酮症酸中毒(DKA)的发生情况。方法以224例初发1型糖尿病患儿为研究对象,进行回顾性分析,分为DKA组和未合并DKA组,各112例。DKA组患儿根据年龄分为≥5岁组(65例)和5岁组(47例),并根据酸中毒情况分为轻度(26例)、中度(29例)、重度(57例)3组。分析DKA发生的影响因素以及不同年龄DKA患儿的临床及实验室特点。结果 224例初发1型糖尿病患儿中最常见的症状为多饮(86.2%)、多尿(78.6%)及体重下降(57.1%)。与未合并DKA患儿比较,DKA组5岁、低收入、父母教育程度高中及以下所占的比例均较高,随机血糖、Hb A1C水平较高,pH、HCO_3~-及C肽水平更低,差异均具有统计学意义(P0.05)。≥5岁组与5岁组的轻、中、重度DKA所占比例的差异无统计学意义(P0.05)。与5岁组相比,≥5岁组DKA患儿的症状持续时间较长,随机血糖较低,HbA1C、C肽水平较高,差异具有统计学意义(P0.05)。结论 1型糖尿病患儿DKA发生率高,DKA的发生与年龄、父母文化程度及家庭收入有关。     

儿童糖尿病临床与分子遗传学病因分析

目的 明确儿童单基因糖尿病的临床特点和分子遗传学病因。方法 回顾性分析2020年8月至2021年12月收治的76例糖尿病患儿的临床表现和初诊时实验室检查。按照儿童糖尿病分型,分为青少年的成人起病型糖尿病(MODY)组(n=7)、2型糖尿病(T2DM)组(n=7)和1型糖尿病(T1DM)组(n=62)。对其中21例疑似单基因糖尿病患儿行全外显子测序(WES)。结果 WES共发现7例单基因糖尿病,均为青少年的成人起病型糖尿病(MODY),3例为GCK变异所致MODY2,3例为HNF1A变异所致MODY3,1例为INS变异所致MODY10。共发现2种未见报道新变异：GCK的c.1124T>G(p.V375G),INS的c.110A>T(p.E37V)变异。7例中5例MODY患儿起病时无典型糖尿病症状,以偶然发现血糖升高入院。MODY组、T2DM组和T1DM组间初诊时空腹血糖、C肽、胰岛素、HbA1c差异均有统计学意义(P<0.05)。MODY组血糖及糖化血红蛋白较T1DM组降低;C肽水平较T1DM组升高,较T2DM组降低;胰岛素水平低于T1DM组和T2DM组,差异均有统计学...     

1型糖尿病酮症酸中毒患儿缺氧诱导因子-1α与血管内皮细胞生长因子mRNA表达水平的变化

目的探讨1型糖尿病(T1DM)酮症酸中毒(DKA)患儿缺氧诱导因子-1α(HIF-1α)与血管内皮细胞生长因子(VEGF)mRNA水平的变化。方法天津市儿童医院住院T1DM并DKA患儿30例,于确诊24 h内(DKA 1组)及DKA纠正后10 d(DKA 2组)采血,另选取同期住院的不伴感染、缺氧、肿瘤或结缔组织病的同年龄同性别患儿30例为对照组。实时荧光定量PCR(Real-time PCR)法测定其外周血CD4+T淋巴细胞HIF-1α与VEGF mRNA的相对表达水平。PCR产物行琼脂糖凝胶电泳鉴定特异性。采用SPSS 13.0软件进行统计学分析。结果 3组HIF-1α及VEGF mRNA相对表达水平比较差异均有统计学意义(Pa<0.01)。DKA1组HIF-1α及VEGF水平明显高于对照组,差异有统计学意义(Pa<0.01);DKA纠正后HIF-1α及VEGF水平恢复,差异有统计学意义(P<0.05,0.01),但直至DKA纠正后10 d(DKA2组)仍未恢复至对照组水平,差异有统计学意义(P<0.01,0.05)。Real-timePCR产物行琼脂糖凝胶电泳,产物位于预期位置,确定产物特异性。结论 T1DM并DKA患儿CD4+T淋巴细胞HIF-1α与VEGFmRNA水平升高,且DKA纠正后HIF-1α与VEGF mRNA水平不能恢复至正常,这可能与T1DM并发症的发生发展有关。     

