糖尿病酮症酸中毒(DKA)是糖尿病最严重的急性并发症之一,具有起病隐匿、进展迅速及病死风险高等特点。尤其值得警惕的是,接受钠－葡萄糖协同转运蛋白2(SGLT2)抑制剂治疗或使用胰岛素泵的患者,可能出现“正常血糖性DKA”,使得传统以高血糖为核心警示信号的监测策略面临严峻挑战,存在显著的漏诊风险。在此背景下,持续酮体监测(CKM)作为一种新兴可穿戴监测技术,为DKA风险的早期识别与分层管理提供了新的可能。不同于传统指尖血或尿酮检测仅能提供零散、非连续的静态数值,CKM通过植入皮下的传感器连续监测组织间液中β-羟丁酸(BHB)浓度,可动态反映酮体变化,并结合阈值报警和趋势信息为干预决策提供参考。《针对糖尿病患者的持续酮体监测:一项新技术应用的国际专家共识》提出CKM有望成为糖尿病管理的重要辅助工具,潜在优先应用于反复发生DKA者、高龄或衰弱患者、使用SGLT2抑制剂者及部分自动胰岛素输注系统应用人群。本文基于该专家共识,对CKM的应用背景、技术原理、临床应用场景、阈值设定及未来研究方向进行解读,以期为其临床合理应用与后续研究提供参考,推动糖尿病管理从“血糖中心”的传统模式向兼顾多维代谢风险的综合预警体系迈进。
Abstract
Diabetic ketoacidosis (DKA) is one of the most severe acute complications of diabetes, characterized by insidious onset, rapid progression, and high mortality risk. Of particular concern is the potential occurrence of "euglycemic DKA" in patients receiving sodium-glucose cotransporter 2 (SGLT2) inhibitor therapy or using insulin pumps, which poses a significant challenge to traditional monitoring strategies centered on hyperglycemia as the core warning signal, carrying a substantial risk of missed diagnosis. Against this backdrop, continuous ketone monitoring (CKM), as an emerging wearable technology, offers new possibilities for the early identification and tiered management of DKA risk. Unlike traditional fingerstick blood or urine ketone tests that only provide sporadic, non-continuous static values, CKM utilizes a subcutaneous sensor to continuously monitor interstitial fluid beta-hydroxybutyrate (BHB) concentrations, dynamically reflecting ketone body fluctuations and providing reference for intervention decisions through threshold alerts and trend information. The recent international expert consensus on CKM published in Lancet Diabetes & Endocrinology suggests that CKM holds promise as a valuable adjunctive tool in diabetes management, with potential priority applications in individuals with recurrent DKA, elderly or frail patients, those using SGLT2 inhibitors, and certain users of automated insulin delivery systems. Based on this expert consensus, this article interprets the application background, technical principles, clinical application scenarios, threshold settings, and future research directions of CKM, aiming to provide a reference for its rational clinical application and subsequent research, thereby facilitating the transition of diabetes management from a traditional "glucose-centric" model towards a comprehensive early warning system that considers multidimensional metabolic risks.
关键词
持续酮体监测 /
糖尿病酮症酸中毒 /
β-羟丁酸 /
正常血糖性糖尿病酮症酸中毒 /
临床应用
Key words
Continuous ketone monitoring /
Diabetic ketoacidosis /
β-hydroxybutyrate /
Euglycemic diabetic ketoacidosis /
Clinical application
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参考文献
[1] UMPIERREZ G E, DAVIS G M, ELSAYED N A, et al. Hyperglycemic crises in adults with diabetes: a consensus report[J]. Diabetes Care,2024,47(8):1257-1275.
[2] GLASER N, FRITSCH M, PRIYAMBADA L, et al. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state[J]. Pediatr Diabetes,2022,23(7):835-856.
[3] DHATARIYA K, BERGENSTAL R M, AL-SOFIANI M, et al. Continuous ketone monitoring for people with diabetes: international expert recommendations on the application of a new technology[J]. Lancet Diabetes Endocrinol,2026,14(1):82-92.
[4] MAAHS D M, HERMANN J M, HOLMAN N, et al. Rates of diabetic ketoacidosis: international comparison with 49,859 pediatric patients with type 1 diabetes from England, Wales, the U.S., Austria, and Germany[J]. Diabetes Care,2015,38(10):1876-1882.
[5] KARGES B, ROSENBAUER J, HOLTERHUS P M, et al. Hospital admission for diabetic ketoacidosis or severe hypoglycemia in 31,330 young patients with type 1 diabetes[J]. Eur J Endocrinol,2015,173(3):341-350.
[6] BENOIT S R, HORA I, PASQUEL F J, et al. Trends in emergency department visits and inpatient admissions for hyperglycemic crises in adults with diabetes in the U.S., 2006-2015[J]. Diabetes Care,2020,43(5):1057-1064.
[7] KOCEVA A, KRAVOS TRAMEK N A. From sweet to sour: SGLT-2-inhibitor-induced euglycemic diabetic ketoacidosis[J]. J Pers Med, 2024, 14(7):665.
[8] DHATARIYA K. Blood ketones: measurement, interpretation, limitations, and utility in the management of diabetic ketoacidosis[J]. Rev Diabet Stud,2016,13(4):217-225.
[9] HEPPRICH M, ROSER P, STIEBITZ S, et al. Awareness and knowledge of diabetic ketoacidosis in people with type 1 diabetes: a cross-sectional, multicenter survey[J]. BMJ Open Diabetes Res Care, 2023, 11(6):e003662.
