目的 探讨糖尿病前期患者周围神经病变的临床和电生理特点。 方法 收集2019—2022年在首都医科大学附属北京天坛医院招募的20~65岁糖代谢异常风险人群行口服糖耐量试验，前瞻性收集符合美国糖尿病协会诊断标准的空腹血糖受损或糖耐量异常患者，排除可能导致周围神经受损的其他病因及神经根病患者。依据2010年多伦多共识多发性神经病（PN）临床诊断标准，按照是否存在PN的症状体征，将患者划分为临床PN组和临床无PN组。对所有患者行感觉运动神经传导检测（NCS）、F波检测、交感皮肤反应、心率变异率及电流感觉阈值测定（CPT），比较各项检查的异常率，比较临床亚组间各项电生理检查异常率的差异。 结果 最终入组糖尿病前期患者共73例，依据多伦多共识标准可诊断为临床PN的患者仅20例（27。4%）。患者的CPT异常率为68。5%（50/73），显著高于F波、下肢NCS、上肢腕管综合征电生理检查、交感皮肤反应、心率变异率的异常率［分别为2。7%（2/73）、0（0/73）、26。0%（19/73）、6。8%（5/73）、5。5%（4/73），McNemar二项分布精确检验，均P<0。001］。采用2 000 Hz、250 Hz和5 Hz的正弦波电刺激，通过CPT分别检测粗髓鞘、薄髓鞘和无髓鞘的感觉神经纤维的感觉阈值。糖尿病前期患者手部无髓鞘的小纤维（C纤维）异常率［21。9%（16/73）］较粗髓鞘的大纤维（Aβ纤维）异常率高［8。2%（6/73），χ²=5。352，P=0。021］；足部薄髓鞘（Aδ纤维）和无髓鞘的小纤维（C纤维）异常率［42。5%（31/73）和39。7%（29/73）］均较粗髓鞘的大纤维（Aβ纤维）异常率高［11。0%（8/73），χ²=18。508、15。965，均P<0。001）。临床PN组与临床无PN组相比，CPT［90。0%（18/20）与60。4%（32/53），χ²=5。904，P=0。015］和交感皮肤反应［20。0%（4/20）与1。9%（1/53），P=0。016］的异常率显著增高。 结论 糖尿病前期的周围神经病变多无症状或为亚临床周围神经病。糖代谢异常早期最易累及无髓鞘和薄髓鞘的小纤维，可通过选择性检测小神经纤维功能的电生理方法早期发现病损。 Objective To explore the clinical and electrophysiological characteristics of peripheral neuropathy in prediabetic patients。 Methods Subjects aged 20-65 years with high-risk factors of impaired glycemia enrolled in Beijing Tiantan Hospital， Capital Medical University from 2019 to 2022 were recruited to conduct oral glucose tolerance test， after excluding other causes of neuropathy or radiculopathy。 Patients with impaired fasting glucose or impaired glucose tolerance were defined by American Diabetes Association criteria。 These patients were divided into clinical polyneuropathy (PN) and clinical non-PN groups， according to the 2010 Toronto consensus criteria and the presence of PN symptoms and signs or not。 Nerve conduction studies (NCS)， F wave， sympathetic skin response (SSR)， R-R interval variation (RRIV) and current perception thresholds (CPT) were performed and the abnormal rate was compared between different electrodiagnostic methods and between clinical subgroups。 Results Among the 73 prediabetic patients ultimately enrolled， only 20 (27。4%) can be diagnosed as clinical PN according to the Toronto consensus criteria。 The abnormal rate of CPT (68。5%， 50/73) was significantly higher than those of F wave (2。7%， 2/73)， lower limb NCS (0， 0/73)， upper limb NCS changes of carpal tunnel syndrome (26。0%， 19/73)， SSR (6。8%， 5/73) and RRIV (5。5%， 4/73 McNemar test， all P<0。001)。 With sinusoid-waveform current stimuli at frequencies of 2 000 Hz， 250 Hz and 5 Hz， the CPT device was used to measure cutaneous sensory thresholds of large myelinated， small myelinated and small unmyelinated sensory fibers respectively。 CPT revealed a 21。9% (16/73) abnormal rate of unmyelinated C fiber in the hands of prediabetic patients， significantly higher than that of large myelinated Aβ fibers [8。2% (6/73)， χ²=5。352，P=0。021]。 Both abnormal rates of small myelinated Aδ [42。5% (31/73)] and unmyelinated C fibers [39。7% (29/73)] in the feet of prediabetic patients were significantly higher than that of large myelinated Aβ fibers [11。0% (8/73)， χ²=18。508， 15。965， bothP<0。001]。 Compared with the clinical non-PN group， the abnormal rates of CPT [90。0% (18/20)vs 60。4% (32/53)， χ²=5。904， P=0。015] and SSR [20。0% (4/20) vs 1。9% (1/53)， P=0。016) were significantly higher in the clinical PN group。 Conclusions Peripheral neuropathies in prediabetic patients are usually asymptomatic or subclinical， and predispose to affect unmyelinated and small myelinated sensory fibers。 Selective electrodiagnostic measurements of small fibers help to detect prediabetic neuropathies in the earliest stages of the disease。
