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CARBOHYDRATE METABOLISM AND THE LABORATORY TESTS

CARBOHYDRATE METABOLISM AND THE LABORATORY TESTS. CARBOHYDRATE METABOLISM. CARBOHYDRATE BLOOD GLUCOSA GLYCOGEN FFA TRIGLYSERIDA LIVER TISSUE AMINO ACID PYRUVATE - LACTATE

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CARBOHYDRATE METABOLISM AND THE LABORATORY TESTS

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  1. CARBOHYDRATE METABOLISM AND THE LABORATORY TESTS

  2. CARBOHYDRATE METABOLISM CARBOHYDRATE BLOOD GLUCOSA GLYCOGEN FFA TRIGLYSERIDA LIVER TISSUE AMINO ACID PYRUVATE - LACTATE ENERGY ATP + H2O + CO2

  3. NORMAL BLOOD SUGAR CONTROLE BY HORMONAL REGULATION BLOOD SUGAR (CONC.) 1. INSULIN 2. GLUCAGON 3. THYROXINE 4. GROWTH HORMONE 5. A.C.T.H 6. CORTICOSTEROID 7. EPINEPHRINE

  4. NORMAL BLOOD SUGAR CONTROLE BY INTERMEDIARY REGULATION 1. GLYCOGENESIS 2. GLYCOGENOLYSIS 3. GLUCONEOGENESIS 4. GLUCOLYSIS

  5. BLOOD SUGAR CONCENTRATION NORMAL DM 1. FASTING 70-110mg/dl > 126 mg./dl 2. POST PRAN < 150 mg/dl > 200 mg/dl DIAL 3. NON FASTING 100-150 mg/dl > 200 mg/dl

  6. CARBOHYDRATE METABOLISM DISORDERS - HYPERGLYCEMIC SYNDROME - HYPOGLYCEMIC SYNDROME - INBORN ERROR - HORMONAL DISORDERS

  7. DISTURBANCE OF CARBOHYDRATE METABOLISM - INSULIN DEFICIENCY, INSULIN RESISTENCY - HORMONAL DISORDERS CAUSES : DIABETES MELLITUS

  8. DIABETES MELLITUS IS CHARACTERIZED BY CHANGES IN THE METABOLISM OF EACH OF THE MAJOR BODY FUELS (CARBOHYDRATE - FAT AND PROTEIN) AND IS ASSOSIATED BY DISTURBANCES OF A VARIETY OF HORMONES.

  9. CLASSIFICATION OF DIABETES MELLITUS 1. IDDM INSULIN DEPENDENT DM TYPE I DM 2. NIDDM NONINSULIN DEPENDENT DM TYPE II DM 3. GESTATIONAL DM 4. MALNUTRITION RELATED DM A. FCPD (FIBROCALCULOUS PANCREATIC DM) B. PDPD (PROTEIN DEFICIENT PANCREATIC DM) 5. DM OTHER CAUSES

  10. PATHOPHYSIOLOGY D.M D.M INSULIN DEFICIENT HYPERGLYCEMIA GLUCOSURIA ACUTECHONIC D.M + STRESS MICROANGIOPATHY D. KETO-ACIDOSIS D. COMA MACROANGIOPATHY

  11. COMPLICATIONS OF DM - MACROANGIOPATHY - MICROANGIOPATHY - DIABETIC RETINOPATHY - DIABETIC NEPHROPATHY - DIABETIC NEUROPATHY - INFECTION, ABSCESS, GANGRENE - HYPERLIPIDEMIA -DIABETES KETOACIDOSIS - COMA KETON BODIES ACETO ACETIC ACID B.HIDROXY BUTYRIC ACID ACETON

  12. LABORATORY EXAMINATIONS 1. URINE GLUCOSE (screening) 2. BLOOD GLUCOSE (diagnostic) 3. ORAL GLUCOSE TOLERANCE TEST (confirmatory test) 4. IV- GLUCOSE TOLERANCE TEST (confirmatory test) 5. HbA1C TEST (follow-up) 6. FRUCTOSAMIN TEST (follow-up) 7. C-PEPTIDE CONC (confirmatory test) 8. URINARY KETON (complication) 9. BLOOD KETON (complication) 10. MICROALBUMIN IN URINE (complication)

  13. DIAGNOSIS BS mg/dl BS FASTING POSTPR NORMAL < 110< 150 GLUCOSE <126< 200 INTOLERANCE DIABETES >126>200 MELLITUS

  14. ORAL GLUCOSE TOLERANCE TEST (OGTT) BS mg/dl NORMAL DM 300 300 SEVERE 200 200 MILD 100 100 Hours Hours 0 1 2 3 0 1 2 3

  15. LABORATORY TESTS BLOOD GLUCOSE PRE-ANALYTIC STEPS • Specimen of choice : venous blood; in certain condition/instruments : capillary blood • Sample of choice : serum or plasma, others : whole blood (venous or capillary blood) • Fasting : 8-10 hours • Meal after fasting : food in usual amount

  16. BLOOD GLUCOSE PRE-ANALYTIC STEPS (contd….) • Specimens handling : • Glycolysis ± 7 mg/dl/h in WB w/o inhibitors • At 4ºC ± 2 mg/dl/h will lost • Bacterial contamination will decrease glucose level • Delay time in serum containing blood clot : < 90 minutes

  17. BLOOD GLUCOSE PRE-ANALYTIC STEPS (contd….) • OGTT • Diet : must consists of > 159g of carbohydrate per day, over a period of 3 days • Discontinue any drugs that can affect glucose plas-ma level 3 days before the test • Fasting : 12 hours

