Sibileva E.N.

the Diabetes (by definition the CART) is a status hronicheskoj giperglikemii which can develop as a result of action of many geneticheskih ekzogennyh the factors often supplementing each other. giperglikemija mozhet to be caused either an insulin lack, or surplus of factors, kotorye counteract its activity. the Aetiology Insulin is synthesised and #946;-cages ostrovkovogo the pancreas device. Predshestvennikami insulin are preproinsulin and proinsulin. Insulin is formed of the last pri otshcheplenii S-peptida, which sekretiruetsja in blood. Insulin - the albuminous hormone, which physiological effect is carried out at vzaimodejstvii with receptors of cages. Gen insulin the gene of receptors insulina - 19 chromosomes is localised on a short shoulder of 11 chromosomes, and. Infringement of secretion, synthesis or linkage of insulin with retseptorami leads to diabetes development. Usually these infringements are connected s by genetic dot mutations. At genetic mutations, as a rule, imeet a place giperinsulinizm. Pri a diabetes of type 2 a cause of infringement of a carbohydrate exchange is decrease svjazyvanija insulin with receptors, reduction of quantity of receptors. At a diabetes tipa 1 reason insulinovoj insufficiency is synthesis and secretion decrease insulina, caused progressing insulitom. In a basis insulita lays destruktsija and #946; the-cages, called or a virus infection, or autoimmunnymi povrezhdenijami. the Genetics and diabetes immunology Nasledovanie type 1 diabetes is autosomnoretsessivnym. At the majority sick s type 1 diabetes it is possible to reveal various combinations gaplotipov antigenes glavnogo a complex gistosovmestimosti II class HLA-DQ and HLA-DR. Inheritance diabeta type 2 - autosomnodominantnoe. At diagnostics of a diabetes of type 1 in the beginning zabolevanija when it still is on doklinicheskoj stages it is possible to reveal autoantitela to and #946; to-cages and to insulin. Occurrence of antibodies is marked long before manifestatsii a diabetes. Markers of a diabetes of 1 type

• Genetic: HLA DR3, DR4 and DQ
• Immunologichesky: autoantitela to gljutamatdekarboksilaze (GAD), to insulin (IAA) and to an alpha cage antigene (ICA), komplementfiksirujushchie plasmatic antibodies

Patogenez Patogenez a diabetes it is combined enough, but at the heart of it relative insufficiency of secretion of insulin lays absolute ili. Relative nedostatochnost it is caused by the raised maintenance kontroinsuljarnyh hormones, negormonalnyh antagonists of insulin or infringement of sensitivity of receptors k to insulin. Insulin is an anabolic hormone, i.e. in usual conditions sposobstvuet to glucose accumulation in a kind glikogena, increases speed albuminous sinteza, stimulates glikogenez, leads to accumulation of energy in the form of molecules ATF. From here it is easy to present to itself, that in absence of action of insulin accrue protsessy katabolizma the squirrel, stocks glikogena are exhausted, is stimulated lipoliz, snizhajutsja stocks ATF, i.e. there is an energy crisis. Uvelichenie glucose maintenances in blood owing to glikogenoliza and neogljukogeneza privodit to increase osmoljarnosti plasmas that conducts behind itself infringement water obmena and osmotic diurez. Usilenie lipoliza at a lack glikogena in a liver it is accompanied strengthened obrazovaniem ketonovyh bodies that is accompanied by development ketoza ketoatsidoza. Takim the image, breaks the kislotno-core an organism status. Power nedostatochnost conducts to accruing deficiency kalija in fabrics. Saharnyj the diabetes is accompanied by infringements of all kinds of a metabolism. diabetes Classification (the CART, 1999)

Diagnostics Javnyj or manifestnyj the diabetes has accurately outlined clinic: polidipsija, poliurija, a weight loss. At blood research in it it is marked povyshenie glucose maintenances, in urine - gljukozurija and atsetourija. If symptoms hronicheskoj giperglikemii are absent, but at research of sugar of blood is casual obnaruzhivaetsja increase of the maintenance of glucose, in this case for acknowledgement diagnoza or diabetes exceptions carry out the test for tolerance to gljukoze. Oral gljukozotolerantnyj the test: Pered it is necessary to appoint test carrying out within three days to the child usual dietu without restriction of carbohydrates. Test is spent in the morning on an empty stomach. Glucose naznachaetsja from calculation of ideal weight of 1,75 g/kg, but no more Glucose rastvorjaetsja in a glass of water also is given than 75 unitary. Sugar research is spent natoshchak in 120 minutes after glucose reception. Diagnostic criteria of a diabetes and other infringements uglevodnogo an exchange (the CART, 1999)  

