Dorchy H
Clinique de pédiatrie ambulatoire et de diabétologie, Hôpital universitaire des enfants Reine-Fabiola, Bruxelles, Belgique.
Arch Pediatr. 1994 Nov;1(11):970-81.
Successful therapeutic management of the child and adolescent with diabetes mellitus requires insulin administration, dietary management, physical activity and physical fitness, and emotional support. The ultimate aim is to avoid long-term microvascular, renal and neurologic complications by maintaining blood glucose concentrations close to the normal range. We determined the mean annual glycosylated hemoglobin levels (HbA1c) that can be achieved in young diabetic patients without residual insulin secretion.
One hundred and twenty-nine patients aged 17.7 +/- 6.4 yr (m +/- SD) were followed sequentially for 1 year by the same pediatric diebetologist. They had a diabetes duration from 2 to 27 yr (mean: 9.7). Mean age at onset of diabetes was 8.1 +/- 3.7 yr. C-peptide was undetectable in all patients. Subclinical retinopathy, neuropathy and nephropathy were looked for in all patients. HbA1c was measured by an HPLC method (normal range: 4.4-6.0%) at each visit (6.6 +/- 1.9 visits/yr/patient).
Mean (SD) annual HbA1c levels were 6.9 +/- 1.5%, ie 115% of normal values. The frequency of monthly home blood glucose monitoring (HBGM) was between 0 and 250 measurements (77 +/- 49). HbA1c was not related to sex, ethnicity, age, and duration of diabetes. There was no difference between the 84 patients on only two or three daily insulin injections (aged 15.1 +/- 5.6 yr with a diabetes duration of 7.5 +/- 5.2 yr), and the 45 patients on four injections using the basal bolus regimen (aged 22.5 +/- 5.2 yr with a diabetes duration of 13.7 +/- 5.5 yr). The regression analysis showed a weak but significant inverse correlation between HbA1c and frequency of HBGM as well as frequency of outpatient clinic attendance. The yearly incidence rates of severe hypoglycemia were 0.10 in the two injection group and 0.31 in the four injection group without relationship to HbA1c levels. Frequency of subclinical complications was 15% for nephropathy, 31% for neuropathy and 39% for retinopathy. The minimum age at which incipient complications appear was 13 yr for one complication, 17 yr for the association of two complications, 23 yr for the association of three, after a diabetes duration of 3, 7, 15 yr, respectively.
In 30% of young diabetic patients without residual insulin secretion, it is possible to obtain mean annual HbA1c levels within the normal range. Increased frequency of HBGM and of clinic attendance help to reduce HbA1c levels. In contrast, multiple insulin injection therapy, allowing more freedom for diet, does not necessarily improve metabolic control and is associated with a higher incidence of severe hypoglycemic episodes. Incipient complications have to be looked for by sensitive methods from puberty.
成功治疗儿童和青少年糖尿病需要胰岛素给药、饮食管理、体育活动和体能锻炼以及情感支持。最终目标是通过将血糖浓度维持在接近正常范围来避免长期微血管、肾脏和神经并发症。我们确定了在无残余胰岛素分泌的年轻糖尿病患者中可达到的平均年度糖化血红蛋白水平（HbA1c）。
129名年龄为17.7±6.4岁（均值±标准差）的患者由同一位儿科糖尿病专家连续随访1年。他们的糖尿病病程为2至27年（平均：9.7年）。糖尿病发病的平均年龄为8.1±3.7岁。所有患者的C肽均检测不到。对所有患者进行亚临床视网膜病变、神经病变和肾病的检查。每次就诊时（每位患者每年6.6±1.9次就诊）通过高效液相色谱法测量HbA1c（正常范围：4.4 - 6.0%）。
平均（标准差）年度HbA1c水平为6.9±1.5%，即正常值的115%。每月家庭血糖监测（HBGM）的频率在0至250次测量之间（77±49）。HbA1c与性别、种族、年龄和糖尿病病程无关。仅每日注射两或三次胰岛素的84名患者（年龄15.1±5.6岁，糖尿病病程7.5±5.2年）与采用基础 - 餐时胰岛素强化治疗方案注射四次胰岛素的45名患者（年龄22.5±5.2岁，糖尿病病程13.7±5.5年）之间无差异。回归分析显示HbA1c与HBGM频率以及门诊就诊频率之间存在微弱但显著的负相关。严重低血糖的年发生率在两次注射组为0.10，在四次注射组为0.31，与HbA1c水平无关。亚临床并发症的发生率肾病为15%，神经病变为31%，视网膜病变为39%。分别在糖尿病病程3、7、15年后，出现初始并发症的最小年龄，一种并发症为13岁，两种并发症联合出现为17岁，三种并发症联合出现为23岁。
在30%无残余胰岛素分泌的年轻糖尿病患者中，有可能使平均年度HbA1c水平处于正常范围内。增加HBGM频率和门诊就诊次数有助于降低HbA1c水平。相比之下，多次胰岛素注射治疗虽在饮食方面给予更多自由，但不一定能改善代谢控制，且与严重低血糖发作的较高发生率相关。从青春期起就必须通过敏感方法寻找初始并发症。