  18. BLOOD GLUCOSE PRE-ANALYTIC STEPS (contd….) OGTT • A parallel urine sample must be taken for fasting glucose and ketone. A positive test strip results is a contraindication for OGTT

  19. BLOOD GLUCOSE PRE-ANALYTIC STEPS (contd….) OGTT • D-glucose : 75 g (adult) 1.75 g/kgBW (children) max up to 75 g 50 g for pregnant women • Patients should remain seated during the test • Blood samples are collected in 0; 60; 120 minutes

  20. BLOOD GLUCOSE • ANALYTICAL STEPS • METHODS : chemical & enzymatic • Chemicalmethods are no longer used, because of lack of specificity, except ortho-toluidine method • ENZYMATIC method : • Glucose oxidase (less specific than hexokinase) • Hexokinase (generally accepted reference method)

  21. BLOOD GLUCOSE • GLUCOSE OXIDASE-PAP : glucose H2O ß-D-glucose + O2 gluconolactone oxidaseO2 gluconic acid + H2O2 peroxidase H2O2 + phenylamine-phenazone color changes + H2O Measured by photometer in specific wavelength

  22. BLOOD GLUCOSE • HEXOKINASE : hexokinase Glucose + ATPglucose 6-phosphate + ADP Mg++ G6PD Glucose 6-phosphate + NADP 6-phosphoglucono- lactone + NADPH + H+ More expensive, but better in specificity and precision

  23. POST-ANALYTICAL STEPS • INTERPRETATION : • Normoglycemia • Hyperglycemia • Hypoglycemia • “Amended” insulin-to-glucose ratio : Insulin µU/ml Glucose – 30 (mg/dl) Normal : 50 – 100 µU/mg X 100

  24. POST-ANALYTICAL STEPS • INTERFERING FACTORS : • Falsely high : dextrose iv-infusion, steroids, stress, infection, caffeine, nicotine, ß-blockers, adrenal gland infection, total parenteral nutrition (TPN), diuretics, estrogen, phenytoin • Falsely low : insulin, alcohol, anabolic steroids, OAD

  25. Benedict’s tes

  26. Principle : Glucose reduces Cu 2+ to become Cu + and precipitated as Cu2O( red brick color substance)

  27. 3 ml benedict sol + 3 drops urine 100 °C

  28. Result ; Blue : negative Green : (+) Yellowish green : (++) Yellow : (+++) Red brick : (++++)

  29. Glycohemoglobin Glycated Hemoglobin Hb A1C atau A1c

  30. Glukosa plasma bila kadarnya lebih dari normal, akan bereaksi dengan Hb di dalam eritrosit, menjadi glycated hemoglobin secara ireversibelsepanjang masa hidup eristrosit (120 hari).

  31. Glycated hemoglobin yang terbentuk proporsional terhadap rerata kadar glukosa plasma selama 6-12 minggu dengan kadar ± 5% kadar total Hb A • Normal kadar Hb A1c : 3% kadar Hb A kadar Hb A1a < 1% kadar Hb A1b < 2% • Bila terjadi hiperglikemia, yang meningkat adalah HbA1C

  32. Glycated hemoglobin memberikan prediksi risiko progresif dari komplikasi diabetik. • Pemeriksaan A1c digunakan untuk kontrol DM tentang kepatuhan pengobatan 2-3 bulan yang lalu. • Tidak direkomendasi untuk diagnosis DM

  33. Hasil: HbA1c HbA1-total • Kontrol DM baik 2,5-6,0% < 7,5% • Kontrol DM kurangbaik 6,1-8,0% 7,6-9,0% • Kontrol DM buruk > 8% > 9%

  34. Metode pemeriksaan : • Ion exchange column chromatography; HPLC. • Untuk cut off A1c diambil sesuai dengan kadar Hb A1 total yaitu = 5 % dari Hb dewasa (HbA) • Bila < 1,1 x batas atas normal; komplikasi renal dan retinal jarang dijumpai. • Bila > 1,7 x batas atas normal; pada > 70% kasus sudah terjadi komplikasi renal dan retinal.

  35. Peningkatan kadar A1c menunjukkan pasti DMbila tak ada faktor-faktor lain yang menyebabkan A1c meningkat : • HbF lebih dari normal • CRF tanpa/dengan hemodialisa • Splenomegali • Serum trigliserida tinggi • Alkoholisme • Keracunan Pb atau opiat. • Fe defisiensi anemia

  36. A1c menurun pada : 1. Masa hidup eritrosit menurun misalnya pada penyakit : • Hemoglobinopati (HbS, HbC, HbD) • Anemia hemolitik • Perdarahan akut atau kronis

  37. A1c menurun pada : 2. Sesudah transfusi 3. Kehamilan 4. Penggunaan dosis tinggi Vit C atau E A1c normal, tidak menghilangkan kemungkinan IGT

  38. INTERPRETASI • A1c dapat meningkat bila kadar glukosa meningkat setelah terapi dihentikan dan tetap tinggi 2 – 4 minggu setelah terapi dilanjutkan.

  39. INTERPRETASI • Bila kadar glukosa puasa<110 mg/dl; A1c normal pada > 96% kasus • Bila kadar glukosa puasa 110–125 mg/dl; A1c normal pada > 80% kasus • Bila kadar glukosa puasa > 126 mg/dl; A1c normal pada > 60% kasus

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