  the Differential diagnosis Differentsialnyj the diagnosis is spent on following clinical symptoms obvious diabeta: polidipsii and poliurii. Similar symptoms are marked at not sugar mocheiznurenii - nesaharnom, and also in initial stage HPN, for which harakterny polidipsija and poliurija. Mochevoj the syndrome is characterised gljukozuriej this or that degree peculiar vsem proksimalnym tubulopatijam: to a syndrome De-SINK-debre-fankoni, nephritic diabetu. Atsetonurija accompanies all statuses characterised by long starvation organizma, and also meets at heavy defeats of a liver. Dlitelnoe the weight loss is peculiar such endokrinopatijam, as diffuznyj toksichesky a craw, gipokortitsizm. bystrorazvivajushchiesja diabetes complications Diabetic ketoatsidoz (DKA II-III) Samoe terrible and quickly developing complication of a diabetes is diabetichesky ketoatsidoz. For this status the combination absolute and otnositelnoj insulinovoj insufficiency is characteristic, last is in turn called povysheniem in an organism both hormonal, and not hormonal antagonists insulina. For ketoatsidoza it is characteristic:

• high giperglikemija and osmotic diurez с
• atsetonuriej
• sharp decrease in buffer properties of blood for the bill
• katabolizma the squirrel
• deducing of the bicarbonates, involving changes of the kislotno-core statuses towards the hardest metabolic atsidoza

Narastanie heavy frustration of a metabolism at nekordiniruemoj insulinovoj nedostatochnosti leads gipovolemii, to the expressed exhaustion of stocks kalija in tkanjah, to accumulation and #946;-oksimasljanoj acids in TSNS. As a result, clinical simptomatika it will be characterised by heavy frustration of haemodynamics, prerenalnoj sharp nephritic insufficiency, frustration of consciousness up to komy, hemostasis frustration.

V rare cases at children are observed:

Treatment diabetic ketoatsidoza

• at children of first 3th years of a life - 150-200 ml/kg weights/days depending on dehydration degrees
• at children of advanced age - 3-4 l/m2/days

V the first 30 minutes of introduction 1/10 daily doses. At the first 6 o`clock 1/3 daily dozy, in the next 6 hours -   1/4 daily doses, and then in regular intervals. Idealno to enter a liquid with the help infuzomata if it is not present - carefully rasschityvat quantity of drops in a minute. As a starting solution ispolzuetsja 0,9 % a solution of chloride of sodium. The physiological solution should vvoditsja no more than 2 hours. Then it is necessary to pass to 10 % a solution gljukozy in a combination to solution Ringera in the ratio 1:1. All liquid, vvodimaja vnutrivvenno is warmed up to temperature 370С. If the child very much istoshchen, we use 10 % a solution albumina prior to the beginning of introduction kristalloidov from rascheta 5 ml/kg of weight, but no more 100 ml since kolloidy keep zhidkost in a blood channel is better. Insulinoterapija Ispolzuetsja insulin of short action. Insulin is better to enter through lineamat on 10 % a solution albumina if lineomata is not present - insulin is entered strujno hourly. The initial dose of insulin of 0,2 Ed/kg, then in an hour 0,1 Unit/kg/hour Pri decrease in sugar of blood to 14-16 mmol/l an insulin dose decreases to 0,05 Unit/kg/hour Pri decrease in sugar of blood to 11 mmol/l we pass to hypodermic introduction of insulin kazhdye 6 hours. Requirement for insulin p ri deducing from a coma makes 1-2 Units/kg/days Vnimanie! Speed of decrease in glucose of blood should not exceed 5 mmol/hour! In protivnom a case probably development of a hypostasis of a brain. Correction atsidoza S atsidoza is used by the correction purpose warm, svezheprigotovlennyj 4 % a solution sody - 4 ml/kg. If it is possible to define VE the bicarbonate dose is equal 0,3-VE h massu the child in kg. Korrektsija atsidoza it is spent at 3-4 o`clock therapy not earlier than since carrying out insulinoterapii against regidratatsii is good korregiruet ketoatsidoz. Povodom for soda introduction serve:

