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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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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.
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VerlagsgesellschaftmbH,Frankfurt/Main,Germany,1Ed.1998,131139.
7.StandardsofMedicalCareinDiabetes2010.AmericanDiabetesAssociation.
8.WHO2006.DefinitionandDiagnosisofDiabetesMellitusandIntermediateHyperglycaemia.
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