肾病综合征患儿长期应用糖皮质激素过程中胰岛素抵抗的发生及其干预

Insulin resistance in children with nephrotic syndrome with long-term glucocorticoid treatment and its intervention

目的 监测NS患儿长期应用糖皮质激素治疗过程中胰岛素抵抗（IR）指数（HOMA-IR）的变化、影响因素及二甲双胍的疗效,以探讨糖皮质激素相关肥胖及2型糖尿病的防治.方法 32例NS患儿均长期接受激素治疗,泼尼松用量＞1 mg/（kg·d）3个月以上,其中男20例,女12例；平均年龄7.6岁（2～14岁）；监测身高、体质量及BMI,采用放射免疫方法检测血清胰岛素、C-肽水平；离子交换高效液相色谱分析法检测血清糖化血红蛋白（HbA1c）水平；应用美国ABBOTTCCX-Ⅱ型全自动生化分析仪检测空腹血糖及血脂等.计算HOMA-IR,当HOMA-IR＞ 3.5时,给予二甲双胍治疗,每4周监测患儿空腹血糖,测量身高、体质量,疗程为12周.结果 32例长期应用激素治疗的NS患儿中23例HOMA-IR＞ 3.5 （72％）,通过对IR组（23例）与非IR组（NIR组,9例）进行比较,IR组在BMI、年龄、激素累积用量及三酰甘油（TG）水平等方面明显高于NIR组,二者比较差异均有统计学意义（P均＜0.05）.二甲双胍治疗12周后,HOMA-IR（5.24±1.82比2.54±1.09P＜0.01）、HbAlc[（6.36±0.82）％比（5.39±0.51）％,P＜0.05]、BMI[（27.42±6.12） kg/m2比（22.72±5.48）kg/m2,P＜0.01]及TG[2.03±1.10）mmol/L比（1.45 ±0.48）mmoL/L,P＜0.05]均较治疗前明显降低.结论 长期应用糖皮质激素能引起年长儿童发生IR;监测HOMA-IR及二甲双胍的早期应用对于防治激素诱导的肥胖及2型糖尿病具有重要意义.

Objective To investigate children with nephrotic syndrome （NS） receiving long-term glucocorticoid treatment while monitoring insulin resistance（IR） index,and analyze the influencing factors,and to observe the efficacy of metformin for preventing glucocorticoid-induced obesity and diabetes mellitus type 2.Methods A total of 32 cases including 20 boys and 12 girls with mean age of 7.6 years old（2 to 14 years old）,were diagnosed as NS.All children undergoing long-term treatment of prednisone ＞ 1 mg/（kg · d） for at least 3 months.The height,body weight and body mass index（BMI） were monitored.The concentrations of serum insulin and C-peptide were determined by radioimmunoassay,the concentrations of serum HbA1 c were determined by high performance liquid chromatography,and the levels of fasting glucose,cholesterol and triglyceride were measured with an automatic measuring analyzer （American ABBO TT CCX-Ⅱ）.The homeostasis model assessment-estimated insulin resistance（HOMA-IR） was calculated;When HOMA-IR ＞ 3.5,the patients were given metformin treatment for 12 weeks while supervising their height,weight,fasting blood glucose levels monthly.Results Out of 32 cases of NS with long-term use of prednisone,23 cases had HOMAIR ＞ 3.5 （72％）.Thus,IR group included 23 patients,and non-IR （NIR） group had 9 patients.There were significant differences between 2 groups in BMI,age,prednisone dosage and the levels of triglyceride （TG） （all P ＜ 0.05）.After 12 weeks of metformin treatment,the HOMA-IR （5.24 ± 1.82 vs 2.54 ± 1.09,P ＜ 0.01）,HbA1 c levels [（6.36 ±0.82）％ vs（5.39 ±0.51）％,P ＜0.05],BMI[（27.42 ±6.12） kg/m2 vs（22.72 ±5.48） kg/m2,P ＜0.01],and TG levels[（2.03 ± 1.10） mmol/L vs（1.45 ±0.48） mmol/L,P＜0.05] were significantly reduced.Conclusions Older children with long-term use of glucocorticoid may easily lead to IR.Therefore,monitoring the HOMA-IR and early administration of mefformin is helpful for prevention and treatment of glucocorticoid-induced obesity and diabetes mellitus type 2.