• saved adinamija
• mramornost skin covers
• noisy deep breath

Pri treatment diabetic atsidoza small doses geparina 100 Ed/kg/days v 4 injections are appointed. If the child arrives with temperature at once is appointed antibiotik a wide spectrum of action. If the child arrives with initial priznakami ketoatsidoza (DKAI), i.e. despite metabolic atsidoz, harakterizujushchijsja dispepticheskimi complaints (a nausea, vomiting), a painful syndrome, glubokim breath, but the consciousness is saved is necessary:

Tactics of conducting the child after knocking over ketoatsidoza

the Note. If at the child at developed ketoatsidoze is available povyshenie temperatures antibiotics of a wide spectrum of action are appointed. In communication s the infringements of the hemostasis caused developed gipovolemiej and metabolicheskim atsidozom for preventive maintenance of a syndrome disseminirovannogo vascular svertyvanija it is appointed geparin in a daily dose of weight of a body of 100 ED/KG. The dose raspredeljaetsja on 4 injections, preparation introduction is spent under the control koagulogrammy.

diabetes Treatment the Diet Obshchy kalorazh is defined by age of the child, and also surplus or a lack massy. Calculation is spent under the formula: 1000 kcal + 100 • n (n - quantity of years starshe year). At surplus of weight kalorazh decreases on 10 - 15 %, and at a lack uvelichivaetsja on 10 - 15 %. Daily allowances kalorazh the child about one year it is defined vozrastom and a kind of feeding and completely corresponds to norms dietetiki zdorovogo the child. It is necessary to specify, that the diet consists on 50 - 60 % from carbohydrates, 15 - 20 % of fibers and 30 - 35 % of fats. Uglevody pay off in grain units - 1 HE = 10 - to 12 grammes of carbohydrates. In pitanie there should be enough of food fibres, and carbohydrates should byt with low glikemicheskim an index. It is necessary to remember, that power tsennost 1 gr. The squirrel and 1 gr.uglevodov = 4 kcal, and 1 gr.zhira = 9 kcal. From a food iskljuchajutsja legkousvojaemye carbohydrates. In quality saharozamenitelej it is possible ispolzovat only aspartam, no more than 3 tablets in day. Fats should be predstavleny on 50 % animal fusible fats and on 50 % - vegetative. Kolichestvo food intakes depends on age and features of the child. To children starshego E.P.Kasatkina`s age offers 2 variants of a food:  

Detjam early age till 1 year calculation of a food and quantity of food intakes, vkljuchaja feedings up are spent by the form feedings (artificial, mixed, estestvennoe). It is necessary to notice, that about 1,5 years chest vskarmlivanie are ideal to save. On our data parents have high motivation on this appearance vskarmlivanija. Kinds of insulin Ultrakorotkie analogues of insulin - Novorapid, Humalog (firms It is new-nordisk, RELLI-poured). Korotkie - Aktrapid, Humulin R Promezhutochnogo actions - protafan, Humulin N (firms It is new-nordisk, Elli-poured). V present time into practice diabetologa enter bespikovye insulin prolonged dejstvija - Detemir (the firm Is new-nordisk), Lantus (firm Aventis). Eti preparations are used as bazalnye insulin in a combination with boljusnym vvedenie ultrashort insulin. Poslednim achievement in insulinoterapii was introduction insulinovyh pumps (pomp) which provide daily correction glikemii in these pompah ispolzujutsja only ultrashort insulin. V practice of therapists it is abroad entered nazalnyj insulin of short action, about ego application for children of data is not present. Insulinoterapija the intensified schemes of treatment Now are used, kotorye assume simultaneous monitoring procedure glikemii with the help vizualnyh test strips or gljukometra and correction of a dose of insulin. In the present vremja at children are used only genoinzhenernye insulin which happen ultrakorotkogo (2 hours), short (6-8 hours) and intermediate action (16 chasov). The scheme of purposes of insulin gets out the doctor-endokrinologom with the account osobennostej the given child, the mode bazisno-boljusnyj is used, i.e. on protjazhenii day simultaneously with introduction bazalnogo insulin (intermediate dejstvija), before the basic food intakes insulin of short action is entered. Insulin intermediate action insulin korotkogo actions - from 4 to 6 times a day can be entered from 1 to 4 times a day, all are defined by the expert. Advantages of insulin of ultrashort action Oni are entered directly ahead of food intake, it is not necessary to wait 30 - 40 minutes kak at purpose of insulin of short action, at their purpose decreases risk gipoglikemy, the child gets freedom in food intake terms. Ultrakorotkie we last time use insulin for teenagers with high motivatsiej both the good control and self-checking glikemii. A daily dose of insulin opredeljaetsja individualn About, usually on the first year of illness it makes 0,5 ED/KG massy bodies, in 5 years - 1 ED/KG of weight of a body. At children of early age of a dose rasschityvajutsja with the account glikemii and increases in weight of a body that demands bole chastoj dose correction, but nevertheless they should not exceed 0,25 - 0,5 ED/KG massy a body. At teenagers in connection with increase in a road clearance of insulin the requirement in insuline can make from 1 to 2 ED/KG of weight of a body. the Syndrome of chronic overdose of insulin V a case of inadequate doses of insulin probably development of effect Somodzhi. This effekt is marked in case of insulin overdose when in reply to night gipoglikemiju there is an emission kontrinsuljarnyh hormones (gljukogona, kortizola, adrenalina, a growth hormone), that leads to increase of sugar of blood on an empty stomach. Clinical displays:

