Diabetes mellitus in children. Autoimmune polyglandular syndrome. Diabetes mellitus - Elite treatment in Europe

IN modern world Diabetes mellitus is one of the diseases that are classified as serious medical and social problems on a global scale, as it has a high prevalence, severe complications, and also requires significant financial costs for diagnostic and medical procedures, which the patient will need throughout his life. That is why a lot of effort and resources throughout the healthcare sector are aimed at a more in-depth study of the causes and mechanisms of the development of diabetes mellitus, as well as to find new effective methods prevention and control.

What is type 1 diabetes?

Diabetes is a chronic disease characteristic feature which is a violation of metabolic processes accompanied by hyperglycemia (increased blood glucose levels), which occurs as a result of impaired insulin production by the gland internal secretion(pancreas), or disruption of its action. Statistics show that the total number of people with diabetes mellitus of all forms in the world exceeds currently 160 million people. New cases of morbidity are recorded so frequently that the number of patients doubles every decade. The most severe form of diabetes mellitus in terms of correction and possible complications is considered to be type 1 diabetes mellitus, the incidence of which ranges from 8-10% of all cases of the disease.

Diabetes mellitus type 1 - disease endocrine system, for which the characteristic feature is increased concentration glucose in the blood, which develops due to destructive processes in specific pancreatic cells that secrete the hormone insulin, resulting in an absolute lack of insulin in the body. High level The incidence of type 1 diabetes mellitus is observed in children of adolescence and youth - 40 cases per 100,000 people. Previously, this form of diabetes was called insulin-dependent and juvenile diabetes.

There are two forms of diabetes mellitus type 1: autoimmune and idiopathic.

Causes contributing to the development of type 1 diabetes mellitus

Development autoimmune form of diabetes mellitus type 1 It most often begins in childhood, but it can also be diagnosed in older people. This identifies autoantibodies (antibodies produced against one’s own antigens). human body) to the structural components of β-cells - specific pancreatic cells that produce insulin, namely, their surface antigens, insulin, glutamate decarboxylase, etc. They are formed due to congenital or acquired loss of tolerance (insensitivity) to self-antigensβ-cells. As a result of this process, autoimmune destruction of β-cells develops. In children, the process of decay of these cells is rapid, so already a year after the onset of the pathological process, the secretion of insulin in the pancreas completely stops. In the body of adults, the process of cell destruction takes longer, so β-cells can secrete sufficient amounts of insulin over a long period of time, which can prevent the development of such complications of diabetes as ketoacidosis. However, a decrease in insulin secretion is inevitable, and after a certain time its absolute deficiency develops.

Predisposes to autoimmune breakdownpancreatic cells that produce insulin, and a number of genetic factors. Type 1 diabetes mellitus is often diagnosed in combination with autoimmune diseases such as diffuse toxic goiter, autoimmune thyroiditis, Addison's disease, vitiligo, and autoimmune syndrome-complex.

Idiopathic form of diabetes mellitus type 1 is quite rare. In this case, patients do not have immunological and genetic factors for type 1 diabetes mellitus, but there are symptoms confirming absolute insulin deficiency.

The course of type 1 diabetes mellitus

Type 1 diabetes mellitus is characterized by latent period, the duration of which can range from a year to several years. The development of the disease goes through several stages:

Stage 1.Availability genetic predisposition. If specific antigens of the system are detected in the blood HLA , then the likelihood of developing type 1 diabetes increases significantly.

Stage 2.Suspected trigger factor. Agents can act as agents infectious nature- enteroviruses, retroviruses, togaviruses, as well as non-infectious causes - diet, psycho-emotional stress, exposure chemical substances, toxins and poisons, insolation (solar irradiation), radiation, etc.

Stage 3.There are violations from immune system- appearance of autoantibodies to antigensβ-cells, insulin, tyrosine phosphatase - with normal level insulin in the blood. In this case, the first phase of insulin production is absent.

Stage 4.It is characterized by serious immune disruptions, namely, insulin secretion rapidly decreases due to the development of insulitis (inflammation in the islets of Langerhans of the pancreas, containing cells that produce insulin), glucose resistance is impaired, while blood sugar levels remain within normal limits.

Stage 5.It is characterized by pronounced clinical manifestations, since three quartersβ-cells are destroyed at this point. Only residual secretion of C-peptide is preserved.

Stage 6.Total death of β-cells. C-peptide is not detected, antibody titers decrease. This stage is otherwise called total diabetes. The course of diabetes mellitus becomes uncontrollable, which threatens the development severe complications- disseminated intravascular coagulation, edema of the cerebral cortex and development diabetic coma.

How does type 1 diabetes manifest?

Since clinical signs appear when most of the β-cells of the pancreas are destroyed, the onset of the disease is always acute and may appear for the first time severe acidosis or diabetic coma. In children and adolescents, the onset of the disease is characterized by signs of ketoacidosis. Sometimes patients can clearly name the day when they noticed the signs of the disease. Sometimes the onset of the disease may be preceded by severe viral infection(flu, mumps, rubella).

