文章摘要

儿童/青少年1型糖尿病血管功能的监测及影响因素

作者: 1李海艳, 2经纬, 1韩敬, 2陶月红
1 大连医科大学研究生院,辽宁 大连 116044
2 扬州大学临床医学院/江苏省苏北人民医院儿科,江苏 扬州 225001
通讯: 陶月红 Email: ektyh520@163.com
DOI: 10.3978/j.issn.2095-6959.2020.08.010
基金: 江苏省妇幼保健协会科研项目(FYX201716)。

摘要

目的:监测1型糖尿病(type 1 diabetes,T1D)患儿血管功能,评估长、短期血糖波动对血管功能的影响,探究不同方式的胰岛素使用、血糖监测对血糖控制及血管功能的影响。方法:收集38例次T1D患儿血管的功能指标数据,根据糖化血红蛋白(glycosylated hemoglobin,HbA1c)是否达标分为HbA1c达标组(HbA1c <7%)、未达标组(HbA1c ≥7%),胰岛素使用、血糖监测方式的不同分为胰岛素泵或(continuous glucose monitoring systems, CGMs)组、传统治疗组(每日4次胰岛素皮下注射及多次指尖血糖监测)。记录并计算TID患儿年龄、病程、高密度脂蛋白(high density lipoprotein,HDL)、胆固醇、三酰甘油(triglyceride,TG)、低密度脂蛋白(low density lipoprotein,LDL)、体重指数(body mass index,BMI)、收缩压(systolic blood pressure,SBP)、血糖标准差(standard deviation of blood glucose,SDBG)、最大血糖波动幅度(largest amplitude of glycemic excursions,LAGE)、餐后血糖波动幅度(postprandial glucose excursion,PPGE)、HbA1c标准差(HbA1c-SD)、尿白蛋白肌酐比(urine albumin creatinine ratio,ACR)、血流介导的内皮依赖的肱动脉舒张功能(flow mediated dilation,FMD)。结果:HbA1c是否达标在肾微血管功能、大血管内皮功能差异无统计学意义(P>0.05)。FMD与BMI,SDBG,LAGE负相关;ACR与年龄、病程、BMI负相关,与HbA1c-SD正相关(P值均<0.05)。多元回归分析FMD主要由SDBG、BMI决定,血糖标准差的影响比例最大;ACR主要受年龄、HbA1c-SD影响。胰岛素泵或CGMs组与传统治疗组相比,SDBG(2.6±0.8 vs 3.5±1.1)、LAGE (6.4±3.6 vs 9.6±4.3)、PPGE(2.2±1.0 vs 3.8±1.5)、FMD(19.4±8.9 vs 12.5±10.4),差异有统计学意义(均P<0.05),HbA1c-SD、ACR两组差异无统计学意义(P>0.05)。结论:仅仅依据HbA1c是否达标无法预测T1D患儿血管功能情况。临床上除了关注HbA1c水平外,更应关注血糖波动对血管的危害。儿童/青少年时期FMD可作为T1D大血管功能的监测指标,ACR则可作为微血管功能的监测指标。使用胰岛素泵或CGMs的血糖监测方式可更好地管理血糖,减小血糖波动,对血糖控制更有意义,从而可以更好地改善血管功能;但未发现此监测方式对微血管功能的保护性作用。
关键词: 1型糖尿病;儿童/青少年;肱动脉血管内皮功能;尿白蛋白肌酐比;血糖波动

Vascular function monitoring and effecting factors in children/adolescents with type 1 diabetes mellitus

Authors: 1LI Haiyan, 2JING Wei, 1HAN Jing, 2TAO Yuehong
1 Graduate School, Dalian Medical University, Dalian Liaoning 116044, China
2 Department of Pediatric, Clinical Medical College of Yangzhou University, Northern Jiangsu People’s Hospital, Yangzhou Jiangsu 225001, China

CorrespondingAuthor: TAO Yuehong Email: ektyh520@163.com

DOI: 10.3978/j.issn.2095-6959.2020.08.010

Foundation: This work was supported by the Research Project of Jiangsu Maternal and Child Health Care Association, China (FYX201716).

Abstract

Objective: To monitor the vascular function of children/adolescents with type 1 diabetes (T1D), assess the effects of long-term and short-term glucose fluctuation on vascular function, and explore the effects of different ways of insulin use and blood glucose monitoring on glycemic control and vascular function. Methods: Vascular function relevant data of 38 children with T1D were collected. According to well-controlling criterion as HbA1c <7%, they were divided into the well-controlled group (HbA1c <7%) and the poorly controlled group (HbA1c ≥7%). According to the different ways of insulin use and blood glucose monitoring, it was divided into the insulin pump or CGMs group and the traditional treatment group (4 times daily subcutaneous insulin injection and multiple fingertip blood glucose monitoring). Recording and calculating age, course of disease, high density lipoprotein (HDL) cholesterol, triglyceride (TG), low density lipoprotein (LDL), body mass index (BMI), systolic blood pressure (SBP), standard deviation of blood glucose (SDBG), largest amplitude of glycemic excursions (LAGE), postprandial glucose excursion (PPGE), glycosylated hemoglobin standard deviation (HbA1c-SD), urine albumin creatinine ratio (ACR), flow mediated dilation (FMD). Results: There were no significant difference in the indicators of vascular function, FMD and ACR in two groups (P>0.05), whether HbA1c was met to standard or not. FMD was negatively correlated with BMI, SDBG and LAGE; ACR was negatively correlated with age, course and BMI, while ACR was positively correlated with HbA1c-SD (P<0.05). Multiple regression analysis: FMD was mainly decided by the SDBG, BMI (P<0.05), and the proportion of SDBG was the largest. ACR was mainly affected by age and HbA1c-SD (P<0.05). In insulin pump or CGMs group, SDBG (2.6±0.8 vs 3.5±1.1), LAGE (6.4±3.6 vs 9.6±4.3), PPGE (2.2±1.0 vs 3.8±1.5), FMD (19.4±8.9 vs 12.5±10.4) had statistical differences from traditional treatment group (P<0.05). But, there were no significant differences in HbA1c-SD and ACR between two groups (P>0.05). Conclusion: It cannot predict the vascular function of children with T1D according to HbA1c level. In clinical practice, besides the level of HbA1c, more attention should be paid to the harm of blood glucose fluctuations to blood vessels. In children/adolescents, FMD can be used as the monitoring index of T1D large vascular function, while ACR can monitor microvascular function. Using CGMs or insulin pump can better manage blood glucose, reduce blood glucose fluctuation, be more meaning helpful for blood glucose control, so as to improve vascular function. However, no protective effect on microvascular function was found.
Keywords: type 1 diabetes mellitus; children/adolescents; flow mediated dilation; urinary albumin/creatinine ratio; glucose fluctuation