Type 1 shuga mellitus mwa ana ndi achinyamata: etiopathogeneis, chipatala, chithandizo

Kuwunikiraku kumapereka malingaliro amakono pa etiology, pathophysiology ya chitukuko cha matenda a shuga 1 mwa ana ndi achinyamata, njira zodziwira matenda komanso mawonekedwe a insulin. Zizindikiro zazikulu za matenda ashuga ketoacidosis ndi chithandizo chake zimawunikidwa.

Kuwunikiraku kumapereka malingaliro amakono pa etiology, pathophysiology ya mtundu 1 shuga mwa ana ndi achinyamata, njira zodziwonera ndi mawonekedwe a insulin. Ikufotokoza zazikuluzikulu za matenda ashuga ketoacidosis ndi chithandizo.

Matenda a shuga mellitus (DM) ndi gulu lochita kupewetsa matenda amtundu wa metabolic omwe amadziwika ndi matenda a hyperglycemia chifukwa cha kubisala kwapakati kapena kuchitapo kwa insulin, kapena kuphatikiza kwa izi.

Kwa nthawi yoyamba, matenda ashuga amafotokozedwa ku India zaka 2,000 zapitazo. Pakadali pano pali odwala oposa mamiliyoni 230 omwe ali ndi matenda ashuga padziko lonse lapansi, ku Russia - 2,076,000. M'malo mwake, kuchuluka kwa matenda ashuga ndiwokwera, chifukwa mitundu yake yaposachedwa siyigwiritsiridwa ntchito, ndiye kuti, pali "mliri wosachiritsika" wa matenda ashuga.

Gulu la matenda ashuga

Malinga ndi gulu la masiku ano, pali:

Mtundu woyamba wa matenda ashuga a mtundu wa shuga (mtundu 1 wa matenda ashuga), womwe umakonda kwambiri ubwana ndi unyamata. Mitundu iwiri yamatendawa imasiyanitsidwa: a) mtundu wa autoimmune 1 shuga (wodziwika ndi chiwonongeko cha chitetezo cha β-cell - insulin), b) idiopathic mtundu 1 shuga, imwenso imachitika ndikuwonongeka kwa maselo a β-cell, koma popanda zizindikilo za autoimmune.
Type 2 matenda a shuga (mtundu 2 matenda ashuga), amadziwika ndi kuperewera kwa insulin ndi kuphwanya kwapakati komanso insulin kanthu.
Mitundu yapadera ya matenda ashuga.
Matenda a shuga.

Mitundu yodziwika bwino ya matenda ashuga ndi mtundu 1 shuga ndi mtundu 2 shuga. Kwa nthawi yayitali, ankakhulupirira kuti mtundu 1 wa matenda ashuga ndiwofanana ndi ubwana. Komabe, kafukufuku pazaka khumi zapitazi agwedeza izi. Kuchulukirapo, adayamba kupezeka mwa ana omwe ali ndi matenda ashuga a 2, omwe amapezeka mwa akulu pambuyo pa zaka 40. M'mayiko ena, matenda ashuga amtundu wa 2 amakhala ochulukirapo mwa ana kuposa matenda a shuga 1, chifukwa cha majini a anthu komanso kuchuluka kwa kunenepa kwambiri.

Epidemiology ya matenda ashuga

Magulu obadwa a mtundu woyamba wa matenda ashuga amtundu wa ana ndi achinyamata adawonetsa kusinthasintha kwakukulu ndi kuchuluka kwake malinga ndi kuchuluka kwa anthu komanso maiko akumayiko osiyanasiyana padziko lapansi (kuyambira 7 mpaka 40 mwa ana 100 miliyoni pachaka). Kwa zaka makumi ambiri, kuchuluka kwa matenda ashuga a mtundu woyamba pakati pa ana akuchulukirachulukira. Kotala odwala ali osakwana zaka zinayi. Kumayambiriro kwa chaka cha 2010, ana zikwizikwi 479,6,000 omwe ali ndi matenda a shuga 1 adalembetsa padziko lonse lapansi. Chiwerengero cha odziwika kumene 75,800. Kukula pachaka kwa 3%.

