糖尿病酮症酸中毒合并高脂血症和急性胰腺炎一例

患者,男性,38岁,因发现血糖升高2年,上腹疼痛、呕吐半天于凌晨1:00入院。2年前在体检中发现空腹血糖升高,行口服葡萄糖耐量试验(OGTT)诊断为“2型糖尿病”,不规则地口服二甲双胍治疗,未服其它药物。半天前在正常饮食的情况下,出现上腹部持续性疼痛,阵发性加剧呈绞痛样,伴恶心、     

儿童及青少年糖尿病酮症酸中毒合并急性胰腺炎患者临床特点分析

目的了解儿童糖尿病酮症酸中毒(DKA)合并胰酶升高患者的临床特点、治疗经验及转归,为避免过度诊断急性胰腺炎(AP)和过度的长期禁食治疗提供证据。方法回顾性调查首都医科大学附属北京儿童医院内分泌遗传代谢中心2015年1月至2019年1月收治的年龄小于18岁的DKA合并胰酶升高的患儿,分析其临床症状、血淀粉酶、脂肪酶、血脂、胰腺影像学资料、治疗及临床转归等,总结治疗经验。数据采用中位数(上下四分位数)表示。结果4年共收治330例DKA患儿,38例(11.5%)合并胰酶升高,升高3倍以上的有22例(6.7%)。16例(4.8%)无胰腺影像学改变为疑诊AP,其中14例无腹痛症状,未经AP相关治疗,预后良好;1例有腹痛症状,常规进行DKA治疗,第2天腹痛症状缓解;另外1例合并腹痛症状的患者按照AP治疗12 d,在第14天开始尝试经口喂养,虽有胰酶复升高,但继续按原计划进行营养治疗病情无反复。6例(1.8%)合并胰酶升高患儿有影像学改变为确诊AP,4例有腹痛,6例均按照AP常规治疗,腹痛症状2~19 d缓解,胰酶2~15 d降至3倍以下,禁食时间3~60 d,随访5~32个月均无AP复发。结论DKA患儿胰酶增高并不少见,但AP发生率低,且预后好,是一个相对良性的过程,尚需更多数据证明。     

Aminoaciduria and metabolic dysregulation during diabetic ketoacidosis: Results from the diabetic kidney alarm (DKA) study

ObjectiveWe examined changes in the excretion of various amino acids and in glycolysis and ketogenesis-related metabolites, during and after diabetic ketoacidosis (DKA) diagnosis, in youth with known or new onset type 1 diabetes (T1D).MethodsUrine samples were collected from 40 youth with DKA (52% boys, mean age 11 ± 4 years, venous pH 7.2 ± 0.1, blood glucose 451 ± 163 mg/dL) at 3 time points: 0–8 h and 12–24 h after starting an insulin infusion, and 3 months after hospital discharge. Mixed-effects models evaluated the changes in amino acids and other metabolites in the urine.ResultsConcentrations of urine histidine, threonine, tryptophan, and leucine per creatinine were highest at 0–8 h (148.8 ± 23.5, 59.5 ± 12.3, 15.4 ± 1.4, and 24.5 ± 2.4% of urine creatinine, respectively), and significantly decreased over 3 months (p = 0.028, p = 0.027, p = 0.019, and p < 0.0001, respectively). Urine histidine, threonine, tryptophan, and leucine per urine creatinine decreased by 10.6 ± 19.2, 0.7 ± 0.9, 1.3 ± 0.9, and 0.5 ± 0.3-fold, respectively, between 0 and 8 h and 3 months.ConclusionsIn our study, DKA was associated with profound aminoaciduria, suggestive of proximal tubular dysfunction analogous to Fanconi syndrome.     

