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首页 糖尿病诊断.pdf

糖尿病诊断.pdf

糖尿病诊断.pdf

luoxiaoyanhao 2013-04-09 评分 0 浏览量 0 0 0 0 暂无简介 简介 举报

简介:本文档为《糖尿病诊断pdf》,可适用于自然科学领域,主题内容包含ORIGINALARTICLESDefinition,DiagnosisandClassificationofDiabetesMellitusand符等。

ORIGINALARTICLESDefinition,DiagnosisandClassificationofDiabetesMellitusanditsComplicationsPart:DiagnosisandClassificationofDiabetesMellitusProvisionalReportofaWHOConsultationKGMMAlberti*,PZZimmetfortheWHOConsultationDepartmentofMedicine,UniversityofNewcastleuponTyne,UKInternationalDiabetesInstitute,Caulfield,AustraliaTheclassificationofdiabetesmellitusandthetestsusedforitsdiagnosiswerebroughtintoorderbytheNationalDiabetesDataGroupoftheUSAandthesecondWorldHealthOrganizationExpertCommitteeonDiabetesMellitusinandApartfromminormodificationsbyWHOin,littlehasbeenchangedsincethattimeThereishoweverconsiderablenewknowledgeregardingtheaetiologyofdifferentformsofdiabetesaswellasmoreinformationonthepredictivevalueofdifferentbloodglucosevaluesforthecomplicationsofdiabetesAWHOConsultationhasthereforetakenplaceinparallelwithareportbyanAmericanDiabetesAssociationExpertCommitteetoreexaminediagnosticcriteriaandclassificationThepresentdocumentincludestheconclusionsoftheformerandisintendedforwidedistributionanddiscussionbeforefinalproposalsaresubmittedtoWHOforapprovalThemainchangesproposedareasfollowsThediagnosticfastingplasma(blood)glucosevaluehasbeenloweredto$mmoll(mmoll)ImpairedGlucoseTolerance(IGT)ischangedtoallowforthenewfastinglevelAnewcategoryofImpairedFastingGlycaemia(IFG)isproposedtoencompassvalueswhichareabovenormalbutbelowthediagnosticcutofffordiabetes(plasma$to,mmollwholeblood$to,mmoll)GestationalDiabetesMellitus(GDM)nowincludesgestationalimpairedglucosetoleranceaswellasthepreviousGDMTheclassificationdefinesbothprocessandstageofthediseaseTheprocessesincludeType,autoimmuneandnonautoimmune,withbetacelldestructionTypewithvaryingdegreesofinsulinresistanceandinsulinhyposecretionGestationalDiabetesMellitusandOtherTypeswherethecauseisknown(egMODY,endocrinopathies)ItisanticipatedthatthisgroupwillexpandascausesofTypebecomeknownStagesrangefromnormoglycaemiatoinsulinrequiredforsurvivalItishopedthatthenewclassificationwillallowbetterclassificationofindividualsandleadtofewertherapeuticmisjudgementsªWHODiabetMed:–()KEYWORDSdiabetesmellitusclassificationdiagnosisTypediabetesTypediabetesgestationaldiabetesmellitusReceivedAprilacceptedAprilContributors:KGMMAlberti,UniversityofNewcastleuponTyne,UK(CoChairman)PZZimmet,InternationalDiabetesInstitute,Caulfield,Australia(CoChairman)AAlwan,WorldHealthOrganization,Alexandria,EgyptPAschner,ACDandJaverlanaUniversity,Bogota,ColombiaJPAssal,UniversityHospital,Geneva,SwitzerlandPHBennett,NIDDK,Phoenix,AZ,USALGroop,UniversityofLund,Malmo,SwedenJJervell,Rikshospitalet,Oslo,NorwayYKanazawa,JichiMedicalSchool,Omiya,JapanHKeen,Guy’sHospitalandMedicalSchool,London,UKHKing,WorldHealthOrganization,Geneva,SwitzerlandRKlein,UniversityofWisconsinMedicalSchool,Madison,WI,USAJCMbanya,CentreHospitalieretUniversitairedeYaounde,CameroonAMotala,UniversityofNatal,Congella,SouthAfricaPanXR,ChinaJapanFriendshipHospital,Beijing,ChinaPR(deceasedJuly)ARamachandran,DiabetesResearchCentre,Madras,IndiaNSamad,DowMedicalCollegeCivilHospital,Karachi,PakistanPVardi,SchneiderChildren’sCentre,PetahTikvah,IsraelCCC––$ÓWHODIABETICMEDICINE,:–Observers:DMcCarty,InternationalDiabetesInstitute,Caulfield,Australia(Rapporteur)NUnwin,UniversityofNewcastleuponTyne,UK(Rapporteur)RKahn,AmericanDiabetesAssociation,USARARizza,AmericnaDiabetesAssociation,USAMBerrens,Bayer,GermanyJNolan,InstituteforDiabetesDiscovery,USASPramming,NovoNordisk,DenmarkNote:ThisdocumentisnotaformalpublicationoftheWorldHealthOrganization(WHO),andallrightsarereservedbytheOrganizationTheviewsexpressedindocumentsbynamedauthorsaresolelytheresponsibilityofthoseauthorsSponsors:Bayer,UKBayer,GermanyNovoNordisk,Copenhagen,DenmarkInstituteforDiabetesDiscovery,NewHaven,USA*Correspondenceto:ProfessorGeorgeAlberti,DepartmentofMedicine,TheMedicalSchool,FramlingtonPlace,NewcastleuponTyneNEHH,UKORIGINALARTICLESIntroductionInthelatesbothWHOandtheNationalDiabetesDataGroupproducednewdiagnosticcriteriaandanewclassificationsystemfordiabetesmellitusThisbroughtordertoachaoticsituationinwhichnomenclaturevariedanddiagnosticcriteriashowedenormousvariationsusingdifferentoralglucoseloadsInWHOslightlymodifiedtheircriteriatocoincidemorecloselywiththeNDDGvaluesNDDGlatermodifiedtheirdiagnosticrequirementsfordiabetesmellitusinadults,droppingtheintermediatesampleandbecomingidenticalwithWHOTherearenowmanydataavailable,andmuchmoreaetiologicalinformationhasappearedItseemedtimelytoreexaminetheissuesandtoupdateandrefineboththeclassificationandthecriteriaInparticularithasseemednecessarytomodifythediagnosticfastingplasmaglucoselevelandtolookatintermediatenondiagnostic,butnotnormal,fastinglevelsItalsoseemedreasonabletoplacetheclassificationsystemonamoreaetiologicalbasisBoththeAmericanDiabetesAssociation(ADA)andaWHOworkinggroupmetseparatelytodiscusstheseissuesFortunatelytherewascrossrepresentationonthetwogroupsand,ingeneral,similarconclusionswerereachedTheADApublishedtheirrecommendationsin,whiletheWHOgrouppresenttheirconclusionsbelowforconsultationandcommentItshouldbeaddedthattheWHOgrouphasalsodevelopedproposalsforthediagnosisandclassificationofthecomplicationsofdiabetes,andthesewillbepublishedshortlyAtthisjunctureweareseekingcommentsandconstructivesuggestionswiththeaimofmodifyingthedocumentItshouldbenotedthat,unliketheADA,wedonotmakerecommendationsaboutscreeningasthesewillvarywidelyaccordingtolocalfactorsWewouldurgeyoutosendcommentstotheCoChairmenoftheWHOgroupbeforetheendofSeptemberDefinitionandDiagnosticCriteriaforDiabetesMellitusandOtherCategoriesofGlucoseIntoleranceDefinitionThetermdiabetesmellitusdescribesametabolicdisorderofmultipleaetiologycharacterizedbychronichyperglycaemiawithdisturbancesofcarbohydrate,fatandproteinmetabolismresultingfromdefectsininsulinsecretion,insulinaction,orbothTheeffectsofdiabetesmellitusincludelongtermdamage,dysfunctionandfailureofvariousorgansDiabetesmellitusmaypresentwithcharacteristicsymptomssuchasthirst,polyuria,blurringofvision,andweightlossInitsmostsevereforms,ketoacidosisoranonketotichyperosmolarstatemaydevelopandleadtostupor,comaand,inabsenceofeffectivetreatment,deathOftensymptomsarenotsevere,KGMMALBERTIETALÓWHODiabetMed:–()ormaybeabsent,andconsequentlyhyperglycaemiaofsufficientdegreetocausepathologicalandfunctionalchangesmaybepresentforalongtimebeforethediagnosisismadeThelongtermeffectsofdiabetesmellitusincludeprogressivedevelopmentofthespecificcomplicationsofretinopathywithpotentialblindness,nephropathythatmayleadtorenalfailure,andorneuropathywithriskoffootulcers,amputation,Charcotjoints,andfeaturesofautonomicdysfunction,includingsexualdysfunctionPeoplewithdiabetesareatincreasedriskofcardiovascular,peripheralvascular,andcerebrovasculardiseaseSeveralpathogeneticprocessesareinvolvedinthedevelopmentofdiabetesTheseincludeprocesseswhichdestroythebetacellsofthepancreaswithconsequentinsulindeficiency,andothersthatresultinresistancetoinsulinactionTheabnormalitiesofcarbohydrate,fatandproteinmetabolismareduetodeficientactionofinsulinontargettissuesresultingfrominsensitivityorlackofinsulinDiagnosisandDiagnosticCriteriaDiagnosisIfadiagnosisofdiabetesismade,theclinicianmustfeelconfidentthatthediagnosisisfullyestablishedsincetheconsequencesfortheindividualareconsiderableandlifelongTherequirementsfordiagnosticconfirmationforapersonpresentingwithseveresymptomsandgrosshyperglycaemiadifferfromthosefortheasymptomaticpersonwithbloodglucosevaluesfoundtobejustabovethediagnosticcutoffvalueSeverehyperglycaemiadetectedunderconditionsofacuteinfective,traumatic,circulatoryorotherstressmaybetransitoryandshouldnotinitselfberegardedasdiagnosticofdiabetesFortheasymptomaticperson,atleastoneadditionalplasmabloodglucosetestresultwithavalueinthediabeticrangeisessential,eitherfasting,fromarandom(casual)sample,orfromtheoralglucosetolerancetest(OGTT)Ifsuchsamplesfailtoconfirmthediagnosisofdiabetesmellitus,itwillusuallybeadvisabletomaintainsurveillancewithperiodicretestinguntilthediagnosticsituationbecomesclearInthesecircumstances,theclinicianshouldtakeintoconsiderationsuchadditionalfactorsasfamilyhistory,age,adiposity,andconcomitantdisorders,beforedecidingonadiagnosticortherapeuticcourseofactionItshouldbereiteratedthatthediagnosisofdiabetesinanasymptomaticsubjectshouldneverbemadeonthebasisofasingleabnormalbloodglucosevalueAnalternativetothesinglebloodglucoseestimationorOGTThaslongbeensoughttosimplifythediagnosisofdiabetesGlycatedhaemoglobin,reflectingaverageglycaemiaoveraperiodofweeks,wasthoughttoprovidesuchatestAlthoughincertaincasesitgivesequaloralmostequalsensitivityandspecificitytoglucosemeasurement,itisnotavailableinmanypartsoftheworldandisnotsufficientlywellstandardizedforitsusetoberecommendedatthistimeORIGINALARTICLESDiabetesinChildrenDiabetesinchildrenusuallypresentswithseveresymptoms,veryhighbloodglucoselevels,markedglycosuria,andketonuriaInmostchildrenthediagnosisisconfirmedwithoutdelaybybloodglucosemeasurements,andtreatment(includinginsulininjection)isinitiatedimmediately,oftenasalifesavingmeasureAnOGTTisneithernecessarynorappropriatefordiagnosisinsuchcircumstancesAsmallproportionofchildrenandadolescents,however,presentwithlessseveresymptomsandmayrequireafastingbloodglucoseandoranOGTTfordiagnosisDiagnosticCriteriaTheclinicaldiagnosisofdiabetesisoftenpromptedbysymptomssuchasincreasedthirstandurinevolume,recurrentinfections,unexplainedweightlossand,inseverecases,drowsinessandcomahighlevelsofglycosuriaareusuallypresentAsinglebloodglucoseestimationinexcessofthediagnosticvaluesindicatedinFigure(blackzone)establishesthediagnosisinsuchcasesFigurealsodefineslevelsofbloodglucosebelowwhichadiagnosisofdiabetesisunlikelyinnonpregnantindividualsThesecriteriaareasinthereportForclinicalpurposes,anOGTTtoestablishdiagnosticstatusneedonlybeconsideredifcasualbloodglucosevalueslieintheuncertainrange(iebetweenthelevelsthatestablishorexcludediabetes)IfanOGTTisperformed,itissufficienttomeasurethebloodglucosevalueswhilefastingandathafteragoralglucoseload(Annexesand)Forchildrentheoralglucoseloadisrelatedtobodyweight:gkgThediagnosticcriteriainchildrenarethesameasforadultsDiagnosticFigureUnstandardized(casual,random)bloodglucosevaluesinthediagnosisofdiabetesinmmoll(mgdl)TakenfromtheWHOStudyGroupReportDIAGNOSISANDCLASSIFICATIONOFDIABETESMELLITUSÓWHODiabetMed:–()interpretationsofthefastingandhpostloadconcentrationsinnonpregnantsubjectsareshowninTableChangeinDiagnosticValueforFastingPlasmaBloodGlucoseConcentrationsThemajorchangeinthediagnosticcriteriafordiabetesmellitusfromthepreviousWHOrecommendationistheloweringofthediagnosticvalueofthefastingplasmaglucoseconcentrationtommoll(mgdl)andabove,fromtheformerlevelofmmoll(mgdl)andaboveForwholebloodtheproposednewlevelismmoll(mgdl)andabove,fromtheformermmoll(mgdl)Thenewfastingcriterionischosentorepresentavaluewhichinmostpersonsisofapproximatelyequaldiagnosticsignificancetothatofthehpostloadconcentration,whichisnotchangedThisequivalencehasbeenestablishedfromseveralpopulationbasedstudies–anditalsorepresentsanoptimalcutoffpointtoseparatethecomponentsofbimodalfrequencydistributionsoffastingplasmaglucoseconcentrationsseeninseveralpopulationsFurthermore,severalstudieshaveshownincreasedriskofmicrovasculardiseaseinpersonswithfastingplasmaglucoseconcentrationsofmmoll(mgdl)andover,andofmacrovasculardiseaseinpersonswithsuchfastingconcentrations,eveninthosewithhvaluesof,mmoll(mgdl)EpidemiologicalStudiesForpopulationstudiesofglucoseintoleranceanddiabetes,individualshavebeenclassifiedbytheirbloodglucoseconcentrationmeasuredafteranovernightfastandorhafteragoralglucoseloadSinceitmaybedifficulttobesureofthefastingstate,andbecauseORIGINALARTICLESTableValuesfordiagnosisofdiabetesmellitusandothercategoriesofhyperglycaemiaGlucoseconcentration(mmoll(mgdl))WholebloodPlasmaaVenousCapillaryVenousDiabetesMellitus:Fasting$($)$($)$($)orhpostglucoseload$($)$($)$($)orbothImpairedGlucoseTolerance(IGT):Fastingconcentration(ifmeasured),(,),(,),(,)andhpostglucoseload$($)and$($)and$($)and,(,),(,),(,)ImpairedFastingGlycaemia(IFG):Fasting$($)and$($)and$($)and,(,),(,),(,)h(ifmeasured),(,),(,),(,)aCorrespondingvaluesforcapillaryplasmaare:forDiabetesMellitus,fasting$($),h$($)forImpairedGlucoseTolerance,fasting,(,)andh$($)and,(,)andforImpairedFastingGlycaemia$($)and,(,)andifmeasured,h,(,)Forepidemiologicalorpopulationscreeningpurposes,thefastingorhvalueaftergoralglucosemaybeusedaloneForclinicalpurposes,thediagnosisofdiabetesshouldalwaysbeconfirmedbyrepeatingthetestonanotherdayunlessthereisunequivocalhyperglycaemiawithacutemetabolicdecompensationorobvioussymptomsGlucoseconcentrationsshouldnotbedeterminedonserumunlessredcellsareimmediatelyremoved,otherwiseglycolysiswillresultinanunpredictableunderestimationofthetrueconcentrationsItshouldbestressedthatglucosepreservativesdonottotallypreventglycolysisIfwholebloodisused,thesampleshouldbekeptat–Corcentrifugedimmediately,orassayedimmediatelyofthestrongcorrelationbetweenfastingandhvalues,epidemiologicalstudiesordiagnosticscreeninghaveinthepastbeenrestrictedtothehvaluesonly(Table)IftheOGTTisdifficulttoperformforanyreason(eglogistical,economic)itisnowrecommendedthatfastingplasmaglucosealonecanbeusedforepidemiologicalpurposesItshouldberecognizedthatsomeoftheindividualsidentifiedbyfastingvaluesmaybedifferentfromthoseidentifiedbythehvalues,andthatoverallprevalencemaybesomewhatdifferent,althoughnotalways,IdeallyboththehandthefastingvalueshouldbeusedClassificationEarlierClassificationsThefirstwidelyacceptedclassificationofdiabetesmellituswaspublishedbyWHOinand,inmodifiedform,inTheandclassificationsofdiabetesmellitusandalliedcategoriesofglucoseintoleranceincludedclinicalclassesandtwostatisticalriskclassesTheExpertCommitteeproposedtwomajorclassesofdiabetesmellitusandnamedthemIDDMorType,andNIDDMorTypeIntheStudyGroupReportthetermsTypeandTypewereomitted,buttheclassesIDDMandNIDDMwereretained,andanewclassofMalnutritionrelatedKGMMALBERTIETALÓWHODiabetMed:–()DiabetesMellitus(MRDM)wasintroducedInboththeandreportsotherclassesofdiabetesincludedOtherTypesandImpairedGlucoseTolerance(IGT)aswellasGestationalDiabetesMellitus(GDM)ThesewerereflectedinthesubsequentInternationalNomenclatureofDiseases(IND)in,andthetenthrevisionoftheInternationalClassificationofDiseases(ICD)inTheclassificationwaswidelyacceptedandisusedinternationallyItrepresentedacompromisebetweenclinicalandaetiologicalclassificationandallowedclassificationofindividualsubjectsandpatientsinaclinicallyusefulmannerevenwhenthespecificcauseoraetiologywasunknownTheclassificationorstagingofdiabetesmellitusbasedonclinicaldescriptivecriteriaiscontinuedintheproposedclassification,butacomplementaryclassificationaccordingtoaetiologyisnowrecommendedProposedClassificationTheproposedclassificationencompassesbothclinicalstagesandaetiologicaltypesofdiabetesmellitusandothercategoriesofhyperglycaemia,assuggestedbyKuzuyaandMatsudaTheclinicalstagingreflectsthatdiabetes,regardlessofitsaetiology,progressesthroughseveralclinicalstagesduringitsnaturalhistoryMoreover,individualsubjectsmaymovefromstagetostageineitherdirectionPersonswhohave,orwhoaredeveloping,diabetesmellitusORIGINALARTICLEScanbecategorizedbystageaccordingtotheclinicalcharacteristics,evenintheabsenceofinformationconcerningtheunderlyingaetiologyTheclassificationbyaetiologicaltyperesultsfromimprovedunderstandingofthecausesofdiabetesmellitusApplicationoftheNewClassificationThenewclassificationcontainsstageswhichreflectthevariousdegreesofhyperglycaemiainindividualsubjectswithanyofthediseaseprocesseswhichmayleadtodiabetesmellitusAllsubjectswithdiabetesmellituscanbecategorizedaccordingtoclinicalstage,andthisisachievableinallcircumstancesThestageofglycaemiamaychangeovertimedependingontheextentoftheunderlyingdiseaseprocesses(Figure)AdiseaseprocessmaybepresentbutmaynothaveprogressedfarenoughtocausehyperglycaemiaTheaetiologicalclassificationreflectsthefactthatthedefectorprocesswhichmayleadtodiabetesmaybeidentifiableatanystageinthedevelopmentofdiabetesevenatthestageofnormoglycaemiaThusthepresenceofisletcellantibodiesinanormoglycaemicindividualmakesitlikelythatthatpersonhastheTypeautoimmuneprocessUnfortunatelytherearefewgoodhighlyspecificindicatorsoftheTypeprocessatpresent,althoughthesenodoubtwillberevealedasaetiologyismoreclearlydefinedThesamediseaseprocesscancauseimpairedfasti

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