Malinga ndi State Record, kuyambira pa 01.01.2011, ana 17 519 omwe ali ndi matenda a shuga 1 adalembetsedwa ku Russian Federation, pomwe 2911 anali milandu yatsopano. Chiyerekezo cha ana mu Russian Federation ndi 11,2 mwa ana 100,000.Tendawa limadziwonekera pa msinkhu uliwonse (pali matenda obadwa nawo), koma ana ambiri amadwala panthawi yakukula kwakukulu (zaka zisanu ndi zinayi, zisanu ndi zitatu ndi zisanu ndi zitatu, zaka za kutha msinkhu) . Makanda amakhudzidwa ndi 0.5% ya matenda a shuga.

Mosiyana ndi maiko omwe ali ndi ziwonetsero zambiri, momwe kuchuluka kwake kwakukulu kumachitika ali aang'ono, mwa anthu aku Moscow kuwonjezeka kwamilandu kumawonedwa chifukwa cha achinyamata.

Etiology ndi pathogenesis a matenda a shuga 1

Mtundu woyamba wa shuga ndi nthenda ya autoimmune mwa anthu omwe ali ndi vuto lakubadwa, momwe kuperewera kwa mitsempha yotupa kumabweretsa chiwonongeko cha β-maselo, ndikutsatiridwa ndi kuperewera kwa insulin kwathunthu. Matenda a shuga a Type 1 amadziwika ndi chizolowezi chokhala ndi ketoacidosis.

Kudziwiratu kwamtundu woyamba wa shuga wa autoimmune kumatsimikiziridwa ndi kuyanjana kwa majini ambiri, ndi mphamvu imodzi yosiyana ya majini osiyanasiyana, komanso kulumikizana kwa kudziwonetsa komanso kuteteza ma proofi.

Nthawi kuyambira chiyambi cha njira ya autoimmune mpaka kukhazikika kwa matenda a shuga 1 amatha pamiyezi ingapo mpaka zaka 10.

Matenda a ma virus (Coxsackie B, rubella, ndi zina), mankhwala (alloxan, nitrate, ndi ena otero) atha kutenga nawo mbali poyambitsa njira zowonongera maselo a islet.

Kuwonongeka kwa autoimmune kwa cells-cell ndi njira yovuta, yosanja mitundu yambiri, yomwe nthawi zonse ma cell ndi ma humenti amachitidwa. Udindo waukulu pakukula kwa insulin umaseweredwa ndi cytotoxic (CD8 +) T-lymphocyte.

Malingana ndi malingaliro amakono a kufalikira kwa chitetezo chamthupi, gawo lofunikira kwambiri kumayambiriro kwa matendawa kuyambira pachiwonetsero kupita ku chiwonetsero cha matenda ashuga.

Zolemba za chiwonongeko cha autoimmune cha β-cell zikuphatikiza:

1) islet cell cytoplasmic autoantibodies (ICA),
2) anti-insulin antibodies (IAA),
3) Ma antibodies ku protein ya islet cell omwe amalemera mozungulira 64,000 kD (ali ndi mamolekyulu atatu):

glutamate decarboxylase (GAD),
tyrosine phosphatase (IA-2L),
tyrosine phosphatase (IA-2B) Pafupipafupi mwadzidzidzi yama autoantibodies angapo mumatundu a matenda a shuga 1: ICA - 70-90%, IAA - 43-69%, GAD - 52-77%, IA-L - 55-75%.

Chakumapeto kwa nthawi ya preclinical, kuchuluka kwa ma cell a decre amatsika ndi 50-70% poyerekeza ndi chizolowezi, ndipo otsala amasungabe insulin, koma ntchito zawo zachinsinsi zimachepa.

Zizindikiro zamatenda a shuga zimawoneka pamene kuchuluka kwa β-maselo akulephera kulipiritsa kufunika kowonjezereka kwa insulin.

Insulin ndi mahomoni omwe amayang'anira mitundu yonse ya kagayidwe. Amapereka njira zamagetsi ndi pulasitiki mthupi. Zida zazikulu za insulin ndi chiwindi, minofu ndi adipose. Mwa iwo, insulin ili ndi anabolic komanso zotsatira za catabolic.

Zotsatira za insulin pa kagayidwe kazakudya

Insulin imapereka kukhathamiritsa kwa zimitsempha zamaselo ku glucose polumikizana ndi ma membrane enieni.
Imayendetsa mapulogalamu a intracellular enzyme omwe amathandiza kagayidwe ka glucose.
Insulin imalimbikitsa dongosolo la glycogen synthetase, lomwe limapereka kapangidwe ka glycogen kuchokera ku glucose m'chiwindi.
Imakakamiza glycogenolysis (kusokonekera kwa glycogen mu glucose).
Imaponderera gluconeogenesis (kaphatikizidwe ka glucose wama protein ndi mafuta).
Amachepetsa kuchuluka kwa shuga m'magazi.

