Hiperglikemija u teškoj akutnoj bolesti - rizični čimbenik kasnijeg poremećaja metabolizma glukoze [Hyperglycemia in critical illness – risk factor for later development of glucose metabolism abnormalities]

Vujaklija Brajković, Ana (2012) Hiperglikemija u teškoj akutnoj bolesti - rizični čimbenik kasnijeg poremećaja metabolizma glukoze [Hyperglycemia in critical illness – risk factor for later development of glucose metabolism abnormalities]. PhD thesis, Sveučilište u Zagrebu.

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Abstract

Introduction: Critical illness is commonly complicated by hyperglycemia caused by mediators of stress and inflammation. Severity of disease is the main risk factor for development of hyperglycemia, but not all severely ill develop hyperglycemia and some do even in mild disease. We hypothesized that acute disease exposes a latent disturbance of glucose metabolism which normalizes after discharge but puts those patients at higher risk for developing pre-diabetes and type 2 diabetes. ----- Patients and methods: Patients admitted to the intensive care unit of the University Hospital Centre Zagreb due to acute coronary syndrome (ACS), sepsis, pulmonary embolism, pulmonary oedema and respiratory insufficiency were included in the research. Patients with no history of impaired glucose metabolism were divided into hyperglycemia group (glucose >or= 7.8 mmol/l, measured on at least two occasions) and normoglycemia group. Glycated hemoglobin, fasting glucose on the day of discharge and oral glucose tolerance test within six weeks after discharge were all performed in order to disclose patients with unknown diabetes or pre-diabetes who were excluded from the research. ----- Results: Hyperglycemia was present in 30.6% of all patients. It was more frequent in patients with sepsis and other diagnoses (pulmonary embolism, pulmonary oedema, respiratory insufficiency) (43%) than with ACS (20.2%). Glucose concentration was 10.2 (8.9 - 13) mmol/l in the hyperglycemia, and 5.7 (5 - 6.4) mmol/l in the normoglycemia group. Patients with hyperglycemia were older, had higher body mass index and were more severely ill (higher APACHE II, SAPS II, SOFA score) than patients in the normoglycemia group. Follow-up was done on 70 patients with hyperglycemia, of which 10 (14.2%) developed impaired fasting glucose/ impaired glucose tolerance (IFG/IGT) and 30 (42.9%) diabetes. 186 patients in the normoglycemia group completed the follow up, of which 10 (5.4%) developed IFG/IGT, and 21 (11.3%) diabetes. Relative risk for developing IFG/IGT was 4.13 (95% CI 1.84 - 9.24), and diabetes 4.19 (95% CI 2.61 - 6.73). ----- Conclusion: Patients with hyperglycemia during critical illness who were not diagnosed with diabetes before or during the hospitalization should be considered a population at increased risk for developing pre-diabetes and diabetes.

Abstract in Croatian

Uvod: Hiperglikemija uzrokovana medijatorima stresa i upale česta je u teškoj akutnoj bolesti. Glavni rizični čimbenik za njen nastanak jest težina bolesti, međutim hiperglikemiju ne razviju svi teško bolesni pacijenti, dok ju neki razviju i u blažem obliku bolesti. Hipoteza istraživanja jest da akutna bolest razotkriva latentan poremećaj metabolizma glukoze, koji se normalizira nakon izlječenja, ali ostaje rizik razvoja šećerne bolesti tipa 2. ----- Ispitanici i metode: U istraživanje su uključeni bolesnici primljeni u Zavod za intenzivnu medicinu Klinike za unutrašnje bolesti KBC Zagreb zbog akutnog koronarnog sindroma (ACS), sepse, plućne embolije, plućnog edema i respiratorne insuficijencije. Bolesnici bez poznate šećerne bolesti su podijeljeni u skupinu hiperglikemije (GUK>7.8 mmol/l izmjeren u najmanje 2 navrata) i normoglikemije. Postojanje ranije neprepoznate šećerne bolesti isključeno je određivanjem glukoziliranog hemoglobina, mjerenjem glukoze natašte na dan otpusta te oralnim testom opterećenja glukozom četiri do šest tjedana nakon otpusta iz bolnice. ----- Rezultati: Prevalencija hiperglikemije iznosila je 30.6%. Hiperglikemija je bila češća u skupini bolesnika sa sepsom i ostalim dijagnozama (plućna embolija, plućni edem, respiratorna insuficijenija) (43%), nego s akutnim koronarnim sindromom (20.2%). Prosječne vrijednosti koncentracije glukoze su bile 10.2 (8.9 - 13) mmol/l u skupini hiperglikemije i 5.7 (5 - 6.4) mmol/l u skupini normoglikemije. Bolesnici u skupini hiperglikemije su bili stariji, imali su veći indeks tjelesne mase i težu bolest (veći APACHE II, SAPS II, SOFA). Istraživanje je završeno za 70 bolesnika u skupini hiperglikemije, od kojih je 10 (14.2%) razvilo povećanu glikemiju natašte/ oštećenu toleranciju glukoze (IFG/IGT) i 30 (42.9%) šećernu bolest tipa 2. 186 bolesnika u skupini normoglikemije je završilo praćenje, 10 (5.4%) ih je razvilo IFG/IGT, a 21 (11.3%) šećernu bolest. Relativni rizik nastanka IFG/IGT iznosio je 4.13 (95% CI 1.84 - 9.24), a šećerne bolesti 4.19 (95% CI 2.61 - 6.73). ----- Zaključak: Bolesnici s hiperglikemijom tijekom teške akutne bolesti, a koji nemaju od ranije poznatu šećernu bolest, imaju povećan rizik nastanka predijabetesa i dijabetesa tipa 2.

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