制动是高钙血症的一种罕见病因，常见于骨折、脊柱损伤、四肢瘫痪或大面积烧伤的患者，而由痛风引起者临床罕见。报告1例因严重痛风而制动所导致的以高钙危象、急性肾衰竭为主要表现的病例，旨在提高临床医师对制动性高钙血症的临床认识和诊疗水平。

例1.先证者(Ⅲ2),男,22岁,因"呼吸困难11个月余,加重6 h"于2020年7月入院.自6岁始间断鼻衄,12岁始生长迟缓,同年患"痛风".近1年多次住院,检查示重度贫血和代谢性酸中毒,肌酐自首次入院109 μmol/L开始进行性升高,未规律用药.有身材矮小、肝大家族史.查体:身高130 cm,体质量30 kg,娃娃脸面容,全身皮肤可见多处痛风石沉积.腹部膨隆,肝肋下10 cm.血气分析示 pH 7. 171,PaO266. 9 mmHg, HCO3- 8. 0 mmol/L,乳酸4. 3 mmol/L;BNP 1404. 77 pg/ml,Hb 65 g/L,白蛋白27. 72 g/L,ALT 11 U/L,血钙1. 35 mmol/L,血糖 3. 68 mmol/L, SCr 351 μmol/L, UA 860 μmol/L, TG 16. 82 mmol/L;尿蛋白( + + +).腹部CT:肝脏体积增大,肝内多发低、稍低密度灶(提示肝腺瘤),右侧第7肋骨骨折.基因检测证实G6PC基因c. 648G>T纯合突变,确诊为糖原累积病( GSD)Ⅰa型.给予"生玉米淀粉"口服及"利尿、纠酸、补钙"等治疗,患者于确诊后1个月内死亡.

口腔颌面部间隙感染为临床常见的面部感染疾病,若治疗不及时,加之糖尿病患者本身血糖控制差,感染细菌很容易入血,引起局部脓肿,甚至败血症,严重时可导致患者死亡.同时少数患者可以因感染导致急性视神经炎,影响患者视力.现报道此患者1例的诊断及治疗经过,希望加强对本病的认识,有利于指导临床治疗.

Objective To investigate whether pancreatic progenitors and islets differentiated from human embryonic stem cells(hESCs) could correct hyperglycemia in non-obese diabetic/severe combined immunodeficient (NOD/SCID) mice.Methods We obtained pancreatic progenitors and islets derived from hES cells line YT1 according to the optimized four-stage differentiation protocol.Stage 1:definitive endoderm formation; Stage 2:pan creatic specialization; Stage 3:amplification of pancreatic progenitors,Stage 4:maturation of pancreatic islets.To observe the morphological changes of each stage and immunofluorescent expression of pancreatic and duodenal homeobox gene(PDX-1),glucagon,insulin,C-peptide,glucose transporter-2(Glut-2).The differentiated cells from stage 3 and stage 4 were then transplanted into one of the epididymal fat pads(EFP) of NOD/SCID mice.The survival and function of the graft were measured by immunohistochemistry and blood glucose monitor.Results The stage 4-differentiated pancreatic islets expressed mature β cell-specific markers such as glucagon,insulin and Glut 2,and even PDX-1 and C-peptide-double-positive.The stage 4-pancreatic islets had nearly 17.1％ insulin-positive cells as assayed by flow cytometry analysis.Differentiated pancreatic islets released insulin/C-peptide in response to glucose stimulation.After implantation into EFP of NOD/SCID mice,hES cell-derived human pancreatic progenitors and islets corrected hyperglycemia for at least 12 weeks.Conclusions Pancreatic progenitors and islets differentiated from hESCs can correct hyperglycemia in NOD/SCID mice.

