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INSULINO REZISTENA
STAREA IN CARE NIVELE ALE INSULINEMIEI, EFICIENTE LA SUBIECTII NORMALI, NU PRODUC EFECTELE BIOLOGICE OBISNUITE.
CELULA BETA PANCREATICA: Functionalitatea si viata celulelor beta pancreatice pot fi afectate de rezistenta la insulina.
25% DIN POPULATIA GENERALA PREZINTA REZISTENTA LA INSULINA REZISTENTA LA INSULINA ESTE INFLUENTATA DE FACTORI DE MEDIU: - gradul adipozitatii corporale si mai ales distributia ei - exercitiul fizic si gradul de antrenament
Insulin resistance =
insulin* (mU/mL) glucose* (mg/dl) 405 20 insulin* (mU/mL) glucose* (mmol/L) - 3.5
Intre sensibilitatea la insulina estimata prin HOMA si cea estimata prin euglycemic clamp a fost gasita o corelatie foarte stransa: - (r = - 0,820) intr-un studiu recent, pe 115 subiecti europeni obezi si neobezi, diabetici si nediabetici (Bonora E et al. Diabetes Care
2000,23:67-63
Glucose clamp
Metoda se bazeaza pe mentinerea unui nivel fix (de aici si numele derivat din limba engleza : to clamp inseamna a fixa) al glicemiei in cursul unei infuzii simultane de insulina si glucoza. Nivelul glicemiei care se mentine constant pe parcursul investigatiei poate fi : 1. Nivelul bazal normal (euglycemic clamp). Aceste metode investigheaza in exclusivitate sensibilitatea tesuturilor (in principal hepatic si muscular) la actiunea insulinei. 3. Nivel crescut al glicemiei, in jur de 180 mg/dl: (hyperglycemic clamp). Hyperglycemic clamp este utilizata deobicei pentru masurarea raspunsului insulinosecretor.
De obicei rata infuziei de insulina este raportata la suprafata corporala. Suprafata corporala ( S ) se calculeaza dupa urmatoarea formula: S (m2) = G 0,425 (kg) x I 0,725 (cm) x 71,84 x 10-4 Rata de infuzie cel mai des folosita este de 40 mUmin-1m2 si corespunde
cu aproximatie la 1 mU/Kgcorp/min.
Euglycemic Clamp
Avantaje:
Posibilitatea de a asocia EC cu alte investigatii :
- calorimetria indirecta - biopsia musculara - cateterism regional (pentru a masura schimburile regionale, la nivelul unui membru sau organ). - rezonanta magnetica nucleara (NMR) - tomografia in emisie de pozitroni (PET).
2. Glucoza captata in muschi poate fi utilizata pe una din cele doua cai:
- oxidativa : - neoxidativa:
-Rata medie a metab neoxidativ al glucozei redusa la diabetici: 22 fata de 42 mmol/Kg/min la normali
-Rata medie a sintezei glicogenului redusa la diabetici: 78 fata de 183 mmol unitati glicosil/Kg/min
CONCLUZIE: Rezistenta la insulina este rezultatul unui defect al caii metabolice a sintezei glicogenului muscular
Shulman, 1990
Rezultate:
Nivelele sintezei glicogenului si ale glucozo 6-fosfatului reduse cu 80% la diabetici
Concluzie: Afectarea transportului glucozei joaca un rol important in producerea rezistentei la insulina
Cellular mechanisms in the insulin resistance associated to obesity and type 2 diabetes mellitus
Melanesian and Polynesian in its descent, the population had a traditional way of life till the beginning of the 20th century.
In 1970, Nauruans were among the richest people and this changed their way of life: become sedentary and consuming a high fat hypercaloric diet.
They sow no need to work for a living while other Pacific Islander were doing the work in the mines. The future looked bright
fattest populations. While diabetes was not known before 1950, now around 50% of Nauruans suffer from the disease and it stems from their sedentary lifestyle and fatty diet coupled with genes more suited to protect them from starvation.
