סכרת נעורים 2012
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סכרת נעורים 2012. איבחון וקלסיפיקציה של סכרת נעורים קטואצידוזיס: הגדרה וטיפול. סכרת נעורים: 2005. אבחון וקלסיפיקציה של סכרת נעורים Expert Committee on the Diagnosis and classification of Diabetes Mellitus Diabetes care, July 1997 National Diabetes Data Group (NDDG) - 1979 WHO - 1980-1985.

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סכרת נעורים 2012

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סכרת נעורים 2012

  • איבחון וקלסיפיקציה של סכרת נעורים

  • קטואצידוזיס: הגדרה וטיפול


סכרת נעורים: 2005

אבחון וקלסיפיקציה של סכרת נעורים

Expert Committee on the Diagnosis and classification of Diabetes Mellitus

Diabetes care, July 1997

National Diabetes Data Group (NDDG) - 1979

WHO - 1980-1985.


סימפטומים של סכרת נעורים

  • פוליאוריה

  • פולידיפסיה

  • אבדן משקל

  • פוליפאגיה (לעתים)

  • טשטוש ראיה (לפעמים)


Etiologic classification of diabetes

  • Type 1 diabetes

  • Type 2 diabetes - may range from predominantly insulin resistance with relative insulin deficiency to vice versa.

  • Other specific type

    genetic defects of beta-cell function

    Genetic defects in insulin action

    Diseases of the exocrine pancreas

    Endocrinopathies

    Drug- or chemical-induced

    Infections

    Unknown forms of immune-mediated diabetes

    Other genetic syndromes sometimes associated with diabetes

  • Gestational diabetes mellitus (GDM)


Criteria for the diagnosis of DM

1] Symptoms of diabetes plus causal plasma glucose levels > 200 mg%.

Casual defined as any time of the day without regard to time since last meal. The classic symptoms include polyuria, polydipsia, and unexplained weight loss.

O r

2] FPG > 126 mg%. Fasting: no caloric intake for at least 8 h.

Or

3] 2h PG>200 mg% during an OGTT: Glucose load of 75g.

In the absence of unequivocal hyperglycemia with acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day.


Impaired glucose tolerance & fasting glucose

  • IFG: > 100 mg% but < 126 mg% Near the level above which acute phase insulin secretion is lost in IV-GTT. Associated with a progressively greater risk of developing micro- & macrovascular complications.

  • IGT: 2h levels of BG after OGTT between 140 mg% to 200 mg%.

  • IGF & IGT are risk factors for future diabetes.

  • Associated with syndrome X (insulin resistance syn)


סיבוכים ארוכי טווח של סכרת (1)

  • Retinopathy: potential loss of vision

  • Nephropathy: potential renal failure

  • Peripheral neuropathy: Foot ulcer

    Amputation

    Charcot joints

  • Autonomic neuropathy: Gastrointestinal

    Genitourinary

    Cardiovascular

    Sexual dysfunction


סבוכים ארוכי טווח של סכרת (2)

  • Vascular disease: Cardiovascular

    Peripheral vascular

    Cerebrovascular

  • Hypertension

  • dislypidemia

  • Periodontal disease

  • Psychosocial dysfunction


Changes of the new classification

  • Elimination of insulin dependent vs. insulin independent

  • Type 1 & type 2:

    Type 1: b-cell destruction with tendency to ketoacidosis, d/t autoimmune process with autoantibodies or without (type 1 idiopathic)

  • Elimination of malnutrition-related diabetes

  • Addition of impaired fasting glucose (IFG) to the entity of IGT.


Type 1 diabetes

  • Cellular-mediated immune destruction of the b-cells

  • HLA association (HLA class II): DQA, DQB, DRB

  • Autoantibodies: insulin autoantibodies (IAA) Islet cells autoantibodies (ICA) anti Glutmic acid decarboxylase (GAD65) antibodies to tyrosine phosphatase IA-2 & IA-2b

  • Young age/ lean habitus/ ketoacidosis/ autoimmune

  • Idiopathic diabetes

  • No autoimmunity, no HLA predisposition (but inherited)