BACKGROUND:Human pancreatic islet transplantation is a prospective curative treatment for diabetes. However, the lack of donor pancreases greatly limits this approach. One approach to overcome the limited supply of donor pancreases is to generate functional islets from human embryonic stem cells (hESCs), a cell line with unlimited proliferative capacity, through rapid directed differentiation. This study investigated whether pancreatic insulin-producing cells (IPCs) differentiated from hESCs could correct hyperglycemia in severe combined immunodeficient (SCID)/non-obese diabetic (NOD) mice, an animal model of diabetes.METHODS:We generated pancreatic IPCs from two hESC lines, YT1 and YT2, using an optimized four-stage differentiation protocol in a chemically defined culture system. Then, about 5-7 × 10(6) differentiated cells were transplanted into the epididymal fat pad of SCID/NOD mice (n = 20). The control group were transplanted with undifferentiated hESCs (n = 6). Graft survival and function were assessed using immunohistochemistry, and measuring serum human C-peptide and blood glucose levels.RESULTS:The pancreatic IPCs were generated by the four-stage differentiation protocol using hESCs. About 17.1% of differentiated cells expressed insulin, as determined by flow cytometry. These cells secreted insulin/C-peptide following glucose stimulation, similarly to adult human islets. Most of these IPCs co-expressed mature β cell-specific markers, including human C-peptide, GLUT2, PDX1, insulin, and glucagon. After implantation into the epididymal fat pad of SCID/NOD mice, the hESC-derived pancreatic IPCs corrected hyperglycemia for ≥ 8 weeks. None of the animals transplanted with pancreatic IPCs developed tumors during the time. The mean survival of recipients was increased by implanted IPCs as compared to implanted undifferentiated hESCs (P<0.0001).CONCLUSIONS:The results of this study confirmed that human terminally differentiated pancreatic IPCs derived from hESCs can correct hyperglycemia in SCID/NOD mice for ≥8 weeks.

Objective To investigate whether pancreatic progenitors differentiated from human embryonic stem(hES) cells could correct hyperglycemia in non-obese diabetic(NOD)/severe combined immunodeficient(SCID) mice or not.Methods Pancreatic islets derived from hES cells line YT1 according to the optimized four-stage differentiation protocol in a chemical-defined culture system were observed.In the first stage,activin A and wortmannin were utilized to induce definitive endoderm formation.In the second stage,the differentiated endoderm cells were treated with all-trans retinoic acid(RA),NOGGIN and basic fibroblast growth factor(bFGF) to induce pancreatic specialization.In the third stage,pancreatic progenitors were induced by epidermal growth factor(EGF)-regulated expansion.Finally,in the fourth stage,a cocktail of factors was utilized to induce mature insulin-producing cells.The differentiated human pancreatic islet cells of(3-5)×106 were then transplanted into one of the epididymal fat pads(EFP) of NOD/SCID mice.Graft survival and function were measured by blood glucose levels.Results The differentiated hES cells obtained by the four-stage approach comprised nearly 17.1% insulin-positive cells and 3.8% C-peptide positive as assayed by flow cytometry analysis,which released insulin/C-peptide in response to glucose stimuli in a manner comparable to that of adult human islets.Most of these insulin-producing cells co-expressed mature β cell-specific markers such as PDX1,insulin,C-peptide and glucagon.After implantation into EFP of NOD/SCID mice,hES cell-derived pancreatic islets corrected hyperglycemia for an least eight weeks.Conclusion Human terminal differentiation pancreatic islet cells can correct hyperglycemia in NOD/SCID mice.

目的探讨体外诱导人胚胎干细胞(hESs)定向分化为胰岛细胞的可行性。方法体外分三阶段诱导hESCs定向分化为胰岛细胞。第一阶段:予以活化素-A、渥曼青霉素诱导分化形成定型内胚层;第二阶段:采用维甲酸(RA)、NOGGIN、碱性成纤维细胞生长因子(bFGF)诱导胰腺细胞定向分化;以EGF扩增胰腺祖细胞;第三阶段:采用尼克酰胺、唾液素4、bFGF及骨形成蛋白(BMP4)促进胰岛细胞成熟;观察诱导各阶段细胞形态变化,免疫荧光法鉴定胰十二指肠同源异型盒基因(PDX-1)、胰高糖素、胰岛素、C肽、葡萄糖转运子2(glut-2)表达。结果诱导14 d时hESs出现胰高糖素荧光表达;20 d时细胞出现PDX-1和C肽共表达;22 d形成的成熟胰岛细胞出现glut-2和胰岛素的阳性表达;胰岛素阳性细胞占17.1%,C肽阳性细胞占3.8%。结论体外可简单高效的诱导hESs定向分化为成熟胰岛细胞。