pleno skrenario a blok 7 2014
Post on 03-Jun-2018
219 Views
Preview:
TRANSCRIPT
-
8/12/2019 Pleno Skrenario a Blok 7 2014
1/27
Pleno Skenario A
blok 7
dr.Swanny, MSc
Dept. Physiology
-
8/12/2019 Pleno Skrenario a Blok 7 2014
2/27
Kasus Nona, 19 thn
Nona, 19 thn, penderita DM sejak
kecil, rutin injeksi Insulin.
Mendapat injeksi Insulin pagi
tidak makan siangpingsan
kadar gula darah 58 mg%.
Gangguan homeostasis Glukosa
-
8/12/2019 Pleno Skrenario a Blok 7 2014
3/27
OVERVIEW OF METABOLIC PATHWAYS
AminoAcids
Glucose-6-P
Pyruvate
ATP
Acetyl-CoA
Urea
AND SYSTEMS OF ENERGY METABOLISM
b a
o
eh
p
NucleicAcidsGLYCOGEN PROTEIN TRIACYLGLYCEROLS
dc
Ribose-5-Pf g i j
k l
a
b
Glucose
Lactate
n
m
Ketone
Bodies
Figure 1. Energy systems
Free Fatty Acids
-
8/12/2019 Pleno Skrenario a Blok 7 2014
4/27
Figure 2. Summary of metabolic events in the well-fed (absorptive) state
Intestine
glucose
viablood
Brain
CO2
Muscle
glycogen
AdiposeTissue
fat
Liver
triacylglycerol
glycogen
RBC
Pancreas
insulin
fattyacids
CO2
-
8/12/2019 Pleno Skrenario a Blok 7 2014
5/27
Figure 3.Metabolic transport of glucose; = stimulation by insulin
A) Insulin-insensitive glucose transport (GLUT-1 or GLUT-2)
GLUCOSE
Red
bloodcell
brain
liverkidney
B) Insulin-stimulatable glucose transport (GLUT-4)
GLUCOSE
INSULIN+ +
muscle
heart
adipocyte
-
8/12/2019 Pleno Skrenario a Blok 7 2014
6/27
BLOOD GLUCOSE HOMEOSTASIS
maintenance of blood glucose concentration
brain depends on glucose; >50% of total
prolonged starvation has
-
8/12/2019 Pleno Skrenario a Blok 7 2014
7/27
Hypoglycemia in Diabetes
-
8/12/2019 Pleno Skrenario a Blok 7 2014
8/27
Hypoglycemia:
Definitions
Mild: Adrenergic (BG
-
8/12/2019 Pleno Skrenario a Blok 7 2014
9/27
Hypoglycemia:
Cause
Imbalancebetween factors raising andlowering blood glucose levels
Blood Glucose Blood Glucose
Food Insulin/Oral Meds
Counterregulatory
Hormones
Physical Activity
-
8/12/2019 Pleno Skrenario a Blok 7 2014
10/27
Hypoglycemia
The Greatest Limiting Factor
In Diabetes Management
-
8/12/2019 Pleno Skrenario a Blok 7 2014
11/27
The Great Limiting Factor
Performance
Impairment
-
8/12/2019 Pleno Skrenario a Blok 7 2014
12/27
The Great Limiting Factor
Accident Risk
-
8/12/2019 Pleno Skrenario a Blok 7 2014
13/27
The Great Limiting Factor
Anxiety /Embarrassment
-
8/12/2019 Pleno Skrenario a Blok 7 2014
14/27
The Great Limiting Factor
LastingDamage?
Spatial memory /performance (if
before age 5)
-
8/12/2019 Pleno Skrenario a Blok 7 2014
15/27
The Great Limiting Factor
DiminishedSymptoms
(HypoglycemicUnawareness)
-
8/12/2019 Pleno Skrenario a Blok 7 2014
16/27
The Great Limiting Factor
Rebound
-
8/12/2019 Pleno Skrenario a Blok 7 2014
17/27
The Great Limiting Factor
Weight Gain
-
8/12/2019 Pleno Skrenario a Blok 7 2014
18/27
-
8/12/2019 Pleno Skrenario a Blok 7 2014
19/27
Frequency of Iatrogenic Hypoglycemia (2)
Type 2 diabetes
event rates for severe hypoglycemia during aggressive insulin therapy intype 1 diabetes range from 62 through 110 to 170 episodes per 100patient-years.