  • Most are of African or Asian origin

  • Insulin requirement may come and go


Diabetic ketoacidosis

DEFINITION

  • Blood glucose > 250 mg%

  • Ketonemia

  • pH < 7.30 and standard bicarbonate < 15 meq/L


Diabetic ketoacidosis [1]

  • Dehydration

    Osmotic diuresis (glycosuria)NS 20cc/kg 1st hour

    vomitingmaintenance + deficit

    Insensible loss

    (Kussmaul breathing, fever)

  • Hyperglycemia

    InsulinopeniaInsulin 0.1 Unit/kg/hour

    Insulin resistance (acidosis)

    Counterregulatory hormones


Diabetic ketoacidosis [2]

  • Hyponatremia

    Water shift to ECFNS 1st hour

    Pseudohyponatremia0.5 NS later

  • Hyperkalemia

    AcidosisK < 3.5 meq/L: 40 meq/L

    pre renal azotemiaK 3.5-5 meq/L: 30 meq/L

    K 5-5.5 meq/L: 20 meq/L

  • Hypophosphatemia

    Phosphaturia½ KCL, ½ KPO4


Diabetic ketoacidosis [3]

  • Acidosis

    Free fatty acids (lypolysis)Insulin

    Lactic acidosisRehydration

  • Hyperlipidemia

  • LypolysisInsulin


Genetic defects of b-cell function

  • Monogenetic defects: autosomal dominant pattern (MODY)

  • Onset: before 25 y, mild hyperglycemia

    1] Mutations in hepatocyte nuclear factor (HNF)-1a, chromosome 12 (MODY 3)

    2] Mutations in glucokinase, chromosome 7 (MODY 2)

    3] Mutations in HNF-4a, chromosome 20 (MODY 1)

    4] Point mutations in mitochondrial DNA (mainly position 3243 in tRNA of leucine gene, similar to MELAS syndrom)

    5]Impaired conversion of proinsulin to insulin (IGT)

    6] Mutant insulin molecule with impaired receptor binding


GLUCOKINASE:YING & YANG INTERPLAY

Glucokinase loss-of-function mutations:

Decreased G phosphorylation decreased Insulin secretion MODY 2.

Glucokinase gain-of-function mutations:

Hyperinsulinism: Glaser et al: NEJM 1998;338,226.

Autosomal dominant (3 generations)

Val455Met mutation

In vitro study: increased affinity of glucokinase for G higher rate of glycolysis at low G concentrations

GSIR threshold: about 40 mg%

Sequels: T1DM at later age


IPF1 (PDX1) deficiency linked to MODY4Stoffers et al: nature genetics 1997;17,138.

Extended-family pedigree (6 generations)

Onset of DM: 35 y (range 17-67 )

Heterozygous individuals: 6/8 Rx of diet or OH

No signs of ketosis or severe insulin deficiency


Genetic defects in insulin action

Murations of the insulin receptor with subsequent insulin resistance (acanthosis nigricans, virilization, PCOS)

  • Leprechaunism: characteristic facial features, fatal

  • Rabson-Mendelhall syndrome: abnormalities of teeth and nails, pineal gland hyperplasia

  • Lipoatrophic diabetes: a defect in the post-receptor signal transduction pathway.


Diseases of the exocrine pancreas

  • Pancreatitis

  • Trauma \ pancreatectomy

  • Neoplasia

  • Cystic fibrosis

  • Hemochromatosis

  • Fibrocalculous pancreatopathy


Other genetic syndromes

  • Down’s syndrome (autoimmune diseases)

  • Kleinfelter syndrome

  • Turner syndrome

  • Wolfram’s syndrome (DIDMOD)


Enedocrinopathies

  • Acromegaly

  • Cushing syndrome

  • Glucagonoma

  • Pheormacytoma

  • Hyperthyroidism

  • Somatostatinoma

  • Aldosteronoma


Drug- or chemical-induced

  • Vacor (rat poison): permanently destroy b-cells

  • Pentamidine: permanently destroy b-cells

  • Nicotinic acid: impair insulin action

  • Glucocorticoids: impair insulin action

  • Interferon-a: induce antibodies’ positive diabetes


I n f e c ti o n s

  • Congenital rubella

  • CMV

  • Coxsackie B virus

  • Adenovirus

  • Mumps


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