六例糖尿病酮症酸中毒合并高脂血症和急性胰腺炎临床分析

目的提高临床医师对糖尿病酮症酸中毒(DKA)合并高脂血症(HL)和急性胰腺炎(AP)的认识。方法回顾性分析6例DKA合并HL和AP患者的临床资料。结果除DKA的临床特征外,还有:(1)6例患者均为中青年,年龄(34.2±4.1)岁,以急性腹痛就诊,均有腹部压痛;(2)入院时均有HL,次晨查甘油三酯(14．2-62．2 mmol/L),总胆固醇(8．9～29．4 mmol/L),治疗48-72h后甘油三酯降至(1.98 -5．39 mmol/L),总胆固醇降至(4．52-7．36 mmol/L);(3)AP发作期间5例患者血和(或)尿淀粉酶升高3倍以上,仅1例患者升高不到1倍;5例患者胰腺CT检查有AP改变,但其中3例患者B超显示胰腺正常;(4)治愈的5例患者以及时有效地纠正DKA和禁食治疗为基本措施,治疗后腹痛消失,血尿淀粉酶恢复正常。结论(1)以腹痛就诊的DKA患者,应查甘油三酯、血尿淀粉酶和腹部CT以排除AP;(2)纠正DKA和禁食是治疗暂时性显著HL和AP的关键。     

Association between diabetic ketoacidosis and thyrotoxicosis

Three cases of diabetic ketoacidosis precipitated by thyrotoxicosis are presented. Two of them are young women with type 1 diabetes mellitus; the third case is a middle-aged woman with type 2 diabetes mellitus. All of them were diagnosed with Graves' disease. They typically showed tachycardia at rest in spite of correction of the metabolic disorder. Hyperthyroidism worsens glycemic control in diabetic patients and may precipitate diabetic ketoacidosis. On the other hand, women with diabetes have a higher prevalence of Graves' disease. Thus, in diabetic ketoacidosis without an obvious triggering factor, the presence of hyperthyroidism should be investigated, particularly in women. Received: 30 September 2001 / Accepted in revised form: 13 May 2002 Correspondence to A. Hernández-Mijares     

糖尿病酮症酸中毒合并急性胰腺炎、重度低磷血症1例

DKA与急性胰腺炎(AP)在诊治上容易误诊漏诊,故提高DKA合并AP、重度低磷血症的诊治水平十分必要.本研究回顾性分析DKA合并AP、重度低磷血症1例患者的临床资料,旨在为临床分析及诊治DKA合并AP、重度低磷血症提供参考.     

Unusual renal involvement during diabetic ketoacidosis (DKA) in a newly diagnosed type I diabetic child

Summary A 10-year-old boy, in a precomatose state, was admitted to our Endocrine Unit for diabetic keatoacidosis. It took unusually long to reequilibrate the acidosis despite a bicarbonate drip. On the 4th day the patient suddenly complained of an acute abdominal pain associated with macrohematuria and oliguria; ankle edema was evident. No radio-opaque image was detected along the urinary tract. An intravenous pyelogram (IVP) showed an almost totally silent left kidney. Ten days later a control IVP showed complete normality of both kidneys. We postulated that the serious and protracted dehydration might have resulted in the formation of a blood clot along the renal tract and that the rehydration may have subsequently removed it.     

Factors associated with mortality in children with diabetic ketoacidosis (DKA) in South India

Mortality in diabetic ketoacidosis (DKA) among children has been reported to be 0.3–3 % in developed countries. Based on the limited data from developing countries, the mortality reported is as high as 13.4 %. A prospective study was conducted to identify the factors leading to high mortality in children with DKA in South India. This was a study of 118 episodes of DKA among children, admitted in a pediatric tertiary care center at Chennai. Clinical presentation, laboratory parameters at admission, parameters during treatment, and complications were considered as risk factors. All children were followed up till discharge from hospital or death. Univariate and multivariate analyses for risk factors were undertaken. Altered sensorium and higher osmolality at admission, delayed diagnosis, cerebral edema, shock, renal failure, and sepsis were the major risk factors associated with mortality in multivariate analysis. Cerebral edema was encountered in 23.7 %, shock in 12.7 %, sepsis in 11 %, and renal failure in 9.3 %. The overall mortality rate was 11 %. Delayed diagnosis may be the root cause for high mortality in children with DKA in developing countries. There is an urgent need to create awareness among physicians, teachers, and parents to avoid a delay in diagnosis and decrease the mortality in children with DKA. Higher incidence of cerebral edema, shock, renal failure, and sepsis are unique problems identified in this study. There is a need for further studies on fluid management of shock, strategies for management of renal failure in DKA, and use of antibiotics in DKA in developing countries.     

