Documente Academic
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Documente Cultură
diabetes mellitus
Nóra Hosszúfalusi
2011.03.29.
Acute and chronic complications
Acute Chronic
- Diabetic ketoacidosis - nephropathy
(DKA) - retinopathy
- Hyperglycemic - neuropathy
hyperosmolaris - Macrovascular diseases
syndrome (HHS) (CHD, peripheral
- hypoglycemia vascular disease,
- metformin associated stroke)
lactic acidosis, MALT
Chronic complications
Associations between HbA1c and MI
and microvascular complications
80
MI
Microvascularis végpontok
60
1000 betegévre (%)
Incidencia
40
20
0
5 6 7 8 9 10 11
Átlagos HbA1c koncentráció (%)
repeated acute,
reversible changes
cumulative, irreversible
changes in
stable macromolecules
other risk factors
Hyperglycemia causes
acute reversible and
cumulative irreversible changes
• Monocyta, macrophage
• Endothel
• Pericyta
• Podocyta
• Astrocyta
• Microglia
Interactions with specific AGE receptors
Hemodynamic disturbances
in diabetes
• Increased blood flow
• Increased permeability
• Hemorrheological and coagulation
abnormalities
- increased plasma viscosity
- decreased red-cell deformability
- increased platelet aggregability
Structural abnormalities
in diabetes
• Leakage of glycated plasma proteins
• Extracellular matrix is increased
- BM is thickened
- mesangial matrix is expanded
- collagen is increased
• Hypertrophy and hyperplasia of
endothelial, mesangial and arterial
smooth muscle cells
Nephropathia
Stages of nephropathy in T1DM
Stages GFR PU RR Histology
I. hypertrophy ↑ No Normal Glomerular
hyperfiltration hypertrophy
II. glomerular ↑/→ No, Normal GBM
tissue changes transient thickening,
mesangium ↑
III. „beginning” ↑/→ MAU + ↑ within the Severe > st. II.
nephropathy persist. normal
IV. manifest ↓ macro- ↑ glomeruloscl.,
nephropathy albumin- arterioscler.,
uria tubulointerst.
V. insuff. renalis ↓↓ ↓ ↑ Severe > st. IV.
Diagnosis and treatment of
microalbuminuria
• Screening once a year in T1DM (at least), at
diagnosis in T2DM
• Urinary albumin excretion 30-300 (299) mg / 24 h
• 2 positive out of 3 samples (collected urine)
(fever, urinary tract infection, heart failure etc.)
• ACE-inhibitors (ARB), good metabolic control
• DM + albuminuria increases the CVD mortality
with 20 x
NOT characteristic for diabetic
nephropathy
Hammer toe
Ulcer
Quantitative sensory tests
,9 NGT
Cum Survival
IGT
,8
NDM
,7
,6
KDM
,5
0 2 4 6 8 10
follow-up (years)
De Vegt et al: Diabetes Care.2000;23:40
Survival rate with DM and/or AMI
100
90
80
(%)
ival (%)
70
60
Survival
40
30 Nondiabetic with prior MI
20 Diabetic with prior MI
10
0
0 1 2 3 4 5 6 7 8
Year
Results of OGTT after AMI
100 n = 181
90
80 IGT Newly diagnosed DM
% of Patients
70
60
50 35% 40% 31% 25%
40
30
20
10
0
At Discharge 3 mo later At Discharge 3 mo later
Norhammar A, et al. Lancet 2002;359:2140-44.
Hypertension/blood pressure control
CV halál,
AMI,
Stroke,
Amputáció
> 50 %-kal ↓
Diabetes and infections
• Infections are more frequent: pneumonia, urinary
tract, skin and mucosal infections 1.5-2 x ↑
• Infections are more severe, mortality rate is
increased 2-3x ↑.
• Provokes hyperglycemic crisis.
• Rare, life threatening infections.
• Immunization: annually influenza vaccine,
pneumococcal polysaccharid vaccine > 2 years
(repeat > 64 years of age, renal disease,
transplantation)
Rare, life threatening infections.
in diabetes
• Mucormycosis (rhinocerebralis)
• Malign otitis externa (Ps. aeruginosa)
• Psoas abscessus (St. aureus)
• Emphysematosus cholecystitis (E. coli, Cl.
Perfringens)
• Emphysematosus urocystitis, pyelonephritis
(E. coli, K. pneumoniae)
• Fasciitis necrotisans (polymicrobe)