Patients may complain of dry mouth and thirst due to excessive excretion of fluid from the body by the kidneys, frequent urination, increased appetite along with significant loss of body weight (up to 10-15 kg per month), general weakness, fatigue. In addition, patients may complain of itching, pustular processes on the skin and nails, and blurred vision. On the sexual side, patients note a decrease in sexual desire and potency. In the oral cavity, signs of periodontal disease, alveolar pyorrhea, gingivitis, and stomatitis may be detected. carious lesions of teeth.

When examining patients with type 1 diabetes, an increase in the concentration of sugar in the blood and its presence in the urine is detected. In the stage of decompensation, experts note dryness of the skin of patients, their mucous membranes, tongue, decreased turgor of subcutaneous fat, redness of the cheeks, forehead and chin due to dilation of the skin capillaries of the face. If the decompensation process is prolonged, patients may develop complications such as diabetic ophthalmopathy, nephropathy, peripheral neuropathy, diabetic osteoarthropathy, etc. Girls may develop infertility, and children may experience noticeable impairment and retardation in growth and physical development.

Diagnostic criteria for type 1 diabetes mellitus

If, along with clinical signs, there is an increased concentration of glucose in the blood (more than 11.1 mmol/l) at any time of the day, then we can talk about diabetes mellitus.

Experts from the World Health Organization have developed a number of criteria that are used to diagnose diabetes mellitus. First of all, this is determining the level of glucose in the blood on an empty stomach, that is, when at least 8 hours have passed since the last meal. It is also necessary to determine the level of glucose in the blood randomly, namely, at any time within 24 hours, regardless of the time of food consumption.

In order to assess at what stage of diabetes the patient is, the following laboratory tests are necessary:

General analysis of urine and blood;

The concentration of glucose in the blood on an empty stomach, and then a couple of hours after eating;

Determination of the level of glycosylated hemoglobin;

Level of ketone bodies and glucose in daily urine;

Blood chemistry;

Urinalysis according to Nechiporenko.

With the aim of differential diagnosis Type 1 diabetes mellitus is analyzed for the content of immunological and genetic markers and the level of C-peptide.

In addition, patients undergo a number of mandatory instrumental studies - electrocardiography, x-rays of organs chest and ophthalmoscopy.

Despite the fact that the clinical picture of insulin-dependent and non-insulin-dependent diabetes mellitus has many similarities, differential diagnosis between them is carried out on the basis of a number of differences. If type 1 diabetes mellitus is characterized by a decrease in the body weight of patients, then type 2 diabetes mellitus is characterized by weight gain. Type 1 diabetes mellitus begins acutely, unlike type 2 diabetes mellitus, which is characterized by a slow increase in symptoms. Type 2 diabetes mellitus is more often diagnosed in adults and older people (over 45 years of age), and type 1 diabetes mellitus is more often diagnosed in children and young people. At laboratory research antibodies to β-cell antigens are detected only in insulin-dependent diabetes.

If a patient is diagnosed with type 1 diabetes for the first time, he must be hospitalized in order to select an insulin treatment regimen, learn how to independently monitor blood glucose levels, develop a diet and work regimen. In addition, patients in a precomatous and comatose state, with diabetic ketoacidosis, with an increase in angiopathy, with the addition of infections, as well as if any surgical intervention is necessary, are subject to hospitalization.

Treatment of type 1 diabetes

The main goal of treating patients with type 1 diabetes is to preserve their life, as well as improve its quality. For this purpose, preventive actions to prevent the development of acute and chronic complications, correction of concomitant pathologies.

Treatment of type 1 diabetes mellitus involves a complex of measures, including insulin therapy, which is currently the only method for correcting absolute insulin deficiency. For these purposes, our country uses analogues of human insulin or insulin obtained by genetic engineering. Insulin replacement therapy can be carried out according to the traditional regimen, when a certain level of insulin is administered subcutaneously without constantly adapting the dose to the glycemic level. Intensive insulin therapy has great advantages, which includes multiple insulin injections, diet correction using counting grain units and monitoring glucose levels throughout the day.

The next point in the diabetes treatment regimen is the development of a special nutrition program that will normalize body weight and help maintain blood glucose levels within normal limits. Food for patients with diabetes should be low in calories and not contain refined carbohydrates ( confectionery, sweet drinks, jams), and meal times must be strictly observed. It is necessary to exclude from the diet canned food, smoked meats, and products with high content fats (sour cream, mayonnaise, nuts). The ratio of the main energy components in the diet is usually equated to physiological, and it is 3:1:1.

Physical activity for patients with type 1 diabetes should be moderate and selected individually, based on the severity of the disease. The most best view physical activity is walking. However, it should be remembered that shoes should be selected in such a way as to prevent the formation of corns and calluses, which can become the beginning of a dangerous complication of diabetes mellitus - diabetic foot.

The outcome of diabetes treatment is directly related to the active participation in it of the patient himself, who must be trained medical personnel methods of self-monitoring of blood glucose levels using glucometers and test strips, because he needs to carry out this manipulation at least 3-4 times a day. In addition, the patient must assess his condition, control his diet and size physical activity, and also regularly visit the attending physician, who, in addition to talking with the patient, must examine the legs and measure arterial pressure. Once a year, a patient with type 1 diabetes must take all necessary tests (biochemical analysis blood, general analysis blood and urine, determination of the level of glycosylated hemoglobin), undergo an examination by an ophthalmologist and neurologist, and take a chest x-ray.