儿童1型糖尿病的10年回顾及白介素-10在糖尿病酮症酸中毒中的临床意义

目的：回顾浙江大学医学院附属儿童医院10年来住院儿童 1 型糖尿病的发病状况并探讨白介素-10（IL-10）在儿童 1 型糖尿病酮症酸中毒（DKA）中的临床意义。方法：对1999年1月至2009年2月在该院住院的263例334例次1型糖尿病患儿的临床资料进行回顾性分析;并对其中48例1型糖尿病患儿进行血脂、细胞因子等检查,根据有无酮症酸中毒分为 DKA组和非DKA组,24例正常健康儿童作为对照组,比较各组间血脂、细胞因子等参数的差异。结果：儿童1型糖尿病患儿中,女性多见（56.3%）,发病年龄以6~11.9岁多见。32.7% 的患儿以酮症酸中毒为就诊表现。DKA组血脂、血糖及糖化血红蛋白均高于非DKA组,二分类logistic 回归分析示上述指标水平的升高均为酮症酸中毒的危险因素。IL-10水平在DKA组明显升高,余细胞因子在DKA组和非DKA组无明显差异。糖尿病组各细胞因子水平明显高于正常对照组。结论：1型糖尿病患儿酮症酸中毒发生率较高,糖、脂代谢紊乱是酮症酸中毒的危险因素。IL-10可能为酮症酸中毒的敏感指标。［中国当代儿科杂志,2010,12（11）：849-854］     

不同血钾水平1型糖尿病175例的临床特征

目的了解不同血钾水平儿童及青少年1型糖尿病临床特征。方法1型糖尿病患者175例根据血钾水平将其分为3组：A组血钾〈4 mmol/L,C组血钾≥5 mmol/L,B组血钾正常（4~5 mmol/L）。对3组性别、年龄、住院时间、伴发呕吐、感染、酮症酸中毒（DKA）的比例及生化指标等临床特征进行观察。分析血钾紊乱和不同临床表现之间的关系及可能原因。结果血钾异常组较易发生代谢紊乱及伴发症状。A组40例,其发生酮症酸中毒及感染比例比B组要高。A组血氯水平最高。C组36例,发生呕吐比例比B组高,其患儿年龄较A组小,C组入院时血糖水平在3组中最高。结论糖尿病发生代谢紊乱和急性并发症时,易并血钾异常,治疗方面应积极纠正血钾紊乱。     

1型糖尿病并低三碘甲状腺氨酸综合征201例

目的探讨1型糖尿病(T1DM)及糖尿病酮症酸中毒(DKA)患儿并低三碘甲状腺氨酸(T3)综合征的临床特点。方法采用放射免疫分析法检测91例T1DM并DKA患儿(DKA组)及110例单纯T1DM患儿(非DKA组)血清T3、甲状腺素(T4)、促甲状腺激素(TSH)水平,观察2组T3、T4下降例数及水平,并将DKA组分为轻、中、重3个亚组,观察不同组别中甲状腺激素变化特点。结果 DKA组易发生T3、T4下降,DKA组T3[(0.54±0.51)μg.L-1]、T4[(5.65±2.80)μg.L-1]与非DKA组T3[(1.02±0.38)μg.L-1]、T4[(9.28±2.85)μg.L-1]比较,差异均有统计学意义(Pa<0.000 1)。中、重度DKA组与非DKA组T3比较,差异有统计学意义(Pa<0.000 1),轻、中、重度DKA组与非DKA组T4比较,差异均有统计学意义(Pa<0.000 4,0.000 1)。DKA组与非DKA组TSH比较,差异无统计学意义(P>0.05)。结论 T1DM患儿甲状腺激素检测的结果主要表现为T3降低,部分伴T4降低,其疾病的严重程度与甲状腺激素降低程度一致,T1DM并DKA患儿的T3、T4水平均有明显下降,提示T1DM患儿需重视甲状腺激素的检测,利于早期防治。     

