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Treatment of type I diabetes mellitus in patient D.A.T.

Female patient D.A.T., born in 1946, was admitted to the Department of Diabetes on August 21, 2003, with complaints of expressed weakness, vertigo, dyspnea under insignificant physical loads, tachycardia, poor appetite, nausea, itching, headache, edema of feet, depraved vision.

It is known from the case history that 13 years ago insulin-dependent diabetes was revealed in the patient. She regularly received insulin and was periodically treated at the hospital. During last two years, aggravation of symptoms was noted: arterial hypertension, lability of disease course appeared; permanent proteinuria was reported. During last year, such symptoms as asthenia, occasional edema of legs and dyspepsia appeared; in addition, a decrease of erythrocytes and hemoglobin peripheral blood was reported. In March 2003, the patient was treated at the Department of Neurology of the Regional Hospital; the chronic renal failure and medium-degree anemia were diagnosed. Four transfusions of the erythrocytes were carried out. After a temporary improvement, in September 2003 the condition of the patient rapidly aggravated, thereby resulting in hospitalization.

At the time of admission to the hospital, condition of the patient was severe. Consciousness was clear. Skin and exposed mucous coats were pale. Peripheral lymph nodes were not enlarged. Pulse rate was 98 beats/min, rhythmic, rather full and tense. Arterial pressure was 190/120 mm Hg. Cardiac sounds were clear and rhythmic, systolic murmur on the top, the accent of the second heart sound on aorta. In the lungs, vesicular respiration was auscultated. The abdomen was soft, moderately distended, and sensitive to palpation in the area of the right hypochondrium. The liver projects by 2 cm from under the edge of the right costal arch, along the right medioclavicular line. The spleen is not increased. Large bowel spasmodic. Stools 4 times a day, chyme-like. Daily diuresis up to 1 l. Face, feet and legs are edematous.

Table 1.The changes of peripheral blood counts (D.A.T.)
Date 13.09.2003 18.09.2003 20.09.2003 25.09.2003 28.09.2003 10.10.2003
Erythrocytes, 1012/l 2.1 3.1 3.1 4 4 4.1
Hemoglobin, g/l 75 105 82 120 120 124
Color index 1.06 0.97 0.78 0.9 0.9 0.9
Reticulocytes, % 7 14 14 15
Leuko-cytes, 109/l 4.9 5.7 5.7 5 7.5 5.3
Basophiles, %
Eosinophiles, % 0.5 2 1 1 1
Stab neutrophiles, % 1 1 2 2 1
Segmented neutrophiles, % 67 64 67 62 63
Lymphocytes, % 25.5 29 28 33 32
Monocytes, % 6 4 2 2 3
Thrombocytes, 109/l 186 254 295
S.R., mm/hr 35 42
Erythrocytes with fetal hemoglobin, % 0 11 13 15

Table 2. The changes in urinalyses before and after the treatment (D.A.T.)
Date   06.09.2003 08.09.2003 18.09.2003 10.10.2003
Volume, ml   100.0   100.0 170.0
Color   Straw yellow   str./yel. str./yel.
Transparency   Transp.   Transp. Transp.
Acidity   Acid.   Acid. Acid.
Relative density, stand. units   1014   1011 1018
Protein, g/l   6.6   6.6 1.7
Sugar, g/l   9.6   8.3
Leukocytes In visual field 6–8   5–7
Erythrocytes 4–6   6–8 2–3
Hyaline 2–4   None None
Granular 5–10   2–4 None
Vasioshaped Single   None None
Acetone   None   None None
Daily proteinuria, g/day     16.5 g/l    

Diabetes mellitus, type 1, severe form, decompensation. Diabetic universal angiopathy (nephropathy, 3rd degree; chronic renal failure, 1st degree; vascular form of proliferating retinopathy; micro- and macroangiopathies of legs, 2nd degree); diabetic polyneuropathy of legs; severe anemia; symptomatic hypertension.
On admittance, the following indices were observed: glycemia, 12.4 mmole/l; glucosuria, 22 g/l; acetonuria (++); proteinuria 3.3 g/l; erythro- and cylindruria, (5 in the visual field); K+ 5.2 mmole/l; urea 14.42 mmole/l; creatinine 0.220 mmole/l; erythrocytes 2.1x1012/l; hemoglobin 64 g/l.

The following treatment has been prescribed: diet, insulin: 22 units/day; detoxication therapy (enterosorbents, hemodesis, intestine lavage), diuretics, hypotensives, antiaggregants, angioprotectors, correction of electrolytic balance, iron preparations, vitamins.

After three weeks, the state of the patient somewhat improved: carbohydrate metabolism was compensated, edemas disappeared, arterial pressure decreased to 170/100-110 mm Hg. A stable and severe anemic syndrome however remained.

On September 15, 2003, cell suspension was administered (sample 3038C-2H): nucleated cell count 25x106/ml; volume of tissue administered 1.5 ml; CFU-GM 13.9x103/ml; CFU-GEMM 1.3x103/ml; CD34+ 2.4x106/ml. Administration was intraosteal (intrasternal).

The patient tolerated treatment well. After 8 to 10 hours, syndrome of the early posttransplantation improvement was observed: headache, weariness and nausea decreased, appetite improved; the patient slept quietly for the first time in the last few months. On the 3rd day, the level of hemoglobin, erythrocytes and reticulocytes increased, and normalized by the 10th day (Table 1); gradually, in the course of three weeks, urinalyses improved considerably (Table 2). Arterial pressure dropped down to 160/100-90 mm Hg, thereby allowing to cut the dosage of hypertensive preparations.