Preventing the development of type 1 diabetes mellitus

The development of type 1 diabetes mellitus in individuals with a high genetic predisposition can be prevented by preventing intrauterine viral infections, as well as viral infections in childhood and adolescence. Should not be included in the diet of children predisposed to the disease, nutritional mixtures containing gluten, products with preservatives and dyes that can cause an autoimmune reaction against insulin-producing cells of the pancreas.

• Complications of diabetes

  The main reason for the development of complications of diabetes mellitus is vascular damage due to prolonged decompensation of diabetes mellitus (prolonged hyperglycemia - high blood sugar). First of all, microcirculation suffers, that is, the blood supply to the to the smallest vessels

• Treatment of diabetes

  Diabetes mellitus is a group of metabolic diseases characterized by increased content blood glucose (“sugar”)

• Types of diabetes

  Currently, there are two main types of diabetes mellitus, differing in the cause and mechanism of occurrence, as well as in the principles of treatment

• Diet for diabetes

  Numerous studies around the world have focused on finding effective means treatment of diabetes mellitus. However, we should not forget that in addition to drug therapy Recommendations for lifestyle changes are no less important.

• Gestational diabetes mellitus during pregnancy

  Gestational diabetes mellitus can develop during pregnancy (in approximately 4% of cases). It is based on a decrease in the ability to absorb glucose

• Hypoglycemia

  Hypoglycemia is called pathological condition, characterized by a decrease in the concentration of glucose in the blood plasma below the level of 2.8 mmol/l, occurring with a certain clinical symptoms, or less than 2.2 mmol/l, regardless of the presence or absence of clinical signs

• Coma with diabetes mellitus

  Information about the most dangerous complication diabetes mellitus requiring emergency medical treatment help - coma. The types of comas in diabetes mellitus are described, their specific signs, treatment tactics

• Autoimmune polyglandular syndrome

  Autoimmune polyglandular syndrome is a group of endocrinopathies characterized by involvement in pathological process several endocrine glands as a result of their autoimmune damage

  Diabetic foot syndrome is one of the complications of diabetes mellitus, along with diabetic ophthalmopathy, nephropathy, etc., which is a pathological condition resulting from damage to the peripheral nervous system, arterial and microvasculature, manifested by purulent-necrotic, ulcerative processes and damage to the bones and joints of the foot

• About diabetes

  Diabetes mellitus is a term that combines endocrine diseases, characteristic feature which is a lack of action of the hormone insulin. The main symptom of diabetes mellitus is the development of hyperglycemia - an increase in the concentration of glucose in the blood, which is persistent.

• Diabetes symptoms

  The effectiveness of diabetes treatment directly depends on the time of detection of this disease. In type 2 diabetes mellitus, the disease can long time cause only mildly expressed complaints, to which the patient may not pay attention. Symptoms of diabetes can be subtle, making diagnosis difficult. The earlier it is delivered correct diagnosis and treatment is started, the lower the risk of developing complications of diabetes mellitus

  Very often, patients under 18 years of age come to see specialists at the Northwestern Endocrinology Center. For them, the center has special doctors - pediatric endocrinologists.

(“diabetes”) is a disease that develops with insufficient release of antidiuretic hormone (ADH) or decreased sensitivity renal tissue to his action. As a result, there is a significant increase in the amount of fluid excreted in the urine, and an unquenchable feeling of thirst occurs. If fluid losses are not fully compensated, then dehydration of the body develops - dehydration, distinctive feature which is concomitant polyuria. Diagnosis of diabetes insipidus is based on the clinical picture and determination of the level of ADH in the blood. To determine the cause of the development of diabetes insipidus, a comprehensive examination of the patient is carried out.

ICD-10

E23.2

General information

(“diabetes”) is a disease that develops when there is insufficient release of antidiuretic hormone (ADH) or a decrease in the sensitivity of the kidney tissue to its action. Impaired secretion of ADH by the hypothalamus (absolute deficiency) or its physiological role with sufficient formation (relative deficiency), it causes a decrease in the processes of reabsorption (reabsorption) of fluid in the renal tubules and its excretion in urine of low relative density. In diabetes insipidus, due to the release of a large volume of urine, unquenchable thirst and general dehydration of the body develop.

Diabetes insipidus is a rare endocrinopathy that develops regardless of gender and age group patients, most often in people 20-40 years old. In every 5th case, diabetes insipidus develops as a complication of neurosurgical intervention.

Classification

Complications

Diabetes insipidus is dangerous due to the development of dehydration of the body in cases where fluid loss through urine is not adequately replenished. Dehydration is manifested by severe general weakness, tachycardia, vomiting, mental disorders, blood thickening, hypotension up to collapse, and neurological disorders. Even with severe dehydration polyuria persists.