胰岛素泵治疗儿童1型糖尿病酮症酸中毒32例临床分析

目的 观察胰岛素泵持续皮下注射胰岛素对儿童1型糖尿病酮症酸中毒(DKA)的疗效.方法 将2005-2008年收治的1型DKA患儿64例分为治疗组32例和对照组32例.治疗组予胰岛素泵治疗,对照组予小剂量胰岛素持续静脉滴注治疗.比较两组患儿血精变化、DKA纠正时间及住院时间.结果 治疗组血糖下降相对稳定,酸中毒纠正时间治疗组[(16.91±4.223)h]短于对照组[(23.31±3.797)h](P<0.001),且无反复.治疗过程中治疗组未出现低血糖,对照组出现1例.住院时间治疗组[(15.63±2.458)d]短于对照组[(20.88±3.348)d](P<0.001).结论 胰岛素泵持续皮下注射胰岛索治疗儿童1型糖尿病酮症酸中毒安全有效.     

Rational use of antibiotics in children with diabetic ketoacidosis needs attention

Diabetic ketoacidosis (DKA) in children may lead to acute kidney injury (AKI). Among 45 children with DKA in our center, eight cases had AKI on admission, and in one child, his kidney function did not recover until 3 mo after discharge. This child was treated with antibiotics (cephalosporin), and we cannot rule out delayed AKI recovery due to the combined effects of the drug and the disease. Pediatricians should be concerned about the impact of nephrotoxic drug and disease interactions on children's kidney function, and need to follow up children with DKA and AKI to determine the development of AKI.     

低白蛋白血症对心脏手术后患儿急性肾损伤发生的影响

目的 探讨小儿心脏病体外循环（CPB）手术后的低白蛋白血症对术后急性肾损伤（AKI）发生的影响。方法 回顾性分析2012~2016年行心脏病CPB手术患儿1 110例临床资料,按术后48 h内最低白蛋白浓度分为低白蛋白组（≤35 g/L）和正常白蛋白组（> 35 g/L）,比较两组患儿的围手术期资料和AKI发生率。对不均衡的围手术期各因素进行倾向评分匹配后再次比较AKI发生率。采用logistic回归分析术后AKI发生的围手术期危险因素。结果 术后AKI发生率为13.78%（153/1 110）,病死率为2.52%（28/1 110）,AKI患儿病死率为13.1%（20/153）,术后白蛋白≤35 g/L 的患儿占44.50%（494/1 110）。匹配前后低白蛋白组AKI发生率均比正常白蛋白组要高（P < 0.05）;匹配前后AKI患儿术后白蛋白浓度均低于非AKI患儿（P < 0.05）;Logistic多因素回归分析结果显示术后白蛋白≤35 g/L是术后AKI发生的独立危险因素之一。结论 术后48 h内白蛋白≤35 g/L是心脏CPB术后患儿AKI发生的独立危险因素,术后加强对白蛋白的检测和补充对控制术后AKI的发生有积极作用。     

Clinical features at the onset of childhood type 1 diabetes mellitus in Shenyang,China

Aim: To describe the clinical picture and laboratory features of Chinese children with newly diagnosed type 1 diabetes mellitus. Methods: The clinical and laboratory data of a total of 203 children who presented with newly diagnosed type 1 diabetes mellitus during a 5‐year period (2004–2008) were retrospectively analysed based on hospital records. Results: There were 88 boys (43.3%) and 115 girls (56.7%) with a median age of 8.3 years. The age distribution was categorised as 0–4 years: 52 (25.6%), 5–9 years: 57 (28.1%) and 10–14 years: 94 (46.3%). We found a peak incidence rate in the older age group. No significant seasonality was observed. The most common symptoms were polydipsia, polyuria and weight loss. Eighty‐five (41.9%) of all patients presented with diabetic ketoacidosis (DKA). The average duration of presenting symptoms before the hospital encounter was 24.5 days. Young age group children had shorter duration (17.1 days, P= 0.03) and significantly lower levels of C‐peptide (P= 0.003) and haemoglobin A1c (P= 0.049) than the other groups. Children with DKA had a higher incidence of preceding infections (P= 0.032), lower free triiodothyronine and free thyroxine levels (P= 0.035, 0.046), and higher white blood cell counts (P= 0.000) than the non‐DKA group. Conclusion: The duration between the onset of the symptoms and diagnosis was long, and the proportion of DKA in children with newly diagnosed diabetes mellitus was high. These findings call for a collaborative effort for the early recognition of symptoms by patients and physicians in order to avoid more severe types of presentation.     