• the Uneasy dream;
• Irritability in the mornings;
• Feeling of weakness;
• the Headache.

V the overwhelming majority of episodes morning gipoglikemy the reason can be otnositelnaja resistance in the mornings to insulin (at early morning o`clock with 5 to 9 o`clock in the morning), a so-called phenomenon of Down, a dawn phenomenon. It is called night sekretsiej kontrinsuljarnogo a hormone - a growth hormone. Dlja diagnostics it is important to define sugar in 3 o`clock in the morning. If in 3 o`clock in the morning sugar in norme, and in the morning giperglikemija is a phenomenon of Down. In this case it is better to transfer inektsiju insulin of intermediate action at 23 o`clock. 2 types and МОDY-diabetes Dlja acknowledgement of the diagnosis to children before and after carbohydrate loading spend Treatment of a diabetes issledovanie IRI or S-peptida, the last more informatively. It is investigated uroven glikirovannogo haemoglobin. Now therapy МОDY-diabetes zavisit from its type, i.e. Can be used both biguanidy (Metformin), and insulin. Sports and physical activities Reguljarnye and sufficient physical activities raise sensitivity to insulinu and reduce requirement for him. Usually in sports are engaged not earlier than cherez hour after food intake. Ideally before and after loading to investigate sugar krovi, that will allow to correct an insulin dose. It is inadmissible, that the child zanimalsja sports as at low, and high glikemii. In the first case before zanjatiem the child should eat 1-2 HE, and in the second - indemnification uglevodnogo an exchange, and then the admission before playing sports is necessary. Duration of loading dolzhna to be on the average 30-40 minutes. If sports come to an end by a supper, it is necessary vechernjuju to reduce a dose of insulin of intermediate action on 2 ED for predotvrashchenija night gipoglikemy. Training the training Purpose consists in the full information of parents and children about zabolevanii. Children and parents are brought up to date that correctly provodit self-checking, and in case of need correctly to react on vozmozhnye changes in a status. Training is spent by the doctor, medical sestroj-obuchitelem at «diabetes School». At training the important place is occupied psihologicheskaja with preparation of the child and parents to the arisen problem which osushchestvljaetsja together with the psychologist. the Purpose of therapy and the control Pravilnaja diabetes therapy is directed on preventive maintenance dekompensatsii diseases, profilaktiku slowly developing complications (vascular). Osnovnaja the purpose: maintenance to the child correct physical and mental razvitija, its successful social orientation. Dlja achievements of this purpose full indemnification of a carbohydrate exchange is necessary, i.e. normoglikemija and agljukozurija, the normal maintenance glikozilirovannogo gemoglobina. Control and self-checking which assume help with it: ezhenedelnyj food calculation, the control during regular physical nagruzok. Idealnym is research glikozilirovannogo haemoglobin of 1 times in 2-3 mesjatsa. In the course of treatment research of dynamics of weight and rosta is obligatory. Pri over 5 years the careful control for arterialnym pressure, urine research on albuminuriju, annual konsultatsija patients in an office of vascular diagnostics of eye clinic for vyjavlenija retinopatii is necessary for duration of a diabetes. Two times a year the child should be examined the stomatologist i the LOR-DOCTOR. Criteria of indemnification of a carbohydrate exchange at a diabetes of I type  

© 2007 Encyclopaedia of blood

the Indicator	Indemnification	Subindemnification	Dekompensatsija
HbA1c , %	6,0 - 7,0	7,1 - 7,5	> 7,5