糖尿病的诊断和分类

糖尿病的诊断和分类历史与今天,Forepidemiologicalstudies,estimatesofdiabetesprevalenceandincidenceshouldbebasedonanFPG126mg/dl(7.0mmol/l).ThisapproachwillleadtoslightlylowerestimatesofprevalencethanwouldbeobtainedfromthecombineduseoftheFPGandOGTT,ThecategoriesofFPGvaluesareasfollows:,FPG110(6.1mmol/l)and126mg/dl(7.0mmol/l)provisionaldiagnosisofdiabetes(thediagnosismustbeconfirmed,asdescribedabove).,ThecorrespondingcategorieswhentheOGTTisusedarethefollowing:,2-hpostloadglucose(2-hPG)140(7.8mmol/l)and200mg/dl(11.1mmol/l)provisionaldiagnosisofdiabetes(thediagnosismustbeconfirmed,asdescribedabove),诊断标准的建立,Determiningtheoptimaldiagnosticlevelofhyperglycemiadependsonabalancebetweenthemedical,social,andeconomiccostsofmakingadiagnosisinsomeonewhoisnottrulyatsubstantialriskoftheadverseeffectsofdiabetesandthoseoffailingtodiagnosesomeonewhois.Unfortunately,notallofthesedataareavailable,sowereliedprimarilyonmedicaldata。,Plasmaglucoseconcentrationsaredistributedoveracontinuum,butthereisanapproximatethresholdseparatingthosesubjectswhoareatsubstantiallyincreasedriskforsomeadverseoutcomescausedbydiabetes(e.g.,microvascularcomplications)fromthosewhoarenot.,Thecutpointforthe2-hPGhasbeenjustifiedlargelybecauseatapproximatelythatpointtheprevalenceofthemicrovascularcomplicationsconsideredspecificfordiabetes(i.e.,retinopathyandnephropathy)increasesdramatically.,Pima印第安人,埃及人研究,第三次人口普查美国,allthreemeasuresofglycemia(FPG,2-hPG,andHbA1c)arestronglyassociatedwithretinopathy。theprevalencerosedramaticallyinthehighestdecileofeachvariable,correspondingtoFPG120mg/dl(6.7mmol/l),2-hPG195mg/dl(10.8mmol/l),andHbA1c6.2%.,Therearenoabsolutethresholdsbecausesomeretinopathyoccurredatallglucoselevels,presumablybecauseofmeasurementordiseasevariabilityandbecauseofnondiabeticcausesofretinopathy.Moreprecisioncannoteasilybeobtainedbyusingnarrowerglycemicintervals(e.g.,20insteadofthe10showninFig.2)becauseofthelimitednumbersofcasesofretinopathyineachsample(32casesinthePimastudy,146intheEgyptianstudy,and111inNHANESIII).,AlmostallindividualswithFPG140mg/dl(7.8mmol/l)have2-hPG200mg/dl(11.1mmol/l)ifgivenanOGTT,whereasonlyaboutone-fourthofthosewith2-hPG200mg/dl(11.1mmol/l)andwithoutpreviouslyknowndiabeteshaveFPG140mg/dl(7.8mmol/l),UnderthepreviousWHOandtheNDDGcriteria,thediagnosisofdiabetesislargelyafunctionofwhichtestisperformed.Manyindividualswhowouldhave2-hPG200mg/dl(11.1mmol/l)inanOGTTarenottestedwithanOGTTbecausetheylacksymptomsorbecausetheyhaveanFPG125mg/dl(6.9mmol/l)or2-hPG140mg/dl(7.8mmol/l).,国人研究,兰州标准,具有糖尿病及其并发症的典型症状，同时检查静脉空腹血浆血糖130mgdl(7.2mmolL)，或及餐后2小时200mgdl(11.1mmolL)(为避免误差，应复查证实)，虽未作OGTT也可诊断为糖尿病。