Insulin resistance states (such as obesity and type 2 diabetes) are characterized by lipid accumulation as triglyceride stores in non-adipose tissue: liver, skeletal and cardiac muscle, and in pancreatic -cells.
IMCL
mi: mithocondria; IMCL droplets in close contact to mitochondria; mf:myofibrils Howald H et al: J Appl Physiol 2002;92:2264-2272
magnetic resonance spectroscopy can quantitate the intracellular (liver and muscle) triglyceride stores
1H
The FFA levels are an important link connecting obesity and type 2 diabetes to insulin resistance. An increased FFA level accounts for 50% ot the insulin resistance in people with obesity and/or type 2 diabetes
Insulin resistance is manifest after a 4-6 hours from increase in FFA levels and is accompanied by: Increase in cellular levels of - Triglycerides - DAG (di-acyl-glycerol) - Increased PKC activity Decreased levels of I
IRS1- serine/threonine
phosph.
PI 3 Kinase/Akt-PKB
Glucose uptake/transport
In the (A-ZIP/F-1) lipoatrophic mice the lack of fat is associated with insulin resistance and hyperglycemia
The phenotype of lipoatrophic mice is similar to that of human lipoatrophic diabetes : -lack of fat, insulinresistance with hyperinsulinemia , hiperphagia, hiperlipidemia, fatty liver and organomegaly. Transplantation of wild-type fat reversed completely or partially the lipoatrophic phenotype. The beneficial effects of fat transplantation were dose dependent. In this figure, lipoatrophic sham operated mice (left) and lipoatrophic mice after 3 weeks of fat (seven graft) transplantation.
Large vacuolated hepatocytes (due to lipid deposition) in the sham-operated but not transplanted mice
But the fat transplanted from ob/ob mice (leptin-deficient) failed to reverse the metbolic disturbances. This highlighted the importance of LEPTIN, an adipocyte derived hormone.
Generalized Lipodystrophy
Girl aged 6 yrs, 2 mo. Height:122 cm Weight:21,5 Kg Lack of adipose tissue at face, trunk and limbs The increase in abdomen is due to hepatosplenomegaly. Echography disclosed hepatic steatosis. Visible ombilical hernia Acanthosis nigricans, gingival hipertrophy.
Basal values:
Plasma Glucose= 93 mg/dl; serum insulin= 32.3 U/ml. HOMA-R index : 7,4 Triglycerides: 193 mg/dl;T-colesterol:126 mg/dl HDL-colesterol: 21 mg/dl ALT/AST: 113/64 U/L
Acanthosis Nigricans
The increase in intracellular triglyceride stores in non-adipose tissues may be the consequence of: -Prolonged exposure to increased plasma levels of FFA -Defects in mitochondrial (oxidative activity) fatty acid oxidation
-Both
Intramyocellular lipid content is increased and muscle mitochondrial phosphorylation activity is decreased in healthy young,lean, insulin-resistant offspring of patients with Type 2 DM
Muscle Mitochondrial oxidativephosphorylation activity is reduced in lean offspring of patients with type 2 DM
80% increase in intramyocellular triglyceride content 60% reduction in insulin-stimulated glucose uptake 30% reduction in mitochondrial phosphorylation Insulin resistance in skeletal muscle of insulin-resistant offspring of patients with type 2 diabetes is associated with dysregulation of intramyocellular fatty acid metabolism, possibly because of an inherited defect in mitochondrial oxidative phosphorylation.
c.
CONCLUSION
Excessive intake of nutrients and/or mitochondrial dysfunction may lead to increased intracellular content of lipid metabolites. Increased intracellular lipid metabolites can activate signal transduction pathways that induce inflammation and impair insulin signalling. Future therapeutic strategies may target the decrease in plasma FFA concentration, normalization of mitochondrial function and inhibition of inflammatory pathways in insulinresponsive tissues.