儿童造血干细胞移植后急性肾损伤相关危险因素的回顾性研究

目的 探讨造血干细胞移植（hematopoietic stem cell transplantation,HSCT）后急性肾损伤（acute kidney injury,AKI）的危险因素。 方法 回顾性研究2018年1月至2020年1月111例行HSCT患儿的临床资料。采用多因素logistic回归分析筛选出AKI发生的影响因素;采用Kaplan-Meier生存分析比较不同级别AKI患儿生存预后差异。 结果 111例HSCT患儿中,AKI发生率为52.3%（58/111）。移植物抗宿主病（Ⅱ~Ⅳ度）（OR=4.406,95%CI：1.501~12.933,P=0.007）、肝小静脉闭塞综合征（OR=4.190,95%CI：1.191~14.740,P=0.026）、血栓性微血管病（OR=10.441,95%CI：1.148~94.995,P=0.037）与HSCT患儿移植后AKI发生密切相关。AKI Ⅲ期患儿的1年生存率（28.6%±12.1%）低于NAKI（82.8%±5.2%）、AKI Ⅰ期（81.7%±7.4%）、AKI Ⅱ期（68.8%±11.6%）患儿（P<0.05）。 结论 患儿HSCT后发生Ⅲ期AKI具有较高的病死率;移植物抗宿主病、肝小静脉闭塞综合征、血栓性微血管病与HSCT后AKI发生密切相关。     

Factors associated with childhood diabetes manifesting as ketoacidosis and its severity]

INTRODUCTION: Type 1 diabetes in children in France is frequently diagnosed at the stage of ketoacidosis (DKA). PATIENTS AND METHODS: A prospective study was performed in a group of 72 children (mean age = 9.4 years) at onset of diabetes, in order to determine which factors were associated to DKA and to the severity of DKA (pH < 7.10) at diagnosis. RESULTS: Younger age was related to DKA (p = 0.03), but not to its severity. A lesser frequency of DKA was found in children with a family history of insulin-treated diabetes ( p = 0.04). Misdiagnosis was more frequently observed in children with DKA than in children without DKA (p = 0.02) and in case of severe DKA at admission by comparison with non severe cases (76 vs 23%; p = 0.002). Children in low economic intake families exhibited more frequently a severe DKA (77 vs 23%; p = 0.002) and were more frequently misdiagnosed before admission (48% vs 10%; p < 0.01). Urine strips for glucose and ketone determinations were underused for diagnosis before admission (15% only). CONCLUSION: Those results underline the need to both inform physicians and ameliorate the access to health care for low social class families, in order to take up the challenge of reducing the incidence of DKA at diagnosis in diabetic children in our country.     

The changing presentation of children with newly diagnosed type 1 diabetes mellitus

Abstract: Although it is known that the incidence of type 1 diabetes mellitus (DM) in childhood is progressively increasing, it is less clear whether the presentation of newly diagnosed DM is changing. The aim of this study was to establish whether any biochemical or clinical presentation parameters have altered over time.
A retrospective study was performed comparing newly diagnosed children with DM in two 24 month time intervals, 8 yrs apart (1988–89 and 1995–96). Fifty-seven children were diagnosed with type 1 DM in 1988–89 and 70 children in 1995–96. At presentation, children born in the later cohort had a higher pH (p < 0.001) and lower serum glucose (p < 0.05). Although the frequency of diabetic ketoacidosis (DKA) was higher in the 1988/89 cohort (63% vs. 42% in 1995/96) the absolute number of children with DKA in each time interval was similar (33 subjects in 1988–89 vs. 30 subjects in 1995/96). Islet cell antibody (ICA) levels were very different between the two cohorts; higher antibody levels were found in the 1988/89 group (p < 0.01). DKA was also associated with higher ICA titres (p < 0.05). Hospital admission stay decreased from 6.5 DS to 3.4 DS over the 8-year period (p < 0.0001).
At our institution, the presentation of children with type 1 D M is changing with many more children diagnosed before developing DKA. We speculate that a new environmental factor(s) may be responsible for the absolute increase in patients presenting without DKA, while older etiologies (both genetic and environmental) are responsible for the steady, unchanging number of patients with a more severe presentation. Greater awareness of diabetes in children is not the factor contributing to earlier diagnosis before DKA develops.     

