暴发性1型糖尿病的临床特征及治疗策略探讨

目的 提高临床医师对暴发性1型糖尿病(FT1DM)的认识.方法 报告并分析2007年1月至2008年3月在上海交通大学附属第六人民医院内分泌代谢科抢救治疗的3例FT1DM患者的临床资料及动态血糖监测(CGM)结果 的特点.结果 (1)3例患者均为男性,年龄29～43岁,体重指数21.5～23.3 kg/m2.(2)出现糖尿病症状后2～4 d迅速发展至酬症酸中毒,其中1例出现心跳骤停.(3)起病时随机血糖大于38 mmol/L,糖化血红蛋白6.2%～6.3%,糖化血清白蛋白15%～24%.(4)血清谷氨酸脱羧酶抗体、酪氨酸磷酸化酶抗体阴件.(5)标准餐试验及精氨酸刺激试验提示胰岛B细胞功能极差.(6)血淀粉酶(263～2319 U/L)和脂肪酶(812～859 U/L)升高,胰腺B超、CT榆查未见明显异常.(7)肌酸激酶(1283～12 239 U/L)严重升高,其中1例腓肠肌活检证实有横纹肌溶解,肝酶、心肌酶谱也明显升高.(8)病例1出院时为胰岛素四次皮下注射(MDI)治疗,病例2为胰岛素泵(CSII)治疗,病例3最初MDI治疗,其后改为CSII治疗.3例患者动态血糖参数的比较,无论24 h的平均血糖水平、日内血糖波动(平均血糖波动幅度、M-value)还是日间血糖波动(日间血糖平均绝对差),均为病例2<病例3(CSII时)<病例1<病例3(MDI时).血糖波动于2.8～11.1 mmol/L的时间百分率亦显示同样的规律,病例2>病例3(CSII时)>病例1>病例3(MDI时).结论 (1)FT1DM患者发病急骤,代谢紊乱严重,胰岛β细胞功能受损严重,并合并肝、肾、心脏、肌肉等多脏器的功能损害,需引起临床医师的高度重视.(2)FT1DM患者血糖波动大、易发生低血糖,可能需要长期的CSII治疗以改善预后.

Fulminant type 1 diabetes:the clinical features and treatment strategy

Objective To enhance the understanding of fulminant type 1 diabetes (FT1 DM). Methods Clinical and laboratory data of 3 patients diagnosed as FT1 DM in our hospital from January 2007 to March 2008 were retrospectively analyzed. Results (1) All of 3 cases were males aged from 29 to 43 years old with body mass index ranged from 21.5 to 23.3 kg/m2. (2)They were developed to ketoacidosis rapidly after the appearance of diabetic symptoms in 2-4 days. One case had a cardiac arrest. (3) At the stage of onset, the plasma glucose level were above 38 mmol/L, glycosylated hemoglobin ranged from 6.2% to 6.3% and serum glycated albumin ranged from 15% to 24%. (4) Serum glutamic acid deearboxylase antibody and protein tyrosine phosphatase antibody were negative. (5) Their β-cell functions were extremely poor confirmed by a standard test meal and arginine stimulation test. (6) Serum hemodiastase (263-2319 U/L) and lipase (812-859 U/L) were high. Ultrasound and computed tomography showed a normal pancreas. (7) Serum creatinekinase level (1283-12 239 U/L) was extremely high. One case had rhabdomyolysis confirmed by biopsy at gastrocnemius muscle. Serum liver enzyme and myocardial enzyme pedigree were risen significantly. (8) Case 1 was treated with multiple daily insulin injections (MDI) when he was discharged. Case 2 was treated with continuous subcutaneous insulin infusion (CSII). Case 3 was treated with MDI at the beginning of the therapy and transferred to CSII later. Comparing glycemic parameters of continuous glucose monitoring, not only mean level of 24 h blood glucose and intra-day giycemic variability (mean amplitude of giycemic excursions and Schlichtkrull's M-value) but also day-to-day glycemic variability (absolute means of daily differences) were indicated case 2 < case 3 (CSII) < case 1 < case 3 (MDI). Conclusions (1) FT1 DM patients had clinical feathers of abrupt onset, serious metabolic disorders, serious impaired islet β-cell function, complicated with multiple organ impair, which required special attention by all medical practitioners. (2) FTI DM patients had a great glycaemia excursion and were subject to hypoglycaemia. Maybe long-term CSII regimen was needed to improve the prognosis.