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一文读懂与糖尿病诊断治疗相关的检测指标

2019-04-09 张时民 中国医学论坛报今日糖尿病

早期发现、诊断并正确治疗糖尿病(DM)十分重要,而DM的诊断、分型、病情的进展、并发症的判断及预后都与实验室检查密切相关。检测项目的选择、检测结果的正确评价及检测时的注意事项都直接关系到患者的疗效。本文对临床常用的DM检测指标进行了总结,分为生化检查、尿液检查、免疫学检查、激素检查几个方面,供您参考。一、生化检查01葡萄糖测定参考值:空腹血清/血浆葡萄糖3.9~6.1 mmol/L临床应用患者

早期发现、诊断并正确治疗糖尿病(DM)十分重要,而DM的诊断、分型、病情的进展、并发症的判断及预后都与实验室检查密切相关。检测项目的选择、检测结果的正确评价及检测时的注意事项都直接关系到患者的疗效。本文对临床常用的DM检测指标进行了总结,分为生化检查、尿液检查、免疫学检查、激素检查几个方面,供您参考。

一、生化检查

01葡萄糖测定

参考值:空腹血清/血浆葡萄糖3.9~6.1 mmol/L

临床应用

患者在急性感染、创伤或其他应激情况下,可出现暂时性血糖增高,不能依此诊断为糖尿病,须在应激过后复查;

随机血糖不能用于诊断空腹血糖异常(IFG)或糖耐量受损(IGT),建议所有空腹血糖高于正常者或空腹血糖在5.6~6.9 mmol/L范围者、随机血糖在6.5~11.0 mmol/L范围者行OGTT检查;

少数儿童及青少年DM患者虽尿糖或尿酮体不严重,但须行OGTT。

注意事项

须告知患者采血要求(若采血,当天清晨保持空腹状态,但禁食不可超过14 h,不可长时间饥饿后采血);

建议使用氟化钠抗凝试管采血,以抑制糖酵解,防止血糖降低,若用普通试管采血须尽快分离血浆或血清;

快速血糖检测仪测定的全血血糖和生化分析仪测定的值有一定差异。

02口服葡萄糖耐量试验(OGTT)

参考值

正常人群:

1 h血糖为6.7~9.4 mmol/L

2 h血糖为3.9~6.7 mmol/L

3 h血糖<7.2 mmol/L

糖尿病人群:

1 h血糖>11.1 mmol/L

2 h血糖>7.8 mmol/L

3 h血糖>7.8 mmol/L

临床应用

对于无症状、轻型DM患者的诊断有较大意义,对于诊断明确的DM患者及其疗效观察意义不大;

主要适用于空腹或餐后血糖在临界值、顽固糖尿、妊娠期女性糖尿、有DM家族史的妊娠期女性及继往有巨大儿或不能解释原因死胎史的女性。

注意事项

须摄入适当比例的糖类物质,受试前8~12 h须空腹,且不可吸烟;

与经期间隔至少3 天,须充分休息,避免剧烈运动;

若受试前2 周有其他疾患可影响检测结果;

某些药物可降低胰岛素分泌,若不是危急患者,须在受试前3 天停药。

03糖化血红蛋白(HbA1c)测定

参考值:HbA1c为3.0%~6.0%

临床应用

用于评价患者过去1~2 个月内的平均血糖水平,监测血糖控制情况,进而评价疗效,尤其对于1型DM或妊娠期DM患者的疗效监控有效;

有助于判断患者预后及发现治疗中存在的问题,并指导治疗方案的调整。

注意事项

溶血性贫血或急性失血时红细胞数量及红细胞平均寿命均减少,这都可使检测结果假性降低;

缺铁性贫血可使检测结果升高。

04糖化血清白蛋白(GSP)测定

参考值:122~236 μmol/L(酶法测定)

临床应用

可反映患者最近2~3 周的血糖水平;

对于血糖不稳定的DM患者,当血糖变化较大时,GSP可及时监测病情,调整治疗方案;

与HbA1c相互补充,有助于了解患者并发症的发生及发展。

注意事项

血液中白蛋白浓度或半衰期的变化可影响GSP的产生;

对于肾病综合征、肝硬化、异常蛋白血症患者,其测定结果不可靠。

05血清乳酸测定

参考值:基础空腹血浆乳酸<2 mmol/L

临床应用

在病理情况下,血乳酸可升至2~26 mmol/L,若血乳酸>7 mmol/L,则提示乳酸性酸中毒;

若运动、严重贫血、急性喘息、抽搐后,患者血乳酸可中度增加;