Those during aggressive insulin therapy in type 2 diabetes range from 3through 10 to 73 episodes per 100 patient-years.
the rates of severe hypoglycemia in type 2 diabetes are roughly 10% ofthose in type 1 diabeteseven during aggressive therapy with insulin.
Over 6 years of follow-up of patients with type 2 diabetes in UKPDS, 2.4%of those using metformin, 3.3% of those using a sulfonylurea, and 11.2%of those using insulinreported major hypoglycemia (that requiringmedical attention or admission to hospital)
For comparison, 65%of the intensively treated patients with type 1diabetes in the DCCTsuffered severe hypoglycemia (that requiring theassistance of another individual) over 6.5 years of follow-up
-
8/12/2019 Pleno Skrenario a Blok 7 2014
20/27
Physiology of Glucose Counterregulation (1)
Glycemic thresholds
Decreased insulin secretionas glucose concentrations decline within thephysiological range. The physiological postabsorptive plasma glucoseconcentration range is 72108 mg/dl(4.06.0 mmol/l). The meanarterialized venous glycemic threshold for a decrease in insulin is 81
mg/dl (4.5 mmol/l).
Increased glucagon and epinephrine secretion, among otherneuroendocrine responses, as glucose concentrations fall just below thephysiological range. The glycemic threshold is 6570 mg/dl(3.63.9mmol/l).
Neurogenic and neuroglycopenic symptoms, and cognitive impairments,at lower plasma glucose concentrations. The glycemic threshold forsymptoms is 5055 mg/dl(2.83.0 mmol/l).
-
8/12/2019 Pleno Skrenario a Blok 7 2014
21/27
N Engl J Med350:22722279, 2004
-
8/12/2019 Pleno Skrenario a Blok 7 2014
22/27
Physiology of Glucose Counterregulation (2)
they shift to higherplasma glucose concentrations in peoplewith poorly controlledtype 1 and type 2 diabetes and tolowerplasma glucose concentrations in people with tightlycontrolled type 1 diabetes
The magnitude of the neuroendocrine responsestohypoglycemia is a function of the nadir plasma glucoseconcentration, not the rate of fall of plasma glucose.
womenexhibit a less vigorous responseto a given level ofhypoglycemia than men.
-
8/12/2019 Pleno Skrenario a Blok 7 2014
23/27
Pathophysiology of Glucose Counterregulation
In Diabetes Type 1 diabetes
Furthermore, as glucose levels fall, glucagon secretion doesnot increasein established type 1 diabetes
the epinephrine secretory responseto falling glucose levels istypically attenuatedin type 1 diabetes
is shifted to a lowerplasma glucose concentration largely theresult of recent antecedent hypoglycemia
a functional disorderrather than the result of a structuralabnormality of the adrenal medullae
-
8/12/2019 Pleno Skrenario a Blok 7 2014
24/27
Clinical Syndromes of Compromised Glucose
Counterregulation In Diabetes(1)
Defective glucose counterregulation
Patients with type 1 diabetes and combined deficiencies oftheir glucagon and epinephrine responsesto hypoglycemiahave been shown, in prospective studies, to be at 25-fold or
even higher increased riskfor severe iatrogenic hypoglycemiaduring aggressive glycemic therapy compared with those withabsent glucagon but normal epinephrine responses.
rates of endogenous glucose productionwere found to be20% lowerin patients with type 1 diabetes than in
nondiabetic control subjects.
-
8/12/2019 Pleno Skrenario a Blok 7 2014
25/27
Figure 1Diagrammatic representation of the concept of hypoglycemia-associated autonomic failure in diabetes.
-
8/12/2019 Pleno Skrenario a Blok 7 2014
26/27
Figure 1.Hypoglycemia-Associated Autonomic Failure in Diabetes. N Engl J Med350:22722279, 2004
-
8/12/2019 Pleno Skrenario a Blok 7 2014
27/27
THANK YOU
top related