Ratner R E
Medlantic Research Institute, Washington, DC, USA.
Diabet Med. 1998;15 Suppl 4:S4-7. doi: 10.1002/(sici)1096-9136(1998120)15:4+<s4::aid-dia735>3.3.co;2-t.
Type 2 diabetes currently accounts for over 100 billion dollars in annual healthcare expenditure in the United States and 28% of the national (Medicare) healthcare budget for elderly Americans. In our inner-city hospital, 20% of all 950 beds are occupied by patients with diabetes; and 28-38% of patients receiving cardiac care in Coronary Care Units, catheterization laboratories or cardiovascular surgery, have diabetes as an underlying disorder. Both computer modelling and controlled clinical trials suggest that intensive therapy of diabetes can reduce significantly the morbidity and costs associated with this increasingly common disorder. Early detection of carbohydrate intolerance holds great promise for preventing the onset, progression and complications of Type 2 diabetes. To date our efforts have been futile, with 20% of newly diagnosed Type 2 diabetic patients already complicated by retinopathy and 14% complicated by peripheral vascular disease. It is now clear that high-risk individuals can be identified, and intervention trials are underway to test the hypothesis that Type 2 diabetes (and its attendant cardiovascular risks) can be prevented. The Study to Prevent Non-Insulin-Dependent Diabetes Mellitus (STOP NIDDM) in Canada and Europe has randomized 1200 individuals with impaired glucose tolerance (IGT) into a three-year trial to prevent disease progression. The Diabetes Prevention Program (DPP) in the US has randomized almost 3000 individuals with IGT into a six-year, three-arm study testing the efficacy of intensive lifestyle and pharmacological therapy in disease progression. Together, these studies should provide a public health model for the recognition of high-risk individuals and interventions to stem the epidemic of Type 2 diabetes. For those patients suffering with Type 2 diabetes already, pancreas transplantation remains an extreme intervention with the potential for 'curing' diabetes. Although applied usually to patients with Type 1 diabetes, experience is accumulating of transplantation in Type 2 diabetic patients with end-stage renal disease. Outcomes for these individuals are as good as for Type 1 diabetes. Islet-cell transplants, in fact, have been more successful in Type 2 diabetes compared with Type 1. Improved islet-cell availability, better immunosuppression, and the possibility of antigen masking make this technology a major hope for the future.
2型糖尿病目前在美国每年的医疗保健支出中占1000多亿美元，占美国老年人国家（医疗保险）医疗保健预算的28%。在我们市中心的医院里，950张床位中有20%被糖尿病患者占用；在冠心病监护病房、导管插入实验室或心血管外科接受心脏护理的患者中，28%至38%患有糖尿病这一基础疾病。计算机建模和对照临床试验均表明，强化糖尿病治疗可显著降低与这种日益常见疾病相关的发病率和成本。早期发现碳水化合物不耐受对于预防2型糖尿病的发病、进展和并发症具有很大的前景。到目前为止，我们的努力一直没有成效，20%新诊断的2型糖尿病患者已经出现视网膜病变并发症，14%出现外周血管疾病并发症。现在很清楚，高危个体是可以识别的，并且正在进行干预试验，以检验2型糖尿病（及其伴随的心血管风险）可以预防这一假设。加拿大和欧洲的预防非胰岛素依赖型糖尿病研究（STOP NIDDM）已将1200名糖耐量受损（IGT）个体随机分组，进行为期三年的试验以预防疾病进展。美国的糖尿病预防计划（DPP）已将近3000名IGT个体随机分组，进行一项为期六年的三臂研究，测试强化生活方式和药物治疗在疾病进展方面的疗效。这些研究共同应为识别高危个体和采取干预措施以遏制2型糖尿病流行提供一个公共卫生模式。对于那些已经患有2型糖尿病的患者，胰腺移植仍然是一种极端的干预措施，有可能“治愈”糖尿病。尽管胰腺移植通常应用于1型糖尿病患者，但在患有终末期肾病的2型糖尿病患者中进行移植的经验正在积累。这些个体的治疗效果与1型糖尿病患者一样好。事实上，胰岛细胞移植在2型糖尿病患者中比在1型糖尿病患者中更成功。胰岛细胞供应的改善、更好的免疫抑制以及抗原屏蔽的可能性使这项技术成为未来的一大希望。