对于糖尿病酮症酸中毒(DKA)患者,血乳酸增加但一般不超过7 mmol/L,而非DKA患者,血乳酸明显升高,多见于口服苯乙双胍治疗的患者。

注意事项

在采血中、后须严格处理标本,须用含氟化钠的抗凝管采集标本,将血样加入试管后须立即混匀;

采血前患者须保持空腹状态,完全静息至少2 h,使血液中乳酸浓度达稳态;

患者在采血前须避免手臂活动,且采血时不应用止血带。

二、尿液检查

01尿糖定性试验

参考值:阴性

临床应用

用于血糖增高性糖尿(可分为代谢性糖尿和内分泌性糖尿两大类)的诊断;

用于血糖正常性糖尿(又称肾性糖尿)的诊断,常见的有家族性糖尿、新生儿糖尿、妊娠或哺乳期糖尿等;

用于暂时性糖尿的诊断;

用于遗传因素或进食过多所引发糖尿的诊断。

注意事项

标本容器需清洁,不含氧化物质;

标本需新鲜,且排除维生素C的干扰;

标本不可酮体浓度过高(0.4 g/L)、比重过低,也不可含左旋多巴、大量水杨酸、氟化钠等;

须注意试纸和标本的反应时间及温度。

02尿酮体测定

参考值:阴性

临床应用

用于糖尿病酮症酸中毒的早期诊断和治疗监测;

用于糖类摄入不足的诊断,多见于饥饿、剧烈运动、寒冷、禁食过久等;

用于糖类丢失的诊断,多见于呕吐(妊娠或疾病)、消化系统疾病、感染性疾病的发热期、肺炎、败血症、结核等;

用于其他疾病(包括全身麻醉后、碱中毒、服用双胍类降糖药等)的诊断。

注意事项

排除因尿液含有较多的肌酐、肌酸,或高色素尿而引发的假阳性结果;

须使用新鲜的尿液标本并尽快检测,若不能立即检测,须密封冷藏或冷冻,检测时先将标本恢复至室温后再操作;

试纸须置于阴凉干燥处,注意其使用有效期。

三、免疫学检查

01抗胰岛素自身抗体(IAA)测定

参考值:正常值<10 U/ml

临床应用

IAA在儿童中的检出率高于成人;

在确诊为1型DM的儿童中,IAA阳性人数>50%;

经胰岛素治疗后,IAA可消失;

IAA还见于淋巴细胞性甲状腺炎等其他自身免疫性疾病。

注意事项

标本过多地溶血、凝集或微生物污染可干扰检测结果;

血清标本避免反复冻融,若不在24 h 内检测,须置于-20℃冷冻保存,检测前须平衡室温后再进行检测;

该检测只是筛查方法,诊断时还须结合其他化验结果。

02抗胰岛细胞抗体(ICA)测定

参考值:阴性

临床应用

ICA对于1型、2型DM的鉴别有一定价值,ICA多见于1型DM,且随病程迁延其阳性率逐渐下降,而在2型DM中少见;

ICA阳性且滴度较高或有其他自身抗体(如抗谷氨酸脱羧酶或IAA)者更易患1型DM。

注意事项

标本过多地溶血、凝集或微生物污染可干扰检测结果;

若血清标本不在24 h内检测,须置于2~8℃冰箱保存;

试验前须将所有试剂(包括血清标本)放置室温平衡;

每次检测须做阳性及阴性对照,以保障结果的有效性。

四、激素检查

01血清胰岛素测定

参考值:5~20 μmol/L(空腹)

临床应用

对于已初步确诊的DM患者,须通过胰岛素测定才能进一步明确诊断,并区分其类型以指导临床治疗和用药;

对于空腹低血糖患者须测定胰岛素才能明确病因;

胰岛素增高见于胰岛素瘤、胰岛素自身免疫病、异常胰岛素血症等情况;

胰岛素降低见于1型DM、部分继发糖尿病、嗜铬细胞瘤、胰腺外肿瘤等疾病。

注意事项

患者的肝、肾功能可影响检测结果;

须告知患者晚餐后不可再进食,可饮水,禁烟、酒、茶和咖啡,次日上午空腹取血,告知取血者标本不加抗凝剂送检;

DM患者使用动物胰岛素后,可使结果假性升高;

溶血标本中胰岛素浓度可下降,且温度越高下降越明显。

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    谢谢分享

    0

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    2019-04-09 misszhang

    谢谢MedSci提供最新的资讯

    0

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    2019-04-09 王秀

    学习了,涨知识了!

    0

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    2019-04-09 一个字-牛

    学习了谢谢分享

    0

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