Characteristics of young adults with multiple episodes of diabetic ketoacidosis

Transition from paediatric to adult diabetes care can be associated with a deterioration in metabolic control and hospitalisation. This was a retrospective review (2012–2016) of medical records of all patients attending a transition diabetes clinic in a teaching hospital with paediatric and adult diabetes on the same site. Among the 91/102 (89.2%) patients with type 1 diabetes, mean age at first visit was 19 ± 2 years, last body mass index was 25.2 ± 4.7 kg/m², diabetes duration was 11 ± 6 years and 22 (24%) used continuous subcutaneous insulin infusions. Loss to follow‐up was 15 (14.7%). Mental health issues were common (59%), as were prior pregnancies (23%) and diabetic ketoacidosis since diagnosis (39%). Those with diabetic ketoacidosis had a higher mean glycated haemoglobin (70 ± 19 vs 86 ± 25 mmol/mol or 8.6 ± 1.7 vs 10.0 ± 2.3%; P = 0.001), fewer clinic attendances (8 ± 5 vs 5 ± 4; P = 0.008) and fewer years in clinic (1.8 ± 1.7 vs 2.3 ± 1.4; P = 0.114). Our data suggest that investment in joint approaches with mental health services should be considered.     

糖尿病酮症酸中毒致高甘油三脂血症性胰腺炎一例报道

12岁患儿因呕吐、腹痛、气促嗜睡入院。实验室检查示血糖、尿糖、尿酮体、尿淀粉酶升高,酸中毒。血呈乳糜微粒状,TG明显升高。腹部CT支持胰腺炎表现。基因检测结果示患儿低密度脂蛋白受体基因存在c.1516G>A杂合突变。诊断患儿DKA致高甘油三脂血症性胰腺炎(HTGP)。给予禁食、Ins、血浆置换及药物降脂治疗后,患儿血脂、血糖正常。DKA致HTGP在儿童发病率低,临床医生认识不足,早期发现并积极降脂治疗有助于减轻临床症状并改善预后。     

Acute pancreatitis with diabetic ketoacidosis associated with hypermyoglobinemia,acute renal failure,and DIC

We report a case of acute pancreatitis with diabetic ketoacidosis associated with increased serum myoglobin concentration, acute renal failure, and disseminated intravascular coagulation. A 49-year-old man suffering from diarrhea, vomiting, and somnolence was admitted to the hospital. He had had flu-like symptoms for 4 days prior to the onset of these symptoms. He was a habitual drinker and had been consuming 360 ml–900 ml of the drink “shochu” (distilled spirits containing 28% alcohol) daily for 30 years. Laboratory data on admission revealed elevated serum levels of pancreatic enzymes, including amylase, trypsin, lipase, pancreatic secretory trypsin inhibitor (PSTI), phospholipase A₂ (PLA₂), and elastase-1, as well as elevated levels of glucose (373 mg/dl), ketone bodies (3675 μmol/l), and myoglobin (229.8 ng/ml). Treatment with subcutaneous insulin and intravenous administration of electrolyte fluid and the systemic protease inhibitor, gabexate mesilate, was begun immediately. Early after the initiation of treatment, there was an increase in serum cretinine (4.9 mg/dl), and thrombocytopenia (15000/μl) was observed. The patient completely recovered from renal failure and acute pancreatitis, but required insulin therapy. Alcohol ingestion and dehydration are thought to have played a major role in the triggering of the acute pancreatitis, We examined the relationship among acute pancreatitis, diabetic ketoacidosis, and hypermyoglobinemia in the literature.     

