糖尿病的诊断和分类.ppt
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1、糖尿病的诊断和分类历史与今天,For epidemiological studies, estimates of diabetes prevalence and incidence should be based on an FPG 126 mg/dl (7.0 mmol/l). This approach will lead to slightly lower estimates of prevalence than would be obtained from the combined use of the FPG and OGTT,The categories of FPG values
2、 are as follows:,FPG 110 (6.1 mmol/l) and 126 mg/dl (7.0 mmol/l) provisional diagnosis of diabetes (the diagnosis must be confirmed, as described above).,The corresponding categories when the OGTT is used are the following:,2-h postload glucose (2-h PG) 140 (7.8 mmol/l) and 200 mg/dl (11.1 mmol/l) p
3、rovisional diagnosis of diabetes (thediagnosis must be confirmed, as described above),诊断标准的建立,Determining the optimal diagnostic level of hyperglycemia depends on a balance between the medical, social, and economic costs of making a diagnosis in someone who is not truly at substantial risk of the ad
4、verse effects of diabetes and those of failing to diagnose someone who is. Unfortunately, not all of these data are available, so we relied primarily on medical data 。,Plasma glucose concentrations are distributed over a continuum, but there is an approximate threshold separating those subjects who
5、are at substantially increased risk for some adverse outcomes caused by diabetes (e.g., microvascular complications) from those who are not.,The cutpoint for the 2-h PG has been justified largely because at approximately that point the prevalence of the microvascular complications considered specifi
6、c for diabetes (i.e., retinopathy and nephropathy) increases dramatically.,Pima 印第安人,埃 及 人 研 究,第三次人口普查美国,all three measures of glycemia (FPG, 2-h PG, and HbA1c) are strongly associated with retinopathy。 the prevalence rose dramatically in the highest decile of each variable, correspondingto FPG120 m
7、g/dl (6.7 mmol/l), 2-h PG 195 mg/dl (10.8 mmol/l),and HbA1c 6.2%.,There are no absolute thresholds because some retinopathy occurred at all glucose levels, presumably because of measurement or disease variability and because of nondiabetic causes of retinopathy. More precision cannot easily be obtai
8、ned by using narrower glycemic intervals (e.g., 20 instead of the 10 shown in Fig. 2) because of the limited numbers of cases of retinopathy in each sample (32 cases in the Pimastudy, 146 in the Egyptian study, and 111 in NHANES III).,Almost all individuals with FPG 140 mg/dl (7.8 mmol/l) have 2-h P
9、G200 mg/dl (11.1 mmol/l) if given an OGTT, whereas only about one-fourth of those with 2-h PG 200 mg/dl (11.1 mmol/l) and without previously known diabetes have FPG 140 mg/dl (7.8 mmol/l),Under the previous WHO and the NDDG criteria, the diagnosis of diabetes is largely a function of which test is p
10、erformed. Many individuals who would have 2-h PG 200 mg/dl (11.1 mmol/l) in an OGTT are not tested with an OGTT because they lack symptoms or because they have an FPG140 mg/dl (7.8 mmol/l). Thus, if it is desired that all people with diabetes be diagnosed and the previous criteria are followed, OGTT
11、s must be performed periodically in everyone. However, in ordinary practice, not only is the OGTT performed infrequently, but it is usually not used even to confirm suspected cases (128),the diagnostic criteria are now revised to,11) avoid the discrepancy between the FPG and 2-h PG cutpoint values a
12、nd 2) facilitate and encourage the use of a simpler and equally accurate testfasting plasma glucosefor diagnosing diabetes.,We chose a cutpoint at the upper end of these estimates (FPG _126 mg/dl, 7.0 mmol/l). This value is slightly higher than most of the estimated cutpoints that would give the sam
13、e prevalence of diabetes as the criterion of 2-h PG _200 mg/dl (11.1 mmol/l). That is, slightly fewer people will be diagnosed with diabetes if the new FPG criterion is used alone than if either the FPG or the OGTT is used and interpreted by the previous WHO and NDDG criteria (Table 4),although the
14、OGTT is an acceptable diagnostic test and has been an invaluable tool in research, it is not recommended for routine use. When OGTTs were repeated in adults during a 2- to 6-week interval, the intraindividual coefficients of variation were 6.4% for the FPG and 16.7% for the 2-hPG,In a recent analysi
15、s of the Paris Prospective Prospective Study, the incidence of fatal coronary heart disease was related to both FPG and 2-h PG determined at a baseline examination (118). Incidence rates were markedly increased at FPG 125 mg/dl(6.9 mmol/l) or 2-h PG 140 mg/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
16、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,FPG 125(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
17、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FPG140mgdl及140mgdl亚组)。以糖尿病组中GHb升高者(68)所占百分比为阳性符合率,以正常组中GHb值于正常范围(68)者所占百分比为阴性符合率。,五种OGTT标准诊断各组分别与GHb做比较分析,所得阳性诊断符合率为NDDGWHOUGDP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
18、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140mgd1+HbAlc67者,可排除糖尿病诊断。,4健康查体中,除查FPG外,应尽可能查HbA1c及GSP,这样不但可了解当时一瞬间血糖,还能知道当时大约60天时间内的血糖平均水平。 1).若FPG140mgd1+HbAlc68
19、,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。,If one accepts the logic that the level of glycemia chosen to diagnose diabete
20、s should be one that is associated with the specific complication of diabetic retinopathy (and I do), HbA1c levels are a better measure of glycemia than values on the OGTT for two reasons.,First, they reflect months of prevailing glucose concentrations rather than one instance of time. Second, there
21、 have been five studies in several thousand diabetic patients carried out over 69 years relating the average HbA1c level to the development and progression of the microvascular complications of diabetes.,All five demonstrated that if the average HbA1c level were 2% above the ULN were associated with
22、 much higher risks for the microvascular complications.,Regarding the 2-h glucose criterion on the OGTT of 200 mg/dl, unchanged by the ADA Expert Committee,9 approximately two thirds of individuals with values of 200239 mg/dl had normal HbA1c levels, and most of the remainder had values 1% above the
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