以酮症起病的糖尿病患者的临床特点和分型

Clinical characteristics and classification of diabetic patients with ketosis-onset

目的探索以酮症起病的糖尿病患者的分型方法和评估这类患者的预后。方法根据胰岛细胞自身抗体是否阳性(A+、A-)及β细胞功能是否保留(β+、β-)将以酮症起病的99例糖尿病患者分成4组:A+β-组(17例),A-β-组(26例),A+β+组(10例)以及A-β+组(46例)。比较各组发病时的临床特点、改良的稳态模型(HOMA2)指数以及出院6个月后的病情转归。结果4组患者在入院时及出院半年后的多项指标上均有显著差别。A+β-组患者平均发病年龄为19.1岁,酮症酸中毒复发率为29.4%,胰岛素停用率为0%;A-β-组患者临床特点类似于A+β-组,但一级亲属糖尿病的患病率相对较高(38.5% vs 17.5%);A-β+组平均发病年龄为44.5岁,伴有明显的代谢紊乱,随访时间内酮症复发率低(2.2%,与A+β-组相比P<0.01),胰岛素停用率高(50%,与A+β-、A-β-组相比P<0.01);A+β+组临床特点类似于A-β+组。结论就区分酮症起病的糖尿病患者而言,A+β-、A-β-、A+β+及A-β+4组患者可分别对应于自身免疫性1型糖尿病、特发性1型糖尿病,成人隐匿型自身免疫性糖尿病及2型糖尿病。

Objective To explore the classification and to evaluate the prognosis in the patients with ketosis-onset diabetes. Methods Based on the determination of islet autoantibodies （A ＋ or A - ） and β-cell function（ β ＋ or β - ）, four groups were identified from 99 diabetic patients with ketosis-onset： 17 cases in A ＋ β - , 26 cases in A - β - , 10 cases in A ＋ β ＋ and 46 cases in A - β ＋ , respectively. Clinical characteristics and HOMA2 indexes were compared at the onset of disease or outcome by 6-month follow-up in 4 groups. Results Patients in A ＋ β - group presented the youngest age of onset （19.1 years old）, the highest diabetic ketoacidosis recurrence rate （29.4%） and the lowest insulin discontinuation rate （0%）. Patients in A - β - subgroup were similar to those in A ＋ β - group except that there was a higher incidence of diabetes in the first-degree relatives. Patients in A - β ＋ group were described as adult-onset diabetes （ mean age 44.5 years old） with apparent metabolic dysfunction. After 6-month follow-up, the recurrence of ketosis was the lowest （2.2%, vs A ＋ β -, P 〈 0.01 ） and the discontinuation rate of insulin was the highest （50%, vs A ＋ β -, P 〈0.01, vs A - β - , P 〈 0.01 ）. Patients in A ＋ β ＋ group had similar manifestations to those in A - β ＋ group. Conclusion The patients with ketosis-onset diabetes are probable to be assigned to autoimmune type 1 diabetes （ A ＋ β - ）, idiopathic diabetes （A - β - ）, latent autoimmune diabetes in adults （A ＋ β ＋ ） and type 2 diabetes （A - β ＋ ）, respectively.