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GlucozasericaPostedBySynevoOnaugust13,2009@3:43pmInBiochimiegeneraldinsngeiurin,Testedebiochimie|NoComments

Informatiigenerale

Glucozaestecelmaiimportantmonozahariddinsange.Rezultadindigestiacarbohidratilorsidinconversiahepaticaaglicogenuluiinglucoza.Glucozaesteunfurnizorindispensabildeenergiecaresustineactivitateacelulara.Ceidoihormonicareregleazainmoddirectnivelulglucozeiinsangesuntglucagonulsiinsulina.Glucagonulaccelereazaconversiaglicogenuluiinglucozasideterminaastfelcrestereaglicemiei.Insulinacrestepermeabilitateamembranelorcelularelaglucoza,transportaglucozaincelule(pentrumetabolism),stimuleazaformareaglicogenuluisireduceconcentratiaglucozeidinsange.Altihormonicaredetinunrolimportantinmetabolismulglucozeisunt:ACTHul,glucocorticoizii,adrenalina,tiroxina.Degradareaglucozeiserealizeazaprinprocesuldeglicoliza.

Metabolismulglucozeipoatefialteratprinmaimultemecanisme:incapacitateacelulelorpancreaticebetadeasecretainsulina,reducereanumaruluireceptorilorinsulinici,malabsorbtiaintestinalaaglucozei,incapacitateaficatuluideametabolizaglicogenul,

modificareaconcentratieihormonilorimplicatiinmetabolismulglucozei246.

Diabetulzaharatesteoconditiedefinitaprinnivelulhiperglicemieicaregenereazarisculdeafectareamicrocirculatiei(retinopatie,nefropatiesineuropatie).Seasociazacuosperantadeviataredusa,omorbiditatesemnificativadatoratacomplicatiilormicrovascularespecifice,unrisccrescutdecomplicatiimacrovasculare(boalacoronariana,accidentvascularcerebral,arteriopatieobliterantaamembrelorinferioare)siocalitateavietiidiminuata.

Inabsentaunuimarkerbiologicmaispecificpentruadefinidiabetuldeterminareaglucozeiplasmaticearamaselementuldebazaalcriteriilordediagnostic.Stabilireavalorilorcutoffpentrudiagnosticuldiabetuluiafostconsecintaanalizeiadouaseturideinformatii:

nivelurileglucozeiplasmaticeasociatecuriscdecomplicatiimicrovascularespecifice,inspecialretinopatie

distributiainpopulatieavalorilorglucozeiplasmatice.

Din1965OrganizatiaMondialaaSanatatii(OMS)ainitiatpublicareadeghiduripentrudiagnosticulsiclasificareadiabetului.Acesteaaufostrevizuitein1998sipublicatesubdenumireadeGhidpentruDefinitia,DiagnosticulsiClasificareaDiabetuluiZaharat.CaurmareacresteriiinformatieidisponibileprivindaceastaafectiuneADA(AmericanDiabetesAssociation)amodificatin2003criteriile

pentrudiagnosticulhiperglicemiilorintermediare8.

CriteriileADA(AmericanDiabetesAssociation)pentrudiagnosticuldiabetuluizaharatinclud:

Simptomesugestive(poliurie,polidipsie,scadereponderalainexplicabila),lacareseadaugaovaloareaglucozeirandom>=200mg/dL(>=11.1mmol/L)sauValoareaglicemieibazale>=126mg/dL(>=6.99mmol/L)sau

Valoareaglicemiei>=200mg/dLla2oredupaadministrareaa75gglucoza(incadrultestuluidetolerantalaglucoza)1.Inabsentauneihiperglicemiicudecompensaremetabolicaacuta,criteriile2si3trebuieconfirmateprinrepetareatestariiinzilediferite.LaacesteaseadaugarecomandarearecentaADA(2010)deaincludeHbA1cindiagnosticuldiabetuluilaovaloarecutoffde6.5%(testultrebuiesafieefectuatprintrometodastandardizataDCCT:DiabetesControlandComplicationsTrialsicertificataNGSP:NationalGlycohemoglobinStandardizationProgram).

Criteriiledediagnosticseaplicaatatadultilorcatsicopiilor17.

Recomandaripentrudeterminareaglucozeiserice/plasmatice

screeningul,diagnosticulsimonitorizareadiabetuluizaharat

diagnosticulhipoglicemiei.

Sepotrecolta4tipurideprobe:

Glucozaplasmatica/sericadeterminatajeun(bazala).Glucozasericadeterminatala2orepostprandial.Glucozaplasmatica/sericadeterminatadintroprobadesangerecoltataintrunmomentoarecarealzilei,indiferentdeintervalulde

laultimamasa(random).