Zokhudza insulin pa mafuta kagayidwe

Insulin imalimbikitsa lipogenesis.
Ili ndi antilipolytic effect (mkati mwa lipocytes imalepheretsa adenylate cyclase, imachepetsa cAMP ya lipocytes, yomwe imayenera njira za lipolysis).

Kuperewera kwa insulin kumayambitsa lipolysis yowonjezereka (kuphwanya kwa triglycerides kumasula mafuta acids (FFAs) mu adipocytes). Kuwonjezeka kwa kuchuluka kwa FFA ndizomwe zimayambitsa chiwindi chamafuta ndikuwonjezeka kwa kukula kwake. Kuwonongeka kwa FFA kumathandizidwa ndikupanga matupi a ketone.

Zotsatira za insulin pa protein metabolism

Insulin amalimbikitsa kaphatikizidwe wa mapuloteni mu minofu minofu. Kuperewera kwa insulin kumayambitsa kusokonekera (catabolism) kwamisempha minofu, kudzikundikira kwa zinthu zokhala ndi nayitrogeni (amino acid) komanso kumapangitsa gluconeogeneis m'chiwindi.

Kuperewera kwa insulini kumawonjezera kutulutsidwa kwa mahomoni otsutsana, kutseguka kwa glycogenolysis, gluconeogeneis. Zonsezi zimabweretsa ku hyperglycemia, kuchuluka kwa magazi osmolarity, kufooka kwa zimakhala, glucosuria.

Gawo lokhala ndi matenda okhudzana ndi chitetezo cha mthupi limatha miyezi yambiri komanso zaka, ndipo ma antibodies amatha kupezeka omwe ali chizindikiro cha autoimmunity to β-cell (ICA, IAA, GAD, IA-L) komanso genetic chizindikiro cha mtundu 1 wa shuga (preisposing and immune HLA haplotypes, chiopsezo chocheperako chimatha kusiyana m'mitundu yosiyanasiyana).

Matenda a shuga

Ngati panthawi ya mayeso a glucose kulolerana (OGTT) (glucose amagwiritsidwa ntchito pa mlingo wa 1.75 g / kg kulemera kwa thupi mpaka mlingo waukulu wa 75 g), mulingo wamagazi ndi> 7.8, koma 11.1 mmol / L.

Kuthamanga shuga m'magazi> 7.0 mmol / L.

Glucose 2 patatha masewera olimbitsa thupi> 11.1 mmol / L.

Mwa munthu wathanzi, shuga mumkodzo kulibe. Glucosuria imachitika pamene zakudya zam'magazi zimakhala pamwamba pa 8.88 mmol / L.

Matupi a Ketone (acetoacetate, β-hydroxybutyrate ndi acetone) amapangidwa m'chiwindi kuchokera ku mafuta acids aulere. Kukula kwawo kumawonedwa ndi kuchepa kwa insulin. Pali zingwe zoyesa kutsimikiza kwa acetoacetate mu mkodzo ndi mulingo wa β-hydroxybutyrate m'magazi (> 0.5 mmol / L). Mchigawo chovundikira cha matenda a shuga 1 popanda ketoacidosis, matupi a acetone ndi acidosis kulibe.

Glycated hemoglobin. M'magazi, shuga amaphatikizika molekyu ya hemoglobin ndikupanga hemoglobin ya glycated₁ kapena kachigawo kake "C" NVA_1s), i.e., akuwonetsa mkhalidwe wa kagayidwe kazakudya kwa miyezi itatu. Mulingo wa HBA₁ - 5-7.8% yabwinobwino, magawo ang'onoang'ono (HBA_1s) - 4-6%. Ndi hyperglycemia, hemoglobin wa glycated ndiwokwera.