Frequent hypoglycemic episodes in the treatment of patients with diabetic ketoacidosis.

BACKGROUND--Previous studies of the management of diabetic ketoacidosis have noted a wide range of incidence of hypoglycemia but have not studied the risk factors associated with it. METHODS--To describe the incidence of hypoglycemia in patients hospitalized with diabetic ketoacidosis, we retrospectively reviewed the charts of all adult patients with the diagnosis of diabetic ketoacidosis at three private, community hospitals in Milwaukee, Wis, between January 1, 1987, and May 31, 1990. Two hundred twenty admissions in 150 patients met our inclusion criteria. RESULTS--In 30% (66/220) of cases of diabetic ketoacidosis, a serum glucose level or Accu-Chek (Boehringer-Mannheim, Indianapolis, Ind) finding was 2.7 mmol/L or less during the first 14 days of hospitalization. No factors could be identified that were associated with a significantly increased risk of early hypoglycemia (within the first 48 hours of admission). The risk of a "late" occurrence of hypoglycemia (after 48 hours of hospitalization) was increased by fever (relative risk, 2.05; 95% confidence interval [CI], 1.16 to 3.63), "nothing orally" status (relative risk, 3.01; 95% CI, 1.88 to 4.83), hepatic disease (relative risk, 2.56; 95% CI, 1.39 to 4.70), and renal disease (relative risk, 2.07; 95% CI, 1.26 to 3.39). A logistic regression analysis showed "nothing orally" status to be associated with an increased risk of any hypoglycemia occurring during the hospitalization (relative risk, 2.39; 95% CI, 1.63 to 3.51). Physicians and nurses documented the first episode of hypoglycemia in their notes 45.5% and 80.3% of the time, respectively. CONCLUSION--Hypoglycemia is still a common complication of diabetic ketoacidosis, is associated with hepatic and renal disease as well as fever and "nothing orally" status, and is not documented well in physician notes.     

胰岛素泵和多次胰岛素皮下注射治疗对糖尿病酮症酸中毒和高渗昏迷的疗效比较

目的比较不同胰岛素给药方法对糖尿病酮症酸中毒（DKA）和糖尿病高渗性昏迷（DHC）的疗效。方法对DKA和DHC患者首先用静脉泵小剂量胰岛素持续输注,在生命体征平稳并能进半流食后分别用不同的胰岛素给药方式进行治疗：（1）持续皮下胰岛素输注（CSII）组;（2）常规4次皮下注射胰岛素（MSII）组。治疗目标为FBG≤7.0mmol/L、2hBG≤10mmol/L。结果两组每日胰岛素用量无统计学差异（P〉0.05）,但平均达标天数CSII组较MSII组明显缩短（P〈0.01）,CSII组血糖波动小,发生低血糖次数明显减少,且FBG及晚餐后2hBG控制亦明显优于MSII组（P〈0.01）。结论在治疗DKA和DHC时采用静脉泵连续小剂量胰岛素输注急救后,使用CSII较MSII能更快、更平稳、更有效地控制高血糖。     

Severe acute pancreatitis: prognostic factors in 270 consecutive patients

Acute pancreatitis (AP) is a common abdominal disorder with severity varying from mild to fatal disease. Predicting a patient's outcome remains problematic. The aim of this study was to analyze a large consecutive series of patients with severe AP and to identify prognostic factors for hospital mortality. Between 1989 and 1997, a consecutive series of 270 patients with severe AP were included in the study. All patients fulfilled the criteria of Atlanta classification for severe AP. Retrospectively and prospectively collected data included age, gender, etiology, number of previous episodes of pancreatitis, medication history, type of admission, body-mass index (BMI), respiratory failure, renal failure, need for pressor support, and abdominal surgery performed during hospitalization. The overall mortality rate was 24.4%. In univariate survival analysis advanced age, history of continuous medication, patient transferred from other hospital, high BMI, respiratory or renal failure, need for pressor support, and need for abdominal surgery were significant prognostic factors for hospital mortality. In a multivariate stepwise logistic regression analysis, the need of pressor support, renal failure requiring dialysis, advanced age, history of continuous medication and need for abdominal surgery were identified as independent prognostic factors for mortality. A logistic regression analysis of variables available on admission (the first seven above mentioned variables) showed that transferral admission, advanced age, and history of continuous medication were independent prognostic factors for mortality. In patients with severe AP, advanced age, history of continuous medication, and need for dialysis, mechanical ventilator support, and pressor support predict fatal outcome and thus should be taken into account in clinical evaluation.     

Cytokine response to diabetic ketoacidosis (DKA) in children with type 1 diabetes (T1DM)

It has been suggested that cytokine release during DKA may result in capillary perturbation and thus may contribute to the development of its acute clinical complications (i.e.cerebral or pulmonary edema). We studied in 38 newly diagnosed T1DM children with DKA, aged 7.68±3.07 years, plasma levels of cytokines IL-1β (interleukin-1β), IL-2, IL-6, IL-8, IL-10, TNF-α (tumour necrosis factor-α) and also WBC (white blood cell count), hs-CRP (high sensitivity C-reactive protein), GH (growth hormone) and cortisol, prior to, during and 120h after DKA management, with the aim to monitor their levels at different time-points and in different degrees of DKA severity. Prior to DKA management the levels of IL-6, IL-8, IL-10, WBC and cortisol were elevated, but were all reduced within 120 h after DKA management. Then the patients were divided into two groups: a. moderate/severe: pH≤7.2, b. mild DKA: pH>7.2. In the group with moderate/severe DKA (ph≤7.2), IL-10 levels were the highest of all cytokines, but were significantly decreased after 6h (91.76 vs 18.04 pg/mL, p=0.008), with no further change, while IL-6 levels were decreased at 120 h (28.32 vs 11.9 pg/mL, p=0.003). The above were not observed in the group with mild DKA. In conclusion, in the children with DKA of our study, in the group with moderate/severe DKA the IL-10 levels were prematurely reduced at 6 hours, while the IL-6 levels remained high and were reduced at 120 hours after the DKA management. These changes may be responsible for increased capillary perturbation, which could lead to the subsequent development of acute DKA complications.     

A sudden onset of diabetic ketoacidosis and acute pancreatitis after introduction of mizoribine therapy in a patient with rheumatoid arthritis

Mizoribine has been recognized to have an acceptable toxicity profile compared with other immunosuppressants. In this study, however, we report a case of diabetic ketoacidosis and acute pancreatitis that suddenly occurred in a rheumatoid arthritis patient 2 weeks after introduction of mizoribine therapy. To the best of our knowledge, this is the first case in the literature to show mizoribine-induced diabetic ketoacidosis. Through prompt diagnosis and treatment, the patient recovered from these extremely rare but potentially lethal complications.     

A sudden onset of diabetic ketoacidosis and acute pancreatitis after introduction of mizoribine therapy in a patient with rheumatoid arthritis

Abstract

Mizoribine has been recognized to have an acceptable toxicity profile compared with other immunosuppressants. In this study, however, we report a case of diabetic ketoacidosis and acute pancreatitis that suddenly occurred in a rheumatoid arthritis patient 2 weeks after introduction of mizoribine therapy. To the best of our knowledge, this is the first case in the literature to show mizoribine-induced diabetic ketoacidosis. Through prompt diagnosis and treatment, the patient recovered from these extremely rare but potentially lethal complications.