Glucozaplasmatica/sericadeterminataincadrultestuluidetolerantalaglucoza(la2oredupaadministrareaa75gglucoza)12.Screeningulpentrudiabetalpersoaneloradulteasimptomaticevafiluatinconsiderarelacategoriilesupraponderalesauobeze(BMI25kg/m2)indiferentdevarsta,precumsilaceicareprezintaunulsaumaimultifactorideriscpentrudiabet:

sedentarism

rudedegradul1cuDZ

antecedentedediabetzaharatgestationalsaunasteredefetimacrosomi(>4000g)

apartenentalarasesaugrupurietnicecurisc(afroamericani,asiaticiamericani,nativiamericani,hispaniciamericanietc.)

HTA(140/90mmHg)

nivelscazutdeHDLcolesterol(250mg/dL)

femeicusindromulovarelorpolichistice

istoricdeafectiunicardiovasculare

scadereatoleranteilaglucozalatesteanterioare

alteconditiicliniceasociatecurezistentalainsulina(ex:acanthosisnigricans).

Inabsentaacestorcriteriitestareapentrudiabetvafiinitiatalavarstade45ani.Dacaseobtinrezultate[2]normalelascreening,testareavafirepetatalaintervaledemaximum3ani(testareamaifrecventavafiluatainconsiderareinfunctiedefactoriide

risc)17.

PorninddelafaptulcaincidentaDZtip2acrescutdramaticlaadolescentiinultimadecada,recomandarileADAdin2010includsicriteriidetestareacopiilorasimptomatici:supraponderalitate,lacareseadaugadoidinurmatoriifactori:

istoricfamilialdeDZtip2larudedegradul1sau2

apartenentalarasesaugrupurietnicecurisc(afroamericani,asiaticiamericani,nativiamericani,hispaniciamericanietc.)

semnederezistentalainsulinasauconditiiasociatecurezistentalainsulina(ex:acanthosisnigricans,HTA,dislipidemie,sindromulovarelorpolichistice,dismaturitate)

istoricdediabetzaharatmaternsaudiabetgestationalintimpulsarciniicucopilulincauza.

Screeningulvafiinitiatlavarstade10anisauladebutulpubertatii(dacaaceastasedezvoltalavarstesub10ani).Testareavafirepetatalaintervalede3ani.

Pentrumulteafectiuniexistaodeosebiresemnificativaintretesteledescreeningsiceledediagnostic.Diabetulconstituieoexceptie:

aceleasitestesuntfolositeatatpentruscreeningulcatsipentrudiagnosticuldiabetului7.

Lanoiintaratestulrecomandatpentruscreeninguldiabetuluiesteglicemiajeundinsangevenos(plasmasauser).Acesttest

estepreferatpentrucaesterapid,usordeefectuatsiarecosturiscazute1.

Pregatireapacientuluiinfunctiedetipulprobei

A.jeun(absentaaportuluicaloricinultimele8ore)3.

B.Farapregatirespecialaprobasevarecoltala2oredupamasa3.

C.Farapregatirespecialapacientulvamentionatimpulscursdelaultimamasa3.

D.VezirecomandarileprecizatelaTestuldetolerantalaglucozaperos.

Ladiabeticiicunoscutirecoltareasefaceinainteaadministrariiinsulineisaumedicatieihipoglicemiante4.

Specimenrecoltatsangevenos4.

Recipientderecoltarea)vacutainerfaraanticoagulantcu/faragelseparatorsau,depreferat,b)vacutainercufluorurade

sodiu/Na2EDTA4.

Prelucrareanecesaraduparecoltarea)seseparaserulprincentrifugareintruninterval=126

Nota:Diagnosticuldediabetzaharatsevastabilipebazaacelputin2valoricrescute>=126aleglicemieibazaleobtinuteinzilediferite.

Persoanelecuglicemiebazalamodificata(impairedfastingglucoseIFG)casicelecucelecuintolerantalaglucoza(impairedglucosetoleranceIGT,valoricuprinseintre140si199mg/dLla2oredupaadministrareadeglucoza)facpartedintrungrupintermediar,care,desinuindeplinestecriteriiledediagnosticalediabetuluizaharat,prezintanivelurialeglucozeipreamaripentruaficonsideratenormale.Acestepersoaneaufostincadrateanteriorcaavandprediabet.ConformnoilorrecomandariADA(2010),IFGsiIGTnutrebuieconsiderateentitaticlinicedesinestatoarecimaidegrabacategoriiderisccrescutpentrudiabetsiafectiunicardiovasculare.IFGsiIGTseasociazacuobezitate(inspecialabdominala),hipertensiunearterialasidislipidemie(trigliceridecrescutesiHDLcolesterolscazut).Crestereaactivitatiifizice,scadereaponderalasiadministrareaanumitoragentifarmacologiciprevinsauintarziedezvoltareadiabetuluilapersoanelecuintolerantalaglucoza.

