糖尿病与血糖监控

糖尿病與血糖監控,Blood Glucose Levels in Diabetics,糖尿病病因,目前仍不知確實的病因。只知糖尿病為一緩慢漸進性的自體免疫性疾患。自體免疫性疾患指病人體內自發性的產生具破壞性的抗體，而攻擊自己的組織。糖尿病童體內可檢測出各種會破壞胰腺中的細胞的抗體和淋巴球。細胞因而逐漸遭到破壞。當80-90%左右的細胞被破壞後，臨床上便漸漸出現症狀。,臨床症狀,常見的症狀有多尿、多飲、消瘦、多食、倦怠、夜尿（甚至尿床）、腹痛、嘔吐、口腔或陰部黴菌感染。 嚴重的會脫水。約有1/3-1/2的病童發生糖尿病酮酸中毒（diabetic ketoacidosis, DKA） 他的尿液中會有酮體出現，血液會轉為酸性（血漿HCO3- 15 mEq/L），病童會有嚴重的脫水，呼吸急促而且用力，稱為糖尿病酮酸中毒。,正常人的血糖標準 FPG 100 mg/dl or 2-h PG (OGTT) 200 mg/dlor FPG 126 mg/dlor 2-h PG (OGTT,75 gm) 200 mg/dl,Pre-diabetes (IFG & IGT ) 126 mg/dl 100 mg/dl or 200 mg/dl 140 mg/dl,IFG:Impaired Plasma Glucose,IGT:Impaired Glucose Tolerance,台灣現況(健保局資料),全民中有4.0%被歸類為糖尿病，但醫療支出佔11.5 %每位糖尿病患的平均給付金額為其他疾病的3.3倍調降1/3的嚴重個案比例，可減少20 %的總支出,糖尿病治療的總體目標,）消除糖尿病的症狀）避免低血糖和酮酸症的發生）恢復日常的活力）預防血管病變和其他的併發症）確保體格和心理的正常發展）維持健全的家庭和人際關係,監測,）自我血糖監測 (self-monitoring of blood glucose, SMBG)理想情形是維持飯前血糖在70-140，飯後140 mg/dl。但應依 病童 的年紀和處理低血糖的能力酌情調整。）醣化血紅素 (HbA1c) 醣化血紅素反映病童最近個月來血糖的平均值和 糖尿病控制的好壞。最好能維持在 7.0% 以下。）尿酮：必須為陰性。）血脂：total Cholesterol, Triglyceride, DHL-Chol 和 LDL-Chol要保持 正常。5）微尿白蛋白(microalbuminuria)：發病5-6年後，必須 開始測定，期能早期檢出腎病變。,Monitoring Diabetes,Blood glucose: self testing.Hemoglobin A1c (HbA1c) testing: hospital, lab or Dr. office testing.,What is Glycated Hemoglobin?,-chain N端Valine,Glucose,糖化作用也會發生在鍵的N端和，鍵上的lysin上。 2003,美國ADA建議統一定名為A1C.,糖化血紅素是葡萄糖和血紅素長期接觸所形成，HbA1c只是眾多糖化血紅素中的一種。,它是血糖代謝的指標,它是糖尿病併發症的危險參數,它是糖尿病管理/治療的指標,FORMATION OF GLYCATED HEMOGLOBIN,Hemoglobin + GlucoseSchiff Base (labile)HbA1c(stable),Fast,Slow,irreversible,Non-enzymatic reaction,糖化血紅素與血糖的關係,形成速率與血中葡萄糖濃度成正比。 良好的血糖標記，可反應過去2-3個月來血糖平均值。 較客觀、方便、不受飯後血糖升高的影響。RBC第0-30天的前段生命期反應50%的糖化血色素值。美國DCCT已建立各種解讀A1C的臨床數據，可供引用。,糖化血紅素(AlC)與平均血糖值的關係,Mean Glucose vs. HbA1c,Plasma glucose = blood glucose *1.11 (Clin. Chem. 44:3, 655-659),Non-Diabetic,Target,Action Required,最常導致視網膜病變及失明,最常導致非外傷性截肢,為什麼要重視糖尿病?,糖尿病,最常導致末期腎臟病及洗腎治療,心血管致死率是一般人的2-4倍,這些併發症可以控制與預防嗎?,醫療面向,1,2,3,4,5,6,7,8,9,5,6,7,8,9,10,11,Study Time in Years,HbA1c During the DCCTIntensive vs Conventional Treatment,Quarterly HbA1c (%),9.0,7.0,A1C%,DCCT STUDYDiabetes Control and Complications Trial,1982 to 1993.1,441 IDDM patients participated.Overall cost: $165 million.Final report: ADA 1993 annual meeting.Intensive treatment： A1C： 7.0%.Conventional treatment： A1C： 9.5%.,DCCT研究結果,Retinopathy 發生率減少76%Nephropathy發生率減少56%Neuropathy 發生率減少60%Ps.: Type I and Type II DM. 有相同結果。