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סכרת נעורים 2012

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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  1. סכרת נעורים 2012 • איבחון וקלסיפיקציה של סכרת נעורים • קטואצידוזיס: הגדרה וטיפול

  2. 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.

  3. סימפטומים של סכרת נעורים • פוליאוריה • פולידיפסיה • אבדן משקל • פוליפאגיה (לעתים) • טשטוש ראיה (לפעמים)

  4. 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)

  5. 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.

  6. 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)

  7. 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

  8. סבוכים ארוכי טווח של סכרת (2) • Vascular disease: Cardiovascular Peripheral vascular Cerebrovascular • Hypertension • dislypidemia • Periodontal disease • Psychosocial dysfunction

  9. 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.

  10. 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

  11. Diabetic ketoacidosis DEFINITION • Blood glucose > 250 mg% • Ketonemia • pH < 7.30 and standard bicarbonate < 15 meq/L

  12. Diabetic ketoacidosis [1] • Dehydration Osmotic diuresis (glycosuria) NS 20cc/kg 1st hour vomiting maintenance + deficit Insensible loss (Kussmaul breathing, fever) • Hyperglycemia Insulinopenia Insulin 0.1 Unit/kg/hour Insulin resistance (acidosis) Counterregulatory hormones

  13. Diabetic ketoacidosis [2] • Hyponatremia Water shift to ECF NS 1st hour Pseudohyponatremia 0.5 NS later • Hyperkalemia Acidosis K < 3.5 meq/L: 40 meq/L pre renal azotemia K 3.5-5 meq/L: 30 meq/L K 5-5.5 meq/L: 20 meq/L • Hypophosphatemia Phosphaturia ½ KCL, ½ KPO4

  14. Diabetic ketoacidosis [3] • Acidosis Free fatty acids (lypolysis) Insulin Lactic acidosis Rehydration • Hyperlipidemia • Lypolysis Insulin

  15. 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

  16. 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

  17. 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

  18. 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.

  19. Diseases of the exocrine pancreas • Pancreatitis • Trauma \ pancreatectomy • Neoplasia • Cystic fibrosis • Hemochromatosis • Fibrocalculous pancreatopathy

  20. Other genetic syndromes • Down’s syndrome (autoimmune diseases) • Kleinfelter syndrome • Turner syndrome • Wolfram’s syndrome (DIDMOD)

  21. Enedocrinopathies • Acromegaly • Cushing syndrome • Glucagonoma • Pheormacytoma • Hyperthyroidism • Somatostatinoma • Aldosteronoma

  22. 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

  23. I n f e c ti o n s • Congenital rubella • CMV • Coxsackie B virus • Adenovirus • Mumps

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