A clinical and electrodiagnostic study of peripheral neuropathy in prediabetic patients
Objective To explore the clinical and electrophysiological characteristics of peripheral neuropathy in prediabetic patients. Methods Subjects aged 20-65 years with high-risk factors of impaired glycemia enrolled in Beijing Tiantan Hospital, Capital Medical University from 2019 to 2022 were recruited to conduct oral glucose tolerance test, after excluding other causes of neuropathy or radiculopathy. Patients with impaired fasting glucose or impaired glucose tolerance were defined by American Diabetes Association criteria. These patients were divided into clinical polyneuropathy (PN) and clinical non-PN groups, according to the 2010 Toronto consensus criteria and the presence of PN symptoms and signs or not. Nerve conduction studies (NCS), F wave, sympathetic skin response (SSR), R-R interval variation (RRIV) and current perception thresholds (CPT) were performed and the abnormal rate was compared between different electrodiagnostic methods and between clinical subgroups. Results Among the 73 prediabetic patients ultimately enrolled, only 20 (27.4%) can be diagnosed as clinical PN according to the Toronto consensus criteria. The abnormal rate of CPT (68.5%, 50/73) was significantly higher than those of F wave (2.7%, 2/73), lower limb NCS (0, 0/73), upper limb NCS changes of carpal tunnel syndrome (26.0%, 19/73), SSR (6.8%, 5/73) and RRIV (5.5%, 4/73 McNemar test, all P<0.001). With sinusoid-waveform current stimuli at frequencies of 2 000 Hz, 250 Hz and 5 Hz, the CPT device was used to measure cutaneous sensory thresholds of large myelinated, small myelinated and small unmyelinated sensory fibers respectively. CPT revealed a 21.9% (16/73) abnormal rate of unmyelinated C fiber in the hands of prediabetic patients, significantly higher than that of large myelinated Aβ fibers [8.2% (6/73), χ²=5.352,P=0.021]. Both abnormal rates of small myelinated Aδ [42.5% (31/73)] and unmyelinated C fibers [39.7% (29/73)] in the feet of prediabetic patients were significantly higher than that of large myelinated Aβ fibers [11.0% (8/73), χ²=18.508, 15.965, bothP<0.001]. Compared with the clinical non-PN group, the abnormal rates of CPT [90.0% (18/20)vs 60.4% (32/53), χ²=5.904, P=0.015] and SSR [20.0% (4/20) vs 1.9% (1/53), P=0.016) were significantly higher in the clinical PN group. Conclusions Peripheral neuropathies in prediabetic patients are usually asymptomatic or subclinical, and predispose to affect unmyelinated and small myelinated sensory fibers. Selective electrodiagnostic measurements of small fibers help to detect prediabetic neuropathies in the earliest stages of the disease.
Prediabetic statePeripheral nervous system diseasesElectrophysiologySensory thresholdsEarly diagnosis
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