CARBOHYDRATE METABOLISM AND THE LABORATORY TESTS

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

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

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

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

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

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

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.

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

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

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

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)

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

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

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

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

OGTT BLOOD GLUCOSE PRE-ANALYTIC STEPS (contd….) 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

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

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

BLOOD GLUCOSE ANALYTICAL STEPS METHODS : chemical & enzymatic Chemical methods 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)

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

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

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

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

Benedict’s tes

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

3 ml benedict sol + 3 drops urine

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

Glycohemoglobin Glycated Hemoglobin Hb A1C atau A1c

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

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

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

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

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.

Peningkatan kadar A1c menunjukkan pasti DM bila 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

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

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

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

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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