Trebuiementionatfaptulcain2003ADAaredusvaloareacutoffpentruIFGdela110mg/dLla100mg/dL,unuldintrescopurifiindacelacaprevalentaIFGsaseapropiedeceaaIGT.OMSsialteorganizatiipreocupatedediabetnuauadoptataceasta

modificare7.

Monitorizareapacientilorcudiabetzaharat

Uncontrolglicemicoptimreducerisculdeinstalareacomplicatiilormicrosimacrovasculare.

Tintelecontroluluiglicemiclapacientiidiabeticiestementionataintabeluldemaijos1.

Optimal Lalimita Suboptimal

HbA1c% 8.5

Glicemiebazala 70126 126144 >144

Glicemiela2orepostprandial

180

Factordeconversie:mg/dlx0.0555=mmol/L4.

Valoricritice2nivelscazut:

Interpretarearezultatelor

Cresteri

diabetzaharat,boalaCushing,acromegalie/gigantism,feocromocitom,adenomhipofizar(secretordehormondecrestere),hemocromatoza,pancreatitaacuta/cronica,neoplasmdepancreas,glucagonom,afectiunirenalecronice,boalahepaticaavansata,deficientadevitaminaB1[3](encefalopatiaWernicke),stresacut

emotionalsaufizic(infarctmiocardic,AVC,convulsii)25.

Scaderi

insulinom,tumoriextrapancreatice(ex.hepatom),boalaAddison,hipopituitarism,malabsorbtie,necrozahepaticafuminanta(hepatita,intoxicatii),prematuri,nounascutidinmamediabetice,deficienteenzimatice(ex.galactozemie),supradozajinsulinic,hipoglicemiereactiva(hiperinsulinismindusalimentar,tulburariendocrine),hipoglicemiepostprandiala(dupainterventiichirurgicalegastrointestinale,intolerantaereditaralafructoza,galactozemie)25.

Limitesiinterferente

Potsaaparacresteriusoarealeglicemieiinsarcinanormala,lamariifumatori,obezisipersoanelesedentare.Efortulfizicintenspoategenerahipoglicemie.Cresterialeglicemeipotsaaparadupaanestezie,interventiichirurgicalesidupaadministrarei.v.deglucoza.

Scaderialeglucozeisericesepotinregistralapacientiicueritrocitoza(hematocrit>55%)sauleucocitozamarcata(leucemii).

Medicamente:

Cresteri:ACTH,asparaginaza,agonistibetaadrenergici(ex.albuterol,isoproterenol,terbutalina),cafeina,calcitonina,corticosteroizi,diazoxid,diuretice(acetazolamida,clortalidona,acidetacrinic,furosemid,tiazide,triamteren),dopamina,epinefrina,estrogeni,fructoza,glucagon,indometacin,carbonatdelitiu,morfina,acidnicotinic(dozemari),octreotid

(somatostatin),contraceptiveorale,fenotiazine,fenitoin,rifampin,streptozotocin,teofilina,tiabendazol,Dtiroxina3.

Scaderi:acetominofen(dozetoxice),blocantibetaadrenergici,steroizianabolizanti(ladiabetici),antihistaminice,aspirina(dozetoxice),bezafibrat,captopril,ciproteron,disopiramid,etanol,fenfluramina(ladiabetici),analogiaiguanetidinei,indometacin(efectevariabile),marijuana,inhibitoriMAO,nifedipina(neconcludent),pentamidina(dupacatevazile),pivampicilina,

protionamida,spironolactona,trometamina3.

Bibliografie

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2.FrancesFischbach.Chemistrystudies.InAManualofLaboratoryandDiagnosticTests.LippincottWilliams&Wilkins,USA,8Ed.2009,

324330.

3.FrancesFischbach.EffectsoftheMostCommonlyUsedDrugsonFrequentlyOrderedLaboratoryTests.InAManualofLaboratoryand

DiagnosticTests.LippincottWilliams&Wilkins,USA,8Ed.2009,12391240.

4.LaboratorSynevo.Referintelespecificetehnologieidelucruutilizate2010.RefType:Catalog.

5.LaboratoryCorporationofAmerica.DirectoryofServicesandInterpretiveGuide.Glucose,Serum.www.labcorp.com2010.RefType:

InternetCommunication.

6.LotharThomas.Bloodglucose.InClinicalLaboratoryDiagnosticsUseandAssessmentofClinicalLaboratoryResults.THBooks

VerlagsgesellschaftmbH,Frankfurt/Main,Germany,1Ed.1998,131139.

7.StandardsofMedicalCareinDiabetes2010.AmericanDiabetesAssociation.

8.WHO2006.DefinitionandDiagnosisofDiabetesMellitusandIntermediateHyperglycaemia.

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