Diagnosis of diabetes insipidus

Typical cases allow one to suspect diabetes insipidus by unquenchable thirst and the release of more than 3 liters of urine per day. To assess the daily amount of urine, a Zimnitsky test is performed. When examining urine, its low relative density (290 mOsm/kg), hypercalcemia and hypokalemia are determined. Diabetes mellitus is excluded by determining fasting blood glucose. In the central form of diabetes insipidus, a low level of ADH is determined in the blood.

The results of the test with dry eating are indicative: abstaining from drinking liquids for 10-12 hours. With diabetes insipidus, weight loss of more than 5% occurs, while maintaining low specific gravity and hypoosmolarity of urine. The causes of diabetes insipidus are clarified by X-ray, psychoneurological, and ophthalmological examinations. Volumetric formations brain are excluded by performing an MRI of the brain. To diagnose the renal form of diabetes insipidus, ultrasound and CT scan of the kidneys are performed. Consultation with a nephrologist is necessary. Sometimes for differentiation renal pathology a kidney biopsy is required.

Treatment of diabetes insipidus

Treatment of symptomatic diabetes insipidus begins with eliminating the cause (for example, a tumor). For all forms of diabetes insipidus it is prescribed replacement therapy synthetic analogue ADH - desmopressin. The drug is administered orally or intranasally (by instillation into the nose). A long-acting drug is also prescribed. oil solution Pituitrina. In the central form of diabetes insipidus, chlorpropamide and carbamazepine are prescribed, which stimulate the secretion of antidiuretic hormone.

Correction in progress water-salt balance by infusion administration saline solutions in large quantities. Sulfonamide diuretics (hypochlorothiazide) significantly reduce diuresis in diabetes insipidus. Nutrition for diabetes insipidus is based on limiting protein (to reduce the load on the kidneys) and sufficient consumption of carbohydrates and fats, frequent meals, and an increase in the amount of vegetable and fruit dishes. As for drinks, it is recommended to quench your thirst with juices, fruit drinks, and compotes.

Diabetes mellitus is a very common disease. It affects 2 to 4% of the population. According to American statistics, 50% of patients with diabetes die from myocardial infarction, from blindness (2nd place), from atherosclerosis of the extremities, from pyelonephritis, from urolithiasis.

Acute complications of diabetes mellitus

1. Diabetic ketoacidosis.

2. Hyperosmolar coma.

3. Hyperglycemia.

Diabetes mellitus is a chronic polyetiological disease, which is characterized in terms of disorders by hyperglycemia, protein and fat catabolism, and regardless of the cause, these disorders are associated with a lack of insulin (absolute and relative). In diabetes mellitus, the fasting blood glucose level is more than 7.2 mmol/l in a double study (*18 mg%).

Types of diabetes

1. Primary (idiopathic).

2. Secondary (symptomatic).

Secondary symptomatic diabetes mellitus

Occurs in pathologies of the endocrine system:

1. Itsenko-Cushing disease or symptom (disease of chronic excess cortisone).

2. Acromegaly (excess growth hormone).

3. Pheochromocytoma (a tumor that produces catecholamines in excess).

4. Cohn's sign (primary hyperaldosteronism). Under the influence of aldosterone, potassium levels decrease, and it is necessary for the utilization of glucose.

5. Glucogonoma (tumor of L-cells of the islets of Langerhans). The patients are exhausted, with ulcers on the extremities.

Secondary pancreatic diabetes: after removal of the pancreas, with pancreatic cancer (body and tail).

Iron storage disease (hemachromatosis). Normally, the level of iron in the blood is regulated by a feedback mechanism. More iron is absorbed than needed, and it goes to the liver, pancreas, skin:

Triad: dark skin, gray color, enlarged liver, diabetes mellitus.

Primary diabetes mellitus

This is a polyetiological disease.

Highlight:

1. Insulin - dependent diabetes mellitus - absolute insulin deficiency - type 1.

2. Insulin - independent diabetes mellitus. Occurs with relative insulin deficiency. In the blood of such patients, insulin is normal or elevated. Can be obese or normal weight.

Insulin-dependent diabetes mellitus is an autoimmune disease. Its development is based on:

1. A defect in chromosome 6 - 1 associated with the NLA system - D 3, D 4. This defect is hereditary.

2. Mumps viruses, measles, coxsackie viruses, severe stressful situations, some chemicals. Many viruses are similar to beta cells. The normal immune system resists viruses. With a defect, the islets are infiltrated by lymphocytes. B lymphocytes produce cytotoxic antibodies. beta cells die, and insufficient insulin production develops - diabetes mellitus.

Insulin-independent diabetes mellitus has a genetic defect, but manifests itself without the influence of external factors.

1. Defect in the beta cells themselves and peripheral tissues. Insulin secretion can be basal and stimulated (at a blood glucose level of 6.5 mmol/l).

2. The sensitivity of peripheral tissues to the action of insulin decreases.

3. Changes in the structure of insulin.

Insulin-dependent diabetes is affected by obesity. At the same time, the cells need more insulin, but there are not enough of its receptors in the cells.

Clinical manifestations

4 groups of violations:

1. Metabolic disorders, carbohydrate metabolism disorders - hyperglycemia, protein catabolism, fat catabolism.

2. Polyneuropathy, peripheral and autonomic.

3. Microangiopathy.

4. Macroangiopathy (atherosclerosis).

Metabolic disorders

The functions of insulin are the utilization of amino acids and glucose from human food.

