初发2型糖尿病合并酮症酸中毒患者再入院强化治疗的预测因素分析

Predictors analysis of readmission intensive therapy in newly diagnosed type 2 diabetes patients with ketoacidosis

目的分析初发2型糖尿病(type 2 diabetes,T2DM)合并酮症酸中毒(diabetic ketoacidosis,DKA)患者出院后36个月内再入院行胰岛素强化治疗的预测因素以及预测临界值。方法回顾性分析郑州市第一人民医院2010年1月到2019年12月因初发T2DM合并DKA住院治疗的193例患者相关资料,均经补液、纠正酮症酸中毒后给予胰岛素强化治疗控制血糖,出院后随访36个月,以出院后36个月内再入院行胰岛素强化治疗为本研究终点,据此将其分为再入院组与对照组(未再入院),比较两组基线数据及血糖控制情况、胰岛素强化治疗前后胰岛功能等,进行单因素分析及Cox多因素回归模型分析,通过ROC曲线获得这些预测因子的临界值,Kaplan-Meier生存分析通过预测因子和临界值比较再次入院强化治疗时间累计率,以P<0.05为差异有统计学意义。结果193例患者中有69例出院后36个月内再入院行胰岛素强化治疗,占35.8%;Cox多因素回归模型分析显示:C肽释放曲线下面积(AUCc)(治疗后)、胰岛素抵抗指数(HOMA-IR)(治疗后)和胰岛β细胞功能(HOMA-β)(治疗后)是初发2型糖尿病合并酮症酸中毒患者再次入院行胰岛素强化治疗的独立预测因子。ROC曲线显示:当AUCc(治疗后)<9.82μg·h/L、HOMA-IR(治疗后)>1.15和HOMA-β(治疗后)<36.81时是预测患者再次入院胰岛素强化治疗的标志,Kaplan-Meier生存分析显示:AUCc(治疗后)<9.82μg·h/L、HOMA-IR(治疗后)>1.15和HOMA-β(治疗后)<36.81的12个月,24个月,36个月再次入院强化治疗时间累计率显著低于AUCc(治疗后)>9.82μg·h/L、HOMA-IR(治疗后)<1.15和HOMA-β(治疗后)>36.81(50.1%、33.5%、15.1%vs82.4%、59.8%、40.9%,45.3%、32.1%、16.5%vs77.9%、52.3%、23.2%,46.3%、28.7%、17.9%vs83.4%、54.6%、28.5%,P<0.05)。结论强化胰岛素治疗前胰岛功能差,强化治疗后胰岛功能恢复不充分是初发2型糖尿病合并酮症酸中毒患者再次入院胰岛素强化治疗的预测因素,也是预后不良的标志。

Objective To analyze the predictors of intensive insulin therapy in patients with type 2 diabetes mellitus(T2 DM)combined with ketoacidosis who were readmitted to hospital within 36 months after discharge.Methods The related data of 193 patients who had been admitted to our hospital with newly diagnosed type 2 diabetes combined with ketoacidosis between January 2010 to December 2019,All the patients were treated with intensive insulin therapy to control blood glucose after rehydration,corrected ketoacidosis.They were followed up for 36 months after discharge.With readmission within 36 months after discharge as the end point of the study,The end point of this study was intensive insulin therapy within 36 months after hospital discharge.The subjects were divided into the readmission group and the control group(no readmission).Baseline data,glycemic control,and islet function before and after intensive insulin therapy were compared between the two groups.The significant single factors were analyzed by the single factor analysis and the Cox regression model analysis,the critical values of these predictors were obtained by ROC curve,Kaplan-Meier survival analysis compared the cumulative rate of readmission intensive treatment time by predictive factors and critical value,P<0.05 was considered statistically significant.Results 69 cases were readmitted within 36 months after discharge,accounting for 35.8%.Cox multivariate analysis showed that AUCc(after treatment),HOMA-IR(after treatment)and HOMA-β(after treatment)were the independent predictors of readmission of newly diagnosed type 2 diabetes mellitus patients with ketoacidosis,ROC curve showed that AUCc(after treatment)<9.82μg·h/L,HOMA-IR(after treatment)>1.15 and HOMA-β(after treatment)<36.81 were the predictors of readmission for insulin intensive therapy.Kaplan-Meier survival analysis showed that the cumulative rate of the 12-months,24-months and 36-months readmission intensive treatment time for AUCc<9.82μg·h/L,HOMA-IR>1.15 and HOMA-β<36.81 were significantly lower than that of AUCc>9.82μg·h/L,HOMA-IR<1.15 and HOMA-β>36.81(50.1%,33.5%,15.1%vs 82.4%,59.8%,40.9%,45.3%,32.1%,16.5%vs 77.9%,52.3%,23.2%,46.3%,28.7%,17.9%vs 83.4%,54.6%,28.5%,P<0.05).Conclusion Poor islet function before insulin intensive therapy and insufficient recovery of islet function after intensive therapy are the predictors of readmission of newly diagnosed type 2 diabetes complicated with ketoacidosis,and also as a sign of poor prognosis.