不同液体负荷状态对持续肾替代治疗脓毒症相关急性肾损伤患儿预后的影响北大核心CSCD

目的评估不同液体负荷(fluid load,FL)对使用持续肾替代治疗(continuous renal replacement therapy,CRRT)的脓毒症相关急性肾损伤(acute kidney injury,AKI)患儿预后的影响。方法回顾性选取2018年8月至2021年3月因脓毒症相关AKI行CRRT的患儿121例为研究对象,根据患儿从入院或病情变化开始至行CRRT前的不同FL分为低液体负荷组(n=35,FL<5%)、高液体负荷组(n=35,5%≤FL<10%)和液体超负荷组(n=51,FL≥10%)。收集各组患儿CRRT治疗前的基线资料和临床生化资料进行比较分析。采用Kaplan-Meier生存曲线分析各组间的28 d生存情况。采用多因素logistic回归分析影响不同FL状态患儿预后的危险因素。结果生存分析结果提示液体超负荷组患儿28 d病死率高于低液体负荷组和高液体负荷组(P<0.05);多因素logistic回归分析结果提示正超液体量增加为导致液体超负荷组患儿28 d病死率增高的危险因素,而CRRT开始时间提前为其保护因素(P<0.05)。结论CRRT开始前液体超负荷会增加脓毒症相关AKI患儿的病死率,对该类患儿应尽早行CRRT治疗。     

Clinical characteristics at presentation of type 1 diabetes mellitus in children younger than 15 years in Croatia

The aim of the study was to determine the clinical and biochemical characteristics of type 1 diabetes mellitus (DM) at presentation in children younger than 15 years in Croatia during a 9-year period, with special attention to diabetic ketoacidosis (DKA) incidence. The registered data set comprised blood glucose, pH, serum bicarbonate levels, and clinical symptoms at disease manifestation. During the study period, 692 children were diagnosed with type 1 DM. Polydipsia (96.7%), polyuria (96.05%), and weight loss (82.7%) were the most frequent symptoms anticipating disease detection. Enuresis was recorded in 11.55%. A total of 36.41% patients had DKA (pH < 7.3) at disease onset. During the 9-year period, the percentage of children presenting with DKA at time of diagnosis decreased from 41.67% to 33.33% (z = 1.68, p = 0.046). A positive family history of DM, the only factor with an impact on the DKA incidence rate in our population, lowers the probability of the development of ketoacidosis. This study confirms the importance of the detection of the classic symptoms of polyuria, polydipsia, and weight loss in patients with new-onset type 1 DM. The percentage of patients with DKA at diabetes onset decreased during the observed period but is still high and includes one-third of all patients. This is why in every acutely ill child, especially at a younger age, one should evaluate the possibility of type 1 DM to avoid the development of ketoacidosis.     

Trends in diabetic ketoacidosis in childhood and adolescence: a 15-yr experience

Abstract: The number of episodes of diabetic ketoacidosis (DKA) is a significant outcome measure for diabetes care. We ascertained patterns of admission due to DKA over 15 yr to determine whether this indicator of diabetes care had improved in parallel with clinical practices. Between 1 January 1985 and 31 December 1999, 630 admissions were reviewed. We subanalyzed these admissions according to whether the patient was newly diagnosed, had infrequent episodes of DKA (non-relapsers) or had frequent (≥ 2/yr) episodes of DKA (relapsers). Overall there was a slight downward trend in the incidence of DKA admissions over the study period. There was a proportionate increase in the incidence of DKA amongst newly diagnosed patients, with a proportionate decrease in the incidence of DKA seen in relapsers. DKA occurring in non-relapsers remained relatively stable. Adverse clinical events during the admission were relatively uncommon and occurred in all three subgroups. There was no significant difference in HbA1C prior to admission between the relapser and non-relapser groups and there was similarity in the degree of acidosis between all three subgroups. The frequency of significant complications associated with DKA remained unchanged over the study period. Slower rehydration policies were not associated with decreases in either cerebral edema or death rates. DKA remains a significant complication of type 1 diabetes associated with a variety of significant adverse events. Our experience indicates that further efforts to reduce the occurrence of DKA must be focused upon earlier diagnosis and intervention in newly diagnosed patients.