已确诊的1型糖尿病患儿病程中酮症酸中毒发生情况及诱因调查

Investigation into the incidence and causes of ketoacidosis in children with established T1DM

目的调查已确诊的1型糖尿病（T1DM）患儿病程中糖尿病酮症酸中毒（DKA）的发生情况。方法以首都医科大学附属北京儿童医院、上海交通大学附属儿童医院、南京医科大学附属南京儿童医院、郑州市儿童医院、江西省儿童医院、西安交通大学第一附属医院、昆明医科大学第一附属医院、武汉市妇女儿童医疗保健中心、苏州大学附属儿童医院、聊城儿童医院、福建省福州儿童医院、成都市妇女儿童中心医院12家医院登记系统为基础调查多中心1995年12月至2014年6月胰岛素治疗下的已确诊T1DM患者病程中发生DKA的频度和诱发原因。其中,T1DM确诊后发生的第1次DKA为组1A,第2次DKA为组1B。选择北京儿童医院2011年12月-至2012年5月T1DM患者血糖控制状况横断面调查病程中无DKA发生者为对照组,即组2。结果 12家医院共新诊断了1676例T1DM患儿,其中89例患者在病程中发生了100次DKA,发生比率为5.3%（89/1676）,发生频率为5.9%（100/1676）。且各中心的DKA发生比率不同,波动在1.1%～24.1%之间。组1A的糖化血红蛋白（Hb A1c）[（11.31±3.03）%vs.（8.26±1.53）%,P〈0.01]及胰岛素剂量[（0.85±0.42）IU vs.（0.71±0.31）IU,P〈0.01]明显高于组2。组1A的胰岛素泵使用率高于组2（25.0%vs.11.2%,P=0.01）。而且,前者的自我血糖监测达标率（12.1%vs.40.1%,P〈0.01）及复诊次数达标率（21.2%vs.46.6%,P〈0.01）明显低于后者。组1A的DKA诱因主要是感染（33.7%）、中断胰岛素注射（21.3%）、饮食异常（20.2%）,1例患者为胰岛干细胞移植后DKA。组1B仍以感染为主要诱因（4/10）,1例患者因为胰岛素泵故障而发生DKA（1/10）。不同病程内发生的DKA诱因分布不同（P〈0.01）,1年内主要以中断胰岛素注射为主,占39.3%（11/28）;1年以上中断胰岛素注射仅占13.1%（8/61）,主要以感染（22/61）和饮食异常（16/61）为诱因。DKA发生率高的医院主要是以感染为诱因,达50%（12/24）,而DKA发生率低的医院感染诱因占28.1%（18/64）（P〈0.01）。结论已确诊T1DM患者病程中DKA发生率为5.3%,各中心不同,最高达24.1%。DKA者的血糖控制水平差,不能规律的进行自我血糖监测及门诊复诊,应该强化糖尿病教育。胰岛素泵使用者及胰岛干细胞移植的患者成为新的教育关注点。DKA发生率高的医院需要强化患者学习感染时的处理措施。

Objective To investigate the occurrance of DKA in established T1 DM children.MethodsAccording to the registration system in the following-hospitals（BeijingChildren＇s Hospital of Capital Medical University,Children＇s Hospital of Shanghai,Nanjing Children＇s Hospital,Chil-dren＇s Hospital of Zhengzhou,Children＇s Hospital of Jiangxi,the First Affiliated Hospital of Xi＇an Jiaotong University,First Affiliated Hospital of Kunming Medical University,Children＇s Hospital of Wuhan,Soo Chow University AffiliatedChildren＇s Hospital,Children＇s Hospital of Liaocheng,Children＇s Hospital of Fuzhou,Chengdu Women Children＇sCentral Hospital）,we investigated the frequency and cause of DKA in children with established T1 DM from December1995 to June 2014. After the diagnosis of T1 DM,the first time DKA was for group 1A,the second DKA for group 1B.We conducted a cross-sectional survey of blood glucose control status for patients with T1 DM from December 2011 toMay 2012 in Beijing Children＇s Hospital. Patients who did not have DKA episode in the course of T1 DM were selectedas control group（group 2）.ResultsTotally 1676 children were newly diagnosed with T1 DM by 12 hospitals,and 89 patients occurred 100 DKA after T1 DM diagnosed. The incidence and frequency of DKA was 5.3%（89/1676）and 5.9%（100/1676）. The frequency was different in 12 hospitals,fluctuating between 1.1% and 24.1%. Compared with group 2,group 1A had high level of Hb A1c[（11.31±3.03）% vs.（8.26±1.53）%,P〈0.01]and insulin dosage[（0.85±0.42）IUvs.（0.71±0.31）IU,P〈0.01]. There were more patients with insulin bump in group 1A than group2（25.0% vs. 11.2%,P=0.01）,and few patients reached the standard of blood glucose monitoring（12.1% vs.40.1%,P〈0.01）and follow-up（21.2% vs. 46.6%,P〈0.01）. The main reasons of DKA in group 1A were infection（33.7%）,interrupting insu-lin therapy（21.3%）and eating disorder（20.2%）;one patient had DKA after islet stem cell transplantation. Infectionwas also the major cause of DKA in group 1B（4/10）,and 1 patient had DKA because of insulin bump failure. For DKAwhich occurred within different course,the distribution of causes was different（P〈0.01）. Within 1 year of T1 DM duration,the major reason was interrupting insulin injection（39.3%）. For patients more than 1 year,it only accounted for13.1%（8/61）;the major causes were infection（22/61）and eating disorder（16/61）. The major cause in mutiple hospitals with high DKA frequency was infection（50.0%）,while in other hospitals 28.1% of patients had DKA because of infection（P〈0.01）.ConclusionThe frequency of DKA is 5.3%,which is different in 12 hospitals,with the highest upto 24.1%. Patients with DKA have poor glycemic control,and they can not regularly monitor blood glucose and follow-up. We should emphasize the education of diabetes. Patients with insulin pump and islet stem cell transplantationmust also become a new focus of education. Hospitals with high DKA frequency should give patients information how todeal with other diseases.