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成人糖尿病酮症酸中毒和高渗性高血糖状态的临床特点和诊断

Authors
Abbas E Kitabchi, PhD, MD, FACP, MACE
Burton D Rose, MD
Section Editor
David M Nathan, MD
Deputy Editor
Jean E Mulder, MD
Translators
焦洋, 主治医师

引言

糖尿病酮症酸中毒(diabetic ketoacidosis, DKA)和高渗性高血糖状态(hyperosmolar hyperglycemic state，HHS，又称非酮症性高血糖)是糖尿病最严重的急性并发症中的两种。它们是高血糖症疾病谱中的一部分，并分别代表了疾病谱的极端情况。

DKA和HHS的临床特点和诊断总结在此。这两种疾病的流行病学、发病机制和治疗将单独讨论。 (参见“糖尿病酮症酸中毒和高渗性高血糖状态的流行病学和发病机制”和“成人糖尿病酮症酸中毒和高渗性高血糖状态：治疗”)

定义

在临床上，根据是否存在酮症酸中毒和高血糖的程度来区分DKA和HHS[1-3]。美国糖尿病协会(American Diabetes Association, ADA)提出的DKA和HHS的定义，以及根据患者动脉血pH值、血清碳酸氢盐浓度和精神状态将DKA分为轻度、中度或重度的标准见表(表 1)。

  • HHS患者体内几乎没有或完全没有酮酸累积，血糖浓度通常超过1000mg/dL(56mmol/L)，血浆渗透压可达380mOsmol/kg，并且常常出现神经系统异常(包括25%-50%的患者出现昏迷)[2-5]。大多数HHS患者入院检查时发现，pH值高于7.30，血清碳酸氢盐浓度高于20meq/L，血糖高于600mg/dL(33.3mmol/L)，尽管可能出现轻度酮血症，血酮和尿酮检查仍为阴性。
  • DKA的特征性三联征包括高血糖、阴离子间隙(anion gap, AG)增高型代谢性酸中毒和酮血症。代谢性酸中毒常常是主要表现。血糖浓度通常高于500mg/dL(27.8mmol/L)且低于800mg/dL(44.4mmol/L)[2,6]。但处于昏迷状态的DKA患者的血糖浓度可能超过900mg/dL(50mmol/L)[7]。一些特殊病例，如处于饥饿或妊娠状态、或者在到达急诊科前已接受胰岛素治疗的DKA患者，其血糖可能仅有轻度升高。促使DKA患者的高血糖水平低于HHS患者的因素将在下文讨论。 (参见下文‘血糖’)

据报道，在超过1/3的患者中，DKA与HHS有明显的重叠[8-11]。DKA和HHS患者典型的全身性失水和电解质缺乏情况的比较见表中所示(表 2)。

                         

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Literature review current through: 2017-06 . | This topic last updated: 2016-12-07.
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