Thirty years of personal experience in hyperglycemic crises: Diabetic ketoacidosis and hyperglycemic hyperosmolar state
Thirty years of personal experience in hyperglycemic crises: Diabetic ketoacidosis and hyperglycemic hyperosmolar state
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DOI：
10.1210/jc.2007-2577
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发表时间：
2008-05-01
影响因子：
5.8
通讯作者：
Stentz, Frankie B.
中科院分区：
文献类型：
--
作者：
Kitabchi, Abbas E.;Umpierrez, Guillermo E.;Stentz, Frankie B.
背景：糖尿病酮症酸中毒(DKA)和高血糖高渗状态(HHS)是糖尿病患者的主要发病率和死亡率。30多年来，我们小组在一系列前瞻性、随机的临床研究中，研究了高血糖危象的发病机制和治疗策略的演变。本文总结了这些关于DKA的治疗和病理生理学的前瞻性研究的结果。背景：我们最早的研究评估了小剂量胰岛素与药理剂量的胰岛素的比较疗效，以及在成人和后来的儿童中通过不同途径使用低剂量治疗的效果。随后的研究评估了磷酸盐和碳酸氢盐治疗、脂代谢、酮西司酮2型患者和快速作用胰岛素类似物的使用以及瘦素状态、心脏危险因素、促炎细胞因子和高血糖时T淋巴细胞激活的机制。主要结果：从这些研究中获得的信息导致2001年美国糖尿病协会(ADA)关于DKA和HHS的技术综述以及关于治疗高血糖的ADA立场和共识文件的产生。结论：未来的研究领域包括以下前瞻性随机研究：1)建立碳酸氢盐治疗DKA的疗效(pH<6.9；2)在DKA的初始治疗中确定胰岛素剂量的必要性；3)确定HHS中无酮症的病理生理学机制；4)调查促炎细胞因子和心血管危险因素升高的原因；5)评估在普通病房使用sc普通胰岛素与更昂贵的胰岛素类似物治疗DKA的疗效和成本效益。
Context: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) cause major morbidity and significant mortality in patients with diabetes mellitus. For more than 30 yr, our group, in a series of prospective, randomized clinical studies, has investigated the pathogenesisand evolving strategies of the treatment of hyperglycemic crises. This paper summarizes the results of these prospective studies on the management and pathophysiology of DKA.Setting: Our earliest studies evaluated the comparative efficacy of low-dose vs. pharmacological amounts of insulin and the use of low-dose therapy by various routes in adults and later in children. Subsequent studies evaluated phosphate and bicarbonate therapy, lipid metabolism, ketosisprone type 2 patients, and use of rapid-acting insulin analogs as well as leptin status, cardiac risk factors, proinflammatory cytokines, and the mechanism of activation of T lymphocytes in hyperglycemic crises.Main Outcome: The information garnered from these studies resulted in the creation of the 2001 American Diabetes Association (ADA) technical review on DKA and HHS as well as the ADA Position and Consensus Paper on the therapy for hyperglycemic crises.Conclusions: Areas of future research include prospective randomized studies to do the following: 1) establish the efficacy of bicarbonate therapy in DKA for a pH less than 6.9; 2) establish the need for a bolus insulin dose in the initial therapy of DKA; 3) determine the pathophysiological mechanisms for the absence of ketosis in HHS; 4) investigate the reasons for elevated proinflammatory cytokines and cardiovascular risk factors; and 5) evaluate the efficacy and cost benefit of using sc regular insulin vs. more expensive insulin analogs on the general ward for the treatment of DKA.