酮症酸中毒仍常为1型糖尿病首要表现

来自小儿糖尿病联合会(PDC)的研究者报告称，大约1/3的1型糖尿病患儿在获得诊断时已发生糖尿病酮症酸中毒(DKA)，这意味着更早出现的征象常常被忽视了(J. Pediatr. 2013;162:330-4)。

在805例患儿中，34%表现为DKA，后者中又有一半为中度或重度DKA(pH＜7.2)。3岁以下患儿和3岁以上患儿的DKA风险分别为54%和33%(P=0.006)。上述发现与既往研究结果一致。

William Tamborlane博士

“不幸的是，在过去25年间，1型糖尿病患儿获得诊断时表现为DKA的比例并未出现明显变化，至今仍然处于较高水平。公众和初级保健医生都需要有效手段来识别1型糖尿病的更早期症状，以减少DKA这种危及生命的并发症。”

PDC主席、耶鲁大学临床研究所副主任William Tamborlane博士指出，问题在于，1型糖尿病的早期症状——例如突然极度口渴和排尿——被不熟悉该病的患者甚至某些医生忽视的情况并不罕见，尤其是当出现在年龄非常小的患儿身上时。

糖尿病患儿的典型表现常被误读。极度口渴可能被认为是由天气炎热或快速生长所致；多尿可能被误认为是尿路感染；体重减轻——尤其当出现在肥胖儿童身上时——可能被误认为是节食的结果。不仅如此，对于年龄不到2岁的婴幼儿，要分辨正常的和异常的口渴和多尿是很困难的，因为他们还不能准确表述自己的感受。

事实上，年幼(P=0.002)被证明是诊断时已发生DKA的一个独立预测因素，没有私人健康保险(P＜0.001)、非裔美国人(P=0.01)和无1型糖尿病家族史(P=0.001)也是独立预测因素。

该研究的受试者年龄均＜19岁(平均9岁)，均有至少1种糖尿病相关自身抗体，男女各半，63%为非西班牙裔白人。

几乎所有的DKA患儿(91%)都需要住院治疗，58%需要ICU治疗，3%发生了脑水肿，但无1例死亡。他们的平均住院时间为3天。DKA定义为静脉pH值低于7.3和(或)血清碳酸氢盐低于15 mEq/L。

《儿科学杂志》编委Alan Rogol博士评论指出，儿科医生和医务人员应考虑到1型糖尿病的可能性，以预防或者至少尽可能减轻这种急性代谢紊乱，并制定长期治疗计划。

Tamborlane博士指出，与青少年糖尿病相似，DKA也容易被漏诊，尤其是当相关恶心、呕吐类似病毒感染时。“假如一名儿童表现为流感样疾病，不妨进行一次简单的尿检以确认尿中没有糖或酮体。”

研究者声称无相关利益冲突。

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By: M. ALEXANDER OTTO, Clinical Endocrinology News Digital Network

About a third of children are already in diabetic ketoacidosis by the time they are diagnosed with type 1 diabetes, which means that earlier signs of the disease were missed, according to researchers from the Pediatric Diabetes Consortium.

Among 805 children in the group’s database, 34% presented in diabetic ketoacidosis (DKA), half of whom had moderate or severe DKA (pH less than 7.2). The risk of DKA was 54% in children under 3 years old and 33% in older children (P = .006). The findings were consistent with previous studies.

"Unfortunately, there has been no apparent change in the rate of DKA at presentation of T1D [type 1 diabetes] in children over the past 25 years; the incidence of DKA in children at the onset of T1D remains high. Effective techniques for increasing awareness of the early symptoms of T1D in both the general public and primary care providers are needed to decrease the incidence of this life-threatening complication," the investigators wrote (J. Pediatr. 2013;162:330-4).

The problem is that those early T1D symptoms – often an abrupt increase in thirst and urination – are "not infrequently" overlooked by parents unfamiliar with the disease and sometimes even by clinicians, especially in very young children, said coinvestigator Dr. William Tamborlane, deputy director for clinical research at Yale University, New Haven, Conn., and chair of the diabetes consortium, a research collaboration between university pediatric diabetes centers.

The classic signs of diabetes in children have a variety of harmless possible explanations. Excess thirst might be chalked up to hot weather or a growth spurt. Polyuria might be mistaken for a urinary tract infection. Weight loss, particularly in an obese child, might be attributed to dieting. It’s also hard to tell the difference between normal and abnormal thirst and urination in children less than 1 or 2 years old, and they’re unlikely to be able to voice any complaints, he said in an interview.

Indeed, younger age (P = .002) proved to be an independent predictor of DKA at diagnosis, as did lack of private health insurance (P less than .001), African American race (P = .01), and no family history of T1D (P = .001).

Children in the study were under 19 years old and positive for at least one diabetes-associated autoantibody. Their average age was 9 years, half were girls, and 63% were non-Hispanic whites.

Almost all of the DKA kids (91%) were admitted to the hospital; 58% required ICU treatment and 3% had cerebral edema, but none died. Their mean hospital stay was 3 days. DKA was defined in the study as a venous pH below 7.3 and/or a serum bicarbonate below 15 mEq/L.

Commenting on the study, Dr. Alan Rogol, a Journal of Pediatrics editorial board member, wrote, "It is incumbent upon us as pediatricians and health care professionals to consider the diagnosis of T1D to prevent, or at least minimize, the severity of the acute metabolic disturbance and to enter into a long-term treatment plan."

Dr. Tamborlane noted that, like juvenile diabetes, DKA can be missed too, especially when its associated nausea and vomiting mimic a viral infection. "When a child presents with a flulike illness, it’s worth getting a simple urine dipstick to make sure there’s no sugar or ketones in the urine," he said.

The investigators said that they had no disclosures.