OGTT：口服葡萄糖100g(100g与75g法相较差别不大，仅后者血糖较早恢复正常)，用邻甲苯胺法测定，各时相正常静脉血浆血糖上限如表11-4。,Joslins标准,FPG125(69)1小时180(100)2小时140(78)3小时125(69)以上四点至少2点达到标准者为糖尿病。,UGDP标准,空腹+1小时+2小时+3小时血糖599mgdl(333mmolL)者为糖尿病，小于此值者为正常人。,依各标准要求将500例观察对象分类为正常组、IGT组及糖尿病组(包括空腹血糖FPGUGDP我国标准Jos1ins，以NDDG和WHO标准为最高，且两者相近(分别为979及966)，Jolins标准最低(782)，说明Joslins标准有过多诊断的倾向。在FPGWHOJoslins我国标准UGDP，也以NDDG和WHO两标准为最高，UGDP符合率最低，说明UGDP有漏诊的倾向。,1在健康查体或门诊病房工作中，凡查见FPG140mgdl+HbA1c68，并经复查证实无误者，无论有无临床症状，都可确诊为糖尿病。2无论有无糖尿病症状，凡餐后(最好是2两馒头或1两馒头+1两粥)半小时到4小时内任何时候(最好是2小时)静脉血糖200mgdl+HbAlc68，并经复查证实无误者，便可确诊为糖尿病。3。凡FPGl00mgdl+餐后2小时血糖68，并经复查证实无误者，即可确诊。2).若FPG200mgd1+HbA1c68即可确诊。若140mgdl，2小时值68则应对其他指标进行检测，若GSF，HbA1c等值都超出正常范围，应重复OGTT，此患者高度怀疑糖尿病，应做近期严密追踪,3).若2小时值200mgdl+HbA1c68应仔细询问病史，了解是否经过治疗及家族史等情况，并应严格遵守OGTT的检查注意事项复查OGTT及HbAlc，如果可能还可做GSP等其他糖化蛋白指标，辅助诊断。,Ifoneacceptsthelogicthatthelevelofglycemiachosentodiagnosediabetesshouldbeonethatisassociatedwiththespecificcomplicationofdiabeticretinopathy(andIdo),HbA1clevelsareabettermeasureofglycemiathanvaluesontheOGTTfortworeasons.,First,theyreflectmonthsofprevailingglucoseconcentrationsratherthanoneinstanceoftime.Second,therehavebeenfivestudiesinseveralthousanddiabeticpatientscarriedoutover69yearsrelatingtheaverageHbA1cleveltothedevelopmentandprogressionofthemicrovascularcomplicationsofdiabetes.,AllfivedemonstratedthatiftheaverageHbA1clevelwere2%abovetheULNwereassociatedwithmuchhigherrisksforthemicrovascularcomplications.,Regardingthe2-hglucosecriterionontheOGTTof200mg/dl,unchangedbytheADAExpertCommittee,9approximatelytwothirdsofindividualswithvaluesof200239mg/dlhadnormalHbA1clevels,andmostoftheremainderhadvalues45kg)，有高患病率的种族或少数民族中成员。倾向于发生IDDM者有：胰岛细胞抗体(ICA)阳性者；IDDM的同卵孪生者；IDDM的子女,此外尚有印度等热带地区所见的糖尿病，1966Tripathy及Kar，1973Ahuja所报告者临床表现颇象1955Hugh-Jones所报告的西印度Jamaica病者，称J糖尿病，大都为青少年，有营养不良史，体形消瘦，需胰岛素治疗，但不发生重型酮症酸中毒，故难以归类。1981,Morrison命名为第3型糖尿病或阵发性IDDM，又可称为热带性糖尿病。,1959Zuidema(TropGeogrMedll：7074)报告印度尼西亚幼年起病的糖尿病伴胰纤维钙化。大都自幼得病，起病年龄自10岁到50岁(平均高峰1535岁)有腹痛及胰外分泌功能减退表现，体重锐减，消瘦明显，有中度高血糖，每日需60u胰岛素治疗，但不生酮症酸中毒，病人大都有口服木薯(Cassava)史，其外层含有HCN，由于进食蛋氨酸不足，不易形成SCN而中毒，以致发生糖尿病，此组又称Z型糖尿病，难以归类于I或型，可能属继发性，即其余型糖尿病。,有人认为MRDM是蛋白缺乏性糖尿病(PDDM)或纤维钙化性胰腺型糖尿病(FCPD)的亚型，这一地区