Kusiyanitsa mitundu

Mpaka pano, kupezeka kwa mtundu woyamba wa shuga kumakhalabe kofunikira. Mwa ana opitilira 80%, matenda a shuga amapezeka ali ndi vuto la ketoacidosis. Kutengera kufalikira kwa zizindikiro zina zamankhwala, munthu ayenera kusiyanitsa ndi:

1) matenda opaleshoni (pachimake appendicitis, "pamimba pamimba"),
2) matenda opatsirana (chimfine, chibayo, meningitis),
3) matenda am'mimba thirakiti (chakudya toxicoinfection, gastroenteritis, etc.),
4) matenda a impso (pyelonephritis),
5) matenda a ubongo wamanjenje (chotupa mu ubongo, vegetovascular dystonia),
6) matenda ashuga.

Ndi kukula pang'onopang'ono komanso matendawa pang'onopang'ono, kuwunika kosiyanitsa kumapangidwa pakati pa matenda a shuga 1, mtundu wachiwiri wa matenda ashuga ndi matenda amtundu wa akulu mwa achinyamata (MODY).

Mtundu woyamba wa shuga

Matenda a shuga amtundu wa 1 amakula chifukwa cha kuchepa kwathunthu kwa insulin. Odwala onse omwe ali ndi mawonekedwe amtundu wa 1 shuga amapatsidwa insulin m'malo mwake.

Mwa munthu wathanzi, kutulutsidwa kwa insulini kumachitika nthawi zonse mosasamala kanthu za kudya (basal). Koma poyankha chakudya, kupuma kwake kumalimbikitsidwa (bolus) poyankha pambuyo pa thanzi la hyperglycemia. Insulin imasungidwa ndi maselo β mu portal system. 50% yake imadyedwa m'chiwindi kuti asinthe glucose kukhala glycogen, 50% yotsala imayendetsedwa mozungulira magazi kupita ziwalo.

Odwala omwe ali ndi matenda amtundu woyamba 1, insulin yakudzayo imalowetsedwa m'njira zina, ndipo imalowa pang'onopang'ono m'magazi (osatinso m'chiwindi, ngati athanzi), momwe mumakhala kuchuluka kwa nthawi yayitali. Zotsatira zake, glycemia ya pambuyo pawo imakhala yapamwamba, ndipo kumapeto kwa nthawi kumakhala chizolowezi cha hypoglycemia.

Komabe, glycogen mwa odwala omwe ali ndi matenda a shuga amawayika m'matumbo, ndipo malo ake mu chiwindi amachepetsa. Minofu glycogen sikuchita nawo kusunga Normoglycemia.

Mu ana, ma insulin aumunthu omwe amapezeka ndi biosynt synt (genetic engineering) ogwiritsira ntchito tekinoloje ya DNA amagwiritsidwanso ntchito.

Mlingo wa insulin umatengera zaka komanso kutalika kwa matenda ashuga. M'zaka 2 zoyambirira, kufunika kwa insulini ndi 0.5-0.6 U / kg pa thupi patsiku. Pulogalamu yofala kwambiri pakadali pano yolimbikitsidwa (bolus-base) yoyendetsera insulin.

Yambani insulin chithandizo ndikuyambitsa insulin yochepa kwambiri kapena yochepa (tebulo. 1). Mlingo woyamba wa ana a zaka zoyambirira za moyo ndi mayunitsi a 0.5-1, mu ana asukulu 2-5 mayunitsi, achinyamata a 4-16 mayunitsi. Kusintha kwina kwa insulin kumachitika malinga ndi kuchuluka kwa shuga m'magazi. Ndi makulidwe a magawo a metabolism a wodwalayo, amawasamutsa ku bolus-base scheme, kuphatikiza ma insulin aafupi komanso okhalitsa.

Ma insulini amapezeka mumbale ndi ma cartridge. Mapensulo ogulitsa kwambiri a insulin.

Posankha mtundu woyenera wa insulin, njira yayikulu yogwiritsira ntchito shuga (CGMS) yakhala ikugwiritsidwa ntchito kwambiri. Njira yam'manja iyi, yovala lamba wa wodwala, imalemba kuchuluka kwa shuga m'magazi 5 aliwonse kwa masiku atatu. Izi zimayikidwa pamakompyuta ndipo zimawonetsedwa mwa magome ndi ma graph omwe kusinthasintha kwa glycemia kumadziwika.

Mafuta a insulin. Ichi ndi chipangizo chamagetsi cham'manja chovala lamba. Pampu ya insulin yolamulidwa ndi kompyuta (chip) imakhala ndi insulin yocheperako ndipo imaperekedwa m'njira ziwiri, bolus ndi baseline.