CARDIOVASCULAR RISK FACTORS DURING THE PRELIMINARY PHASES LEADING TO TYPE 2 DIABETES
-For 2025 it is estimated that at least 300 million people throughout the world will suffer from diabetes.
-The estimated lifetime risk to develop diabetes, for individuals born in year 2000 in USA is: 32.8% for males and 38.5% for females. -For an individual diagnosed at 40 years, men will lose 11.6 life-years and 18.6 quality-adjusted life-years and women will lose 14.3 life-years and 22.0 quality-adjusted life-years
King H et al. Diabetes Care 1998; 21: 1414-1431 Narayan KMV et al. JAMA 2003; 290: 1884-1830
% of Deaths
30
20 10 0 Ischemic Other Diabetes Cancer Stroke Infection Other heart heart disease disease
The vascular complications are associated predominantly with different risk factors
Data from UKPDS MACROVASCULAR Complications (Strokes, heart attacks,peripheral arterial disease) were predominantly associated with hypertension, hypertrigliceridemia, low HDL-cholesterol, smoking and increased urinary albumin excretion. MICROVASCULAR Complications: Retinopathy was predominantly associated with hyperglycemia
THE CLOCK
FOR
CARDIOVASCULAR DISEASE START TICKING LONG BEFORE THE ONSET OF CLINICAL DIABETES
Haffner SM et al: JAMA 1990;263:2893-2898
San Antonio Heart Study:Clinical characteristics of subjects at baseline according to conversion status at follow-up
Nondiabetic (n=1539) Type 2 Diabetes (n=195) Difference (DM Non-DM) p
-0.11 -0.14
<0.001 0.459
<0.001
0.016 0.042 <0.001 <0.001 <0.001
Data from NHANES III demonstrate presence of metabolic syndrome in 23% of the general population ATP III criteria recognize IR as a CVD risk factor
EGIRb
Insulin resistance (hyperinsulinaemia) Plus 2 or more of: Blood pressure TG, HDL-Cd
NCEPc
FPG Plus 2 or more of: Blood pressure TG HDL-C Central obesity
aWorld Health Organisation; bEuropean Group for the study of Insulin resistance; cNational Cholesterol Education Program; dand/or treatment for dyslipidaemia Eschwege E. Diabetes Metab 2003;29:6S19-27
Metabolic Syndrome
The IDF worldwide consensus definition
Prevalence of metabolic syndrome among NHANES III participants over 50 years of age categorized by glucose intolerance
Prevalence of CHD among NHANES III participants over 50 years of age categorized by presence of metabolic syndrome and diabetes
The risk for incidence of type 2 diabetes is greatly increased in persons with the metabolic syndrome traits
San Antonio Heart Study: more than 60% of the insulin resistant subjects developed diabetes during 7.5 year follow-up
Five-year conversion rates for developing diabetes by the numbers of RFs present at baseline
The Insulin Resistance Atherosclerosis Study
Five-year conversion rates for developing diabetes by the presence at baseline of one or more CVD RFs.
DAgostino RB et al. Diabetes Care 2004; 27: 2234 - 2240
The metabolic syndrome is a precursor and a significant predictor of CVD and type 2 diabetes
The risk increase with the onset of elevated blood glucose levels.
The risk for macrovascular complications increase much earlier being predominantly associated to metabolic abnormalities that cluster around insulin resistance.
The best time point to start preventive interventions is different for micro and macro-vascular complications.
-Individuals with prediabetes susceptible to clinical interventions to prevent or delay the progress to clinical diabetes. - Individuals with diabetes in which multifactorial treatment of risk factors may delay or prevent complications.
Conclusions (1)
Early detecton of T2DM could offer the possibility to implement therapeutic interventions during the preclinical asymptomatic phase:
-Counseling for lifestyle optimisation. -Tight glycemic control. -Intensive use and targeted choice of antihypertensive agents.
Conclusions (2)
It is presumed, from indirect evidence, that the impact of earlier