Tetraanabolic hormone lowers blood glucose levels. He is opposed by:

1. Glucagon. The stimulus for its secretion is a decrease in blood glucose levels. It acts through glycogenolysis. An increase in blood glucose stimulates the breakdown of protein, and glucose is formed from amino acids.

2. Cortisone - stimulates protein catabolism and gluconeogenesis.

3. Growth hormone - promotes protein synthesis, saves glucose for RNA synthesis.

4. Adrenaline - stimulates the breakdown of glycogen, inhibits insulin secretion.

Normal blood glucose concentration is less than 6.1 mmol/l. The maximum limit during the day is 8.9 mmol/l.

Action of insulin

With an increased amount of glucagon, little glucose is consumed in the cells, so permeability decreases.

The patient complains of thirst, polyuria (with type 1 diabetes), loss of body weight, increased appetite.

Polyuria is due to the fact that when the glucose concentration increases to more than 9 - 10 mmol/l, glucose appears in the urine. Osmotic diuresis - a lot of urine with a high specific gravity.

Thirst: blood osmolarity increases, the thirst center is stimulated. Reducing body weight: contrainsular factors have a lipolytic effect --> weight loss. Increased appetite: since the tissue does not utilize glucose efficiently, the hunger center is stimulated.

With type 2 diabetes mellitus, obesity develops. since insulin is enough to carry out lipogenesis, However, in 5% of patients it is difficult to decide what type of diabetes they have.

Type 1 diabetes mellitus is an organ-specific autoimmune disease that leads to the destruction of insulin-producing beta cells of the pancreatic islets, manifested by an absolute deficiency of insulin. In some cases, patients with overt type 1 diabetes mellitus lack markers of autoimmune damage to beta cells (idiopathic diabetes mellitus type 1).

Etiology

Type 1 diabetes mellitus is a disease with a hereditary predisposition, but its contribution to the development of the disease is small (it determines its development by approximately 1/3). The probability of developing type 1 diabetes in a child with a sick mother is 1-2%, father - 3-6%, brother or sister - 6%. One or more humoral markers of autoimmune beta cell damage, which include anti-pancreatic islet antibodies, anti-glutamate decarboxylase antibodies (GAD 65) and anti-tyrosine phosphatase antibodies (IA-2 and IA-2beta), are found in 85-90 % of patients. Nevertheless, the main importance in the destruction of beta cells is given to factors cellular immunity. Type 1 diabetes mellitus is associated with HLA haplotypes DQA and DQB. With increased frequency, type 1 diabetes mellitus is combined with other autoimmune endocrine diseases ( autoimmune thyroiditis, Addison's disease) and non-endocrine diseases such as alopecia, vitiligo, Crohn's disease, rheumatic diseases.

Pathogenesis

Type 1 diabetes manifests itself when 80-90% of beta cells are destroyed by an autoimmune process. The speed and intensity of this process can vary significantly. Most often when typical course diseases in children and young people, this process proceeds quite quickly with subsequent rapid manifestation of the disease, in which from the appearance of the first clinical symptoms It may take only a few weeks for the development of ketoacidosis (up to and including ketoacidotic coma).

In other, much rarer cases, usually in adults over 40 years of age, the disease may be latent. (latent autoimmune diabetes adults - LADA), Moreover, at the onset of the disease, such patients are often diagnosed with type 2 diabetes mellitus, and for several years, compensation for diabetes mellitus can be achieved by prescribing sulfonylurea drugs. But later, usually after 3 years, signs of absolute insulin deficiency appear (weight loss, ketonuria, severe hyperglycemia, despite taking tableted hypoglycemic drugs).

The pathogenesis of type 1 diabetes mellitus is based on absolute insulin deficiency. The inability of glucose to enter insulin-dependent tissues (fat and muscle) leads to energy deficiency, resulting in intensified lipolysis and proteolysis, which are associated with weight loss. An increase in glycemic levels causes hyperosmolarity, which is accompanied by osmotic diuresis and severe dehydration. Under conditions of insulin deficiency and energy deficiency, the production of contrainsular hormones (glucagon, cortisol, growth hormone) is disinhibited, which, despite increasing glycemia, causes stimulation of gluconeogenesis. Increased lipolysis in adipose tissue leads to a significant increase in the concentration of free fatty acids. With insulin deficiency, the liposynthetic capacity of the liver is suppressed, and free fatty acid begin to engage in ketogenesis. The accumulation of ketone bodies leads to the development of diabetic ketosis, and subsequently ketoacidosis. With a progressive increase in dehydration and acidosis, a coma develops, which, in the absence of insulin therapy and rehydration, inevitably ends in death.

Epidemiology

Type 1 diabetes mellitus accounts for 1.5-2% of all diabetes cases. The lifetime risk of developing type 1 diabetes in a Caucasian person is about 0.4%. The peak age for the manifestation of type 1 diabetes mellitus is approximately 10-13 years. In the vast majority of cases, type 1 diabetes manifests itself before the age of 40.