Zakudya

Chofunikira pakulipira matenda a shuga ndi zakudya. Mfundo zapakati pazakudya ndizomwezo ngati mwana wathanzi. Kuwerengera kwa mapuloteni, mafuta, chakudya, zopatsa mphamvu zimayenera kukhala zofanana ndi zaka za mwana.

Zina mwa zakudya za ana omwe ali ndi matenda ashuga:

Chepetsani, komanso mwa ana aang'ono, chotsani shuga yoyenera.
Chakudya chimalimbikitsidwa kuti chikonzedwe.
Chakudyacho chimayenera kukhala ndi kadzutsa, nkhomaliro, chakudya chamadzulo ndi masakudya atatu 1.5-2 maola atatha chakudya.

Mphamvu yowonjezera shuga kumachitika makamaka chifukwa cha kuchuluka ndi kuchuluka kwa chakudya chambiri.

Malinga ndi index ya glycemic, zakudya zamasamba zimamasulidwa zomwe zimachulukitsa shuga wamagazi kwambiri (lokoma). Amagwiritsidwa ntchito kuyimitsa hypoglycemia.

Zakudya zomwe zimachulukitsa shuga m'magazi (mkate Woyera, zopaka, chimanga, shuga, maswiti).
Zakudya zomwe zimachulukitsa shuga m'magazi (mbatata, masamba, nyama, tchizi, soseji).
Zakudya zomwe zimachulukitsa shuga pang'onopang'ono (zokhala ndi fiber ndi mafuta ambiri, monga mkate wamafuta, nsomba).
Zakudya zomwe sizikuwonjezera shuga ndi masamba.

Zochita zolimbitsa thupi

Kuchita masewera olimbitsa thupi ndichinthu chofunikira chomwe chimayang'anira kagayidwe kazachilengedwe. Ndi masewera olimbitsa thupi mwa anthu athanzi, kuchepa kwa insulin kutulutsa ndi kuwonjezeka munthawi yomweyo ndikupanga mahomoni otsutsana. Mu chiwindi, kupanga kwa glucose kuchokera ku mankhwala osagwiritsa ntchito carbohydrate (gluconeogeneis) kumalimbikitsidwa. Izi zimagwira ngati gwero lofunikira pazochita zolimbitsa thupi ndipo zikufanana ndi kuchuluka kwa glucose pogwiritsa ntchito minofu.

Kupanga kwa glucose kumakula pamene kuchita masewera olimbitsa thupi kumakulirakulira. Mlingo wa glucose umakhala wokhazikika.

Mtundu woyamba wa matenda ashuga, zochita za insulin yakuthupi sizitengera zochitika zolimbitsa thupi, ndipo mphamvu ya mahomoni olimbana ndi ena sikokwanira kukonza kuchuluka kwa shuga. Pankhani imeneyi, mukamachita masewera olimbitsa thupi kapena mukangowona mutha kuonedwa ngati hypoglycemia Pafupifupi mitundu yonse ya masewera olimbitsa thupi yopitilira mphindi 30 imafunikira kusintha kwa zakudya ndi / kapena mlingo wa insulin.

Kudziletsa

Cholinga chodziletsa ndi kuphunzitsa wodwala yemwe ali ndi matenda ashuga komanso am'banja lake kuti athe kudzipereka mwaufulu. Mulinso:

malingaliro ofala okhudza matenda ashuga,
kuthekera kudziwa shuga ndi glucometer,
Konzani mlingo wa insulin
Werengani ziwerengero zama mkate
kuthekera kochotsa mu dziko la hypoglycemic,
sungani chidule cha kudziletsa.

Kuzolowera chikhalidwe

Pozindikira matenda ashuga mu mwana, makolo nthawi zambiri amakhala otaika, chifukwa matendawa amakhudza moyo wabanja. Pali mavuto omwe amakhala ndi chithandizo chanthawi zonse, zakudya, hypoglycemia, matenda opatsirana. Mwanayo akamakula, mkhalidwe wake wamavuto umapangidwa. Mu kutha msambo, zinthu zambiri zakuthupi komanso zamaganizidwe amisala zimayendetsa shuga. Zonsezi zimafuna chithandizo chokwanira chamzeru kuchokera kwa am'banja, a endocrinologist ndi psychologist.