[10] MACFARLANE J, DHATARIYA K. Incidence of euglycemic diabetic ketoacidosis in adults with type 1 diabetes in the United Kingdom before the widespread use of sodium glucose cotransporter 2 inhibitors[J]. Mayo Clin Proc,2019,94(9):1909-1910.
[11] STATHI D, LEE F N, DHAR M, et al. Diabetic ketoacidosis in pregnancy: a systematic review of the reported cases[J]. Clin Med Insights Endocrinol Diabetes,2025,18:11795514241312849.
[12] TAYLOR S I, BLAU J E, ROTHER K I. SGLT2 inhibitors may predispose to ketoacidosis[J]. J Clin Endocrinol Metab,2015,100(8):2849-2852.
[13] MAYS J A, JACKSON K L, DERBY T A, et al. An evaluation of recurrent diabetic ketoacidosis, fragmentation of care, and mortality across chicago, illinois[J]. Diabetes Care,2016,39(10):1671-1676.
[14] HAMMERSEN J, TITTEL S R, WARNCKE K, et al. Previous diabetic ketoacidosis as a risk factor for recurrence in a large prospective contemporary pediatric cohort: Results from the DPV initiative[J]. Pediatr Diabetes,2021,22(3):455-462.
[15] LYERLA R, JOHNSON-RABBETT B, SHAKALLY A, et al. Recurrent DKA results in high societal costs - a retrospective study identifying social predictors of recurrence for potential future intervention[J]. Clin Diabetes Endocrinol,2021,7(1):13.
[16] GARRETT C J, CHOUDHARY P, AMIEL S A, et al. Recurrent diabetic ketoacidosis and a brief history of brittle diabetes research: contemporary and past evidence in diabetic ketoacidosis research including mortality, mental health and prevention[J]. Diabet Med,2019,36(11):1329-1335.
[17] RODRIGUEZ ALVAREZ P, SAN MARTIN V T, MOREY-VARGAS O L. Hyperglycemic crises in adults: a look at the 2024 consensus report[J]. Cleve Clin J Med,2025,92(3):152-158.
[18] ALVA S, CASTORINO K, CHO H, et al. Feasibility of continuous ketone monitoring in subcutaneous tissue using a ketone sensor[J]. J Diabetes Sci Technol,2021,15(4):768-774.
[19] NGUYEN K T, XU N Y, ZHANG J Y, et al. Continuous ketone monitoring consensus report 2021[J]. J Diabetes Sci Technol,2022,16(3):689-715.
[20] KONG Y W, JONES H C, NGAN J, et al. Preventing diabetic ketoacidosis with continuous ketone monitoring: insights from a clinical research case[J]. Diabetes Technol Ther, 2026, 28(1):73-77.
[21] MASUDA S, OTA K, OKAZAKI R, et al. Clinical characteristics associated with the development of diabetic ketoacidosis in patients with type 2 diabetes[J]. Intern Med,2022,61(8):1125-1132.
[22] CHEPULIS L, PAPA V, LAO C, et al. Epidemiology of diabetic ketoacidosis in the waikato region of New Zealand: 2000-2019[J]. J Diabetes Res,2023,2023:4715783.
[23] KAO K T, LEI S, CHEEK J A, et al. Paediatric diabetes-related presentations to emergency departments in Victoria, Australia from 2008 to 2018[J]. Emerg Med Australas,2024,36(1):101-109.
[24] BLAU J E, TELLA S H, TAYLOR S I, et al. Ketoacidosis associated with SGLT2 inhibitor treatment: analysis of FAERS data[J]. Diabetes Metab Res Rev, 2017, 33(8):10.1002/dmrr.2924.
[25] BAPAT P, BUDHRAM D R, BAKHSH A, et al. Longitudinal determination of diabetes complications and other clinical variables as risk factors for diabetic ketoacidosis in type 1 diabetes[J]. Diabetes Care,2025,48(4):614-622.
[26] STATHI D, DHATARIYA K K, MUSTAFA O G. Management of diabetes-related hyperglycaemic emergencies in advanced chronic kidney disease: review of the literature and recommendations[J]. Diabetic Med, 2025, 42(2): e15405.
[27] ALROOBI H, DARGHAM S, MAHFOUD Z, et al. Diabetic ketoacidosis and hyperosmolar hyperglycemic state in diabetes patients with heart failure: insight from the National inpatient sample[J]. BMC Cardiovasc Disord,2025,25(1):384.
[28] TECCE N, DE ALTERIIS G, DE ALTERIIS G, et al. Harnessing the synergy of SGLT2 inhibitors and continuous ketone monitoring (CKM) in managing heart failure among patients with type 1 diabetes[J]. Healthcare (Basel), 2024, 12(7):753.
[29] BERGER B, JENETZKY E, KÖBLÖS D, et al. Seven-day fasting as a multimodal complex intervention for adults with type 1 diabetes: feasibility, benefit and safety in a controlled pilot study[J]. Nutrition,2021,86:111169.
[30] COBRY E C, VIGERS T, BERGET C, et al. Frequency and causes of nocturnal alarms in youth and young adults with type 1 diabetes using a first-generation hybrid closed-loop system[J]. Diabetes Spectr,2024,37(2):118-123.
[31] BARNARD-KELLY K D, MARTÍNEZ-BROCCA M A, GLATZER T, et al. Identifying the deficiencies of currently available CGM to improve uptake and benefit[J]. Diabetic Med, 2024, 41(8): e15338.
[32] BATTELINO T, DANNE T, BERGENSTAL R M, et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range[J]. Diabetes Care,2019,42(8):1593-1603.
基金
2025年度上海市卫生健康委员会卫生行业临床研究专项(202540071)
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