Clinical manifestations

In typical cases, Especially in children and young people, type 1 diabetes mellitus debuts with a clear clinical picture that develops over several months or even weeks. The manifestation of type 1 diabetes mellitus can be triggered by infectious and other concomitant diseases. Characteristic symptoms common to all types of diabetes, associated with hyperglycemia: polydipsia, polyuria, itching, but in type 1 diabetes mellitus they are very pronounced. So, throughout the day, patients can drink and excrete up to 5-10 liters of fluid. Specific For type 1 diabetes, the symptom, which is caused by an absolute deficiency of insulin, is weight loss reaching 10-15 kg over 1-2 months. Characterized by a pronounced general and muscle weakness, decreased performance, drowsiness. At the beginning of the disease, some patients may experience an increase in appetite, which gives way to anorexia as ketoacidosis develops. The latter is characterized by the appearance of an acetone odor (or fruity odor) from the mouth, nausea, vomiting, often abdominal pain (pseudoperitonitis), severe dehydration and ends with the development comatose state. In some cases, the first manifestation of type 1 diabetes mellitus in children is a progressive impairment of consciousness up to coma due to concomitant diseases, usually infectious or acute surgical pathology.

In rare cases of the development of type 1 diabetes in people over 35-40 years of age (latent autoimmune diabetes of adults) the disease may not manifest itself so clearly (moderate polydipsia and polyuria, no loss of body weight) and may even be detected by chance during routine determination of glycemic levels. In these cases, the patient is often first diagnosed with type 2 diabetes mellitus and prescribed tableted hypoglycemic drugs, which for some time provide acceptable compensation for diabetes mellitus. However, over the course of several years (often within a year), the patient develops symptoms caused by an increasing absolute deficiency of insulin: weight loss, inability to maintain normal glycemia on the background of tableted glucose-lowering drugs, ketosis, ketoacidosis.

Diagnostics

Considering that type 1 diabetes mellitus has a clear clinical picture, and is also relatively rare disease, screening determination of glycemic levels for the diagnosis of type 1 diabetes mellitus is not indicated. The likelihood of developing the disease in the patients' immediate relatives is low, which, coupled with the lack of effective methods primary prevention type 1 diabetes mellitus determines the inappropriateness of studying immunogenetic markers of the disease in them. Diagnosis of type 1 diabetes mellitus in the vast majority of cases is based on the identification of significant hyperglycemia in patients with severe clinical manifestations of absolute insulin deficiency. Oral glucose tolerance test for the purpose of diagnosing type 1 diabetes mellitus it is necessary to carry out very rarely.

Differential diagnosis

In doubtful cases (detection of moderate hyperglycemia in the absence of obvious clinical manifestations, manifestation at a relatively advanced age), and also for the purpose of differential diagnosis with other types of diabetes mellitus, determination of the level is used C-peptide(basal and 2 hours after meals). Indirect diagnostic value in doubtful cases may have a definition immunological markers type 1 diabetes mellitus - antibodies to pancreatic islets, glutamate decarboxylase (GAD65) and tyrosine phosphatase (IA-2 and IA-2P).

Treatment any type of diabetes mellitus is based on three main principles: hypoglycemic therapy (for type 1 diabetes mellitus - insulin therapy), diet and patient education. Insulin therapy for type 1 diabetes mellitus is substitutive nature and its goal is to mimic physiological hormone production as much as possible in order to achieve accepted compensation criteria. Intensive insulin therapy is the closest to physiological insulin secretion. The need for insulin corresponding to its basal secretion provided by two insulin injections average duration actions (morning and evening) or one insulin injection long acting(glargine). The total dose of basal insulin should not exceed half of the total daily requirement in the drug.

Food or bolus insulin secretion replaced by injections of short or ultra insulin short acting before each meal, and its dose is calculated based on the amount of carbohydrates expected to be taken during the upcoming meal, and the existing level of glycemia, determined by the patient using a glucometer before each insulin injection.

After the manifestation of type 1 diabetes mellitus and the initiation of insulin therapy for quite a long time, the need for insulin may be small and be less than 0.3-0.4 U/kg. This period is referred to as the remission phase, or "Honeymoon". After a period of hyperglycemia and ketoacidosis, which suppress insulin secretion by the 10-15% remaining beta cells, compensation for hormonal-metabolic disorders by administering insulin restores the function of these cells, which then take over providing the body with insulin at a minimum level. This period can last from several weeks to several years, but eventually, due to autoimmune destruction of the remaining beta cells, the honeymoon ends.

– a chronic metabolic disease characterized by impaired insulin secretion and the development of hyperglycemia. Diabetes mellitus in children usually develops rapidly; is accompanied by rapid weight loss in the child with increased appetite, uncontrollable thirst and excessive urination. In order to identify diabetes mellitus in children, a detailed examination is carried out laboratory diagnostics(determination of sugar, glucose tolerance, glycated hemoglobin, insulin, C-peptide, Ab to pancreatic β-cells in the blood, glycosuria, etc.). The main directions in the treatment of diabetes mellitus in children include diet and insulin therapy.