,美國ADA recommendations for Diabetes carequality (2005),Perform the A1C test at least 2 times per year in stable patients.Achieve A1C 7.0% as goal of glycemic control.Lower A1C is associated with lower risk of cardiovascular diseases.A1C 6.0% can be considered in individual patients.,UK(英國) Consensus Statement,Glycemic control is best monitored by HbA1cThe assay used should be a DCCT-aligned HbA1c method.The assay used should have acceptable within (3%) and between (300 g/mg creatinine,From ADA (American Diabetes Association)criteria,Microalbuminuria(微白蛋白尿),Methodology: Nephrometry (散色比濁法) Immuno-turbidimetry (免疫比濁法) Immuno-chromatography (免疫層析法)Specimen : at least 2 ml. random urine Limitation : Physical exercise, infection, fever, congestive heart failure, marked hyperglycemia, and marked hypertension can result in increased microalbumin levels.,Clinical applicationNormal reference range,Age Urine ACR (ug/mg creatinine)Men Women50 yr. 6.9+/- 4.7 8.2+/-4.4 50yr. 4.8+/-3.6 6.2+/-4.0,Annals of Clin.&Lab. Science,2005,35,2,p149,Annals of Clin.&Lab. Science,2005,35,2,p149,Normal reference range in age group,Annals of Clin.&Lab. Science,2005,35,2,p149,Microalbuminuria related to CVD and Diabetes,From Diabetes Care,1994,17,8,p891,From Diabetes Care,2005,28,11p2376,Development of Microalbuminuriaunder Glycemic and Blood pressure control,From Diabetes Care,2005,28,11,p2376,Progression and Regression of Microalbuminuriaunder Glycemic and Blood pressure control,Steno-2 study in type 2 diabetes (with microalbuminuria),Condition:160 high-risk type 2 diabetic patients with microalbuminuria aged 55.1 years (average), who were randomly assigned to a conventional or an intensive, multifactorial intervention for a period of 7.8 years.Results:44% of patients in the conventional group had a cardiovascular event compared with 24% in the intensive group, ie, a relative risk reduction of about 50% the relative risk of nephropathy, retinopathy, and autonomic neuropathy (secondary end points) was diminished by about 60% in the intensively treated group,Metabolism. 2003 Aug;52(8 Suppl 1):19-23.,In the intensive group,lifestyle education Goal-oriented pharmacological treatmentReduced-fat diet and exercise Smoking cessation Receive angiotensin-converting enzyme (ACE) inhibitor regardless of blood pressure.Vitamin supplementation and aspirin,我們的調查數據,(本縣與台中縣共 2150 位病人數),16.0% 26.17.0% 37.18.0% 48.19.0% 59.110.0% 610.111.0% 711.012.0% 812.0%,ACR and A1C相關性分析圖(III),1. 34%的受檢者已有蛋白尿(Proteinuria),其中 26%為microalbuminuria.2. Microalbuminuria 與高血壓、HbA1c和罹病年數 有正比關係。3. 利用 Blood Creatinine level作為評估早期 腎病變的指標,敏感度不如microalbumin。,結 論,NycoCard U-Albumin - for measurement of low albumin concentrations in human urine,Complete for 24 analysis: 24 tubes of Dilution Liquid 24 Test Devices 2.0 mL Conjugate 2.0 mL Washing Solution,NycoCard U-Albumin kit contents,TD/Test Device,Plastic device sealed with aluminium foilMembrane coated with monoclonal anti-albumin antibodiesLiquid absorbing layer underneath the membrane Entrapment of human albumin,NycoCard Reader,Stability of kit in use,An opened test kit was s