General information

Diabetes mellitus in children is a disorder of carbohydrate and other types of metabolism, which is based on insulin deficiency and/or insulin resistance, leading to chronic hyperglycemia. According to WHO, every 500th child and every 200th adolescent suffers from diabetes. Moreover, in the coming years, the incidence of diabetes mellitus among children and adolescents is predicted to increase by 70%. Considering the wide distribution, the tendency towards “rejuvenation” of the pathology, the progressive course and severity of complications, the problem of diabetes mellitus in children requires an interdisciplinary approach with the participation of specialists in the field of pediatrics, pediatric endocrinology, cardiology, neurology, ophthalmology, etc.

Classification of diabetes mellitus in children

In patients childhood Diabetologists in most cases have to deal with type 1 diabetes mellitus (insulin-dependent), which is based on absolute insulin deficiency. Type 1 diabetes mellitus in children is usually autoimmune in nature; it is characterized by the presence of autoantibodies, destruction of β-cells, association with the genes of the major histocompatibility complex HLA, complete insulin dependence, a tendency to ketoacidosis, etc. Idiopathic diabetes mellitus type 1 has an unknown pathogenesis and is more often recorded in people of non-European race.

In addition to the dominant type 1 diabetes mellitus, children also have more rare forms diseases: diabetes mellitus type 2; diabetes mellitus associated with genetic syndromes; diabetes mellitus MODY type.

Causes of diabetes in children

The leading factor causing the development of type 1 diabetes mellitus in children is hereditary predisposition, as evidenced by the high frequency of familial cases of the disease and the presence of pathology in close relatives (parents, siblings, grandparents).

However, to initiate autoimmune process influence of a provoking factor is necessary external environment. The most likely triggers leading to chronic lymphocytic insulitis, subsequent destruction of β-cells and insulin deficiency are viral agents (Coxsackie B, ECHO, Epstein-Barr, mumps, rubella, herpes, measles, rotavirus, enterovirus, cytomegalovirus, etc.) viruses. .

In addition, the development of diabetes mellitus in children with a genetic predisposition can be facilitated by toxic effects, nutritional factors (artificial or mixed feeding, nutrition cow's milk, monotonous carbohydrate foods, etc.), stressful situations, surgical interventions.

The risk group for the development of diabetes mellitus includes children with a birth weight of over 4.5 kg, those who are obese, who lead an inactive lifestyle, who suffer from diathesis, and who are often ill.

Secondary (symptomatic) forms of diabetes mellitus in children can develop with endocrinopathies (Itsenko-Cushing syndrome, diffuse toxic goiter, acromegaly, pheochromocytoma), diseases of the pancreas (pancreatitis, etc.). Type 1 diabetes mellitus in children is often accompanied by other immunopathological processes: systemic lupus erythematosus, scleroderma, rheumatoid arthritis, periarteritis nodosa, etc.

Diabetes mellitus in children can be associated with various genetic syndromes: Down syndrome, Klinefelter syndrome, Prader-Willi syndrome, Lawrence-Moon-Bardet-Biedl syndrome, Wolfram syndrome, Huntington's chorea, Friedreich's ataxia, porphyria, etc.

Symptoms of diabetes in children

Manifestations of diabetes mellitus in a child can develop at any age. There are two peaks of manifestation of diabetes mellitus in children - at 5-8 years and in the puberty period, i.e. during periods of increased growth and intense metabolism.

In most cases, the development of insulin-dependent diabetes mellitus in children is preceded by a viral infection: mumps, measles, ARVI, enterovirus infection, rotavirus infection, viral hepatitis, etc. Type 1 diabetes mellitus in children is characterized by an acute, rapid onset, often with the rapid development of ketoacidosis and diabetic coma. From the moment of the first symptoms to the development of a coma, it can take from 1 to 2-3 months.

Diabetes mellitus in children can be suspected based on pathognomonic signs: increased urination (polyuria), thirst (polydipsia), increased appetite (polyphagia), and weight loss.

The mechanism of polyuria is associated with osmotic diuresis, which occurs with hyperglycemia ≥9 mmol/L, exceeding the renal threshold, and the appearance of glucose in the urine. Urine becomes colorless, its specific gravity increases due to high content Sahara. Daytime polyuria may go unrecognized. More noticeable is nocturnal polyuria, which in diabetes mellitus in children is often accompanied by urinary incontinence. Sometimes parents pay attention to the fact that urine becomes sticky, and so-called “starchy” stains remain on the child’s underwear.

Polydipsia is a consequence increased secretion urine and dehydration of the body. Thirst and dry mouth can also plague your child at night, causing him to wake up and ask for something to drink.

Children with diabetes experience a constant feeling of hunger, but along with polyphagia, they experience a decrease in body weight. This is due to energy starvation of cells caused by the loss of glucose in the urine, disruption of its utilization, and increased processes of proteolysis and lipolysis under conditions of insulin deficiency.

Already at the onset of diabetes mellitus, children may experience dry skin and mucous membranes, the appearance of dry seborrhea on the scalp, flaking of the skin on the palms and soles, seizures in the corners of the mouth, candidal stomatitis, etc. Pustular skin lesions, furunculosis, mycoses, diaper rash, etc. are typical. vulvitis in girls and balanoposthitis in boys. If the debut of diabetes mellitus in a girl occurs at puberty, this can lead to menstrual irregularities.

With decompensated diabetes mellitus, children develop cardiovascular disorders(tachycardia, functional murmurs), hepatomegaly.

Complications of diabetes mellitus in children

The course of diabetes mellitus in children is extremely labile and is characterized by a tendency to develop dangerous conditions hypoglycemia, ketoacidosis and ketoacidotic coma.

Hypoglycemia develops as a result of a sharp decrease in blood sugar caused by stress, excessive physical activity, insulin overdose, poor diet, etc. Hypoglycemic coma is usually preceded by lethargy, weakness, sweating, headache, feeling severe hunger, trembling in the limbs. If measures are not taken to increase blood sugar, the child develops convulsions, agitation, followed by depression of consciousness. In hypoglycemic coma, body temperature and blood pressure are normal, there is no smell of acetone from the mouth, skin wet, blood glucose

Diagnosis of diabetes mellitus in children

In identifying diabetes, an important role belongs to the local pediatrician, who regularly monitors the child. At the first stage, the presence of classic symptoms of the disease (polyuria, polydipsia, polyphagia, weight loss) and objective signs should be taken into account. When examining children, attention is drawn to the presence of diabetic blush on the cheeks, forehead and chin, a crimson tongue, and decreased skin turgor. Children with characteristic manifestations diabetes mellitus should be referred for further management to a pediatric endocrinologist.

The final diagnosis is preceded by a thorough laboratory examination of the child. Basic tests for diabetes mellitus in children include determination of blood sugar levels (including through daily monitoring), insulin, C-peptide, proinsulin, glycosylated hemoglobin, glucose tolerance, blood CBS; in urine - glucose and ketone bodies. The most important diagnostic criteria diabetes mellitus in children are hyperglycemia (above 5.5 mmol/l), glucosuria, ketonuria, acetonuria. For the purpose of preclinical detection of type 1 diabetes mellitus in groups with high genetic risk or for the differential diagnosis of type 1 and type 2 diabetes, determination of Abs to pancreatic β-cells and Abs to glutamate decarboxylase (GAD) is indicated. An ultrasound examination is performed to assess the structural condition of the pancreas.

Differential diagnosis of diabetes mellitus in children is carried out with acetone syndrome, diabetes insipidus, nephrogenic diabetes. Ketoacidosis and who needs to be distinguished from acute abdomen(appendicitis, peritonitis, intestinal obstruction), meningitis, encephalitis,.

Treatment of diabetes mellitus in children

The main components of treatment for type 1 diabetes mellitus in children are insulin therapy, diet, the right image life and self-control. Dietary measures include excluding sugars from the diet, limiting carbohydrates and animal fats, fractional meals 5-6 times a day, taking into account individual energy needs. An important aspect The treatment of diabetes in children is competent self-control: awareness of the seriousness of one’s disease, the ability to determine the level of glucose in the blood, adjust the dose of insulin taking into account the level of glycemia, physical activity, and dietary errors. Self-control techniques are taught to parents and children with diabetes in “diabetes schools.”

Replacement therapy for children suffering from diabetes mellitus is carried out with human preparations. genetically engineered insulin and their analogues. The dose of insulin is selected individually, taking into account the degree of hyperglycemia and the age of the child. Basis-bolus insulin therapy has proven itself well in pediatric practice, providing for the administration of long-acting insulin in the morning and evening to correct baseline hyperglycemia and the additional use of short-acting insulin before each main meal to correct postprandial hyperglycemia.

A modern method of insulin therapy for diabetes mellitus in children is an insulin pump, which allows insulin to be administered in a continuous mode (imitation of basal secretion) and bolus mode (imitation of post-alimentary secretion).

The most important components of the treatment of type 2 diabetes mellitus in children are diet therapy, sufficient physical activity, and the use of oral hypoglycemic drugs.

During development diabetic ketoacidosis infusion rehydration, administration of an additional dose of insulin taking into account the level of hyperglycemia, and correction of acidosis are necessary. If a hypoglycemic state develops, it is necessary to urgently give the child sugar-containing products (a lump of sugar, juice, sweet tea, caramel); if the child is unconscious, it is necessary intravenous administration glucose or intramuscular injection of glucagon.

Forecast and prevention of diabetes mellitus in children

The quality of life of children with diabetes mellitus is largely determined by the effectiveness of disease compensation. Subject to the recommended diet, regimen, therapeutic measures life expectancy corresponds to the average in the population. In case of gross violations of doctor's instructions, or decompensation of diabetes, specific diabetic complications develop early. Patients with diabetes mellitus are monitored for life by an endocrinologist-diabetologist.

Vaccination of children with diabetes mellitus is carried out during the period of clinical and metabolic compensation; in this case, it does not cause deterioration in the course of the underlying disease.

Specific prevention of diabetes mellitus in children has not been developed. It is possible to predict the risk of the disease and identify prediabetes based on immunological examination. In children at risk for developing diabetes mellitus, it is important to support optimal weight, daily physical activity, increase immunoresistance, treat concomitant pathologies.