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Endocrine-Study guide

Endocrine Sensory
STUDY
PLAY
DM
-Group of disorders
-Glucose intolerance
-Chronic hyperglycemia
-Disturbances in carb, AA, fat metabolism
DM Type
Type I: Total insulin deficiency
Type II: Insulin resistance w/ insulin secrection deficit
Gestational: During pregnancy
Other: Conditions influence DM
DM- Type I
-Absolute insulin deficiency
-Primary B cell defect or failure
-Prone to ketoacidosis
DM- Type II
-Insulin Resistance w/ insulin sectetory deficiency
-Not ketosis prone (but may develop under stress)
Other types of DM
Associated w/ other conditions--
pancreatic dz, hormonal disease, drugs & chm agents
Gestational DM
Gluc intolerance 1st recognized during prego (~3rd trimst)
After prego-norm, impared OR become DM
DM Labs
-Fasting plasma glucose
-Glucose tolerance test (oral glucose)
-Clinical Manifestations
-Glycosated hemoglobin (elev. HbA1C)- not dx test, life rbc 120 day
glucose + Hb=glycosylated hemoglobin...inc=hypergly
glucose cell is exposed to, shows results of therapy
LT glucose regulation
-Impaired fasting glucose (Inc. hepatic glucose output)
>100&<126 mg/dL (fasting plasma gluc)
-Impaired glucose tolerance (d/t dec insulin secretion)
>140&<200 mg/dL (2 hr after oral gluc tol test)
Diabetes S/S
3 P's
-Polyuria (Inc urination)
-Polyphagia (Inc hunger)
-Polydipsia (Inc thirst)
-Wt loss
-Glucose conc >200 mg/dL
-Inc. UTI (bacteria love glucose)
-Fatigue
DM- Goals of Txt
Maintain euglycemia
Avoid hypoglycemia
Prevent severe CV & Neuro complications
Type I DM Cause
-auto-immune destruction of beta cells (gene-environ interaction?)
-Loss of islet cells/beta cells=genetic, a-immune, envir
-Gen. Risk marker: Human leukocyte antigen of chrom 6
-Most common: Type IA, beta cell autoantib, insulin antibodies to glutamic acid decarboxylase which participate in damage to islet cells
-Environmental factors-***Box 18-12
-Nonimmune type I: Secondary to dz, ex. pancreatitis
-B/c hyperglyc occurs, 80-90% of insulin secreting beta cells of the islet of Langerhans must be destroyed
-Beta cell abnorm, dec insulin prod, prod of amylin (beta cell hormone co-secreted w/ insulin, funct: supress glucagon release from alpha cells) fails
DM
-Disequilibrium of hormones produced by Iselet of Langerhans occurs. Both beta cell function & alpha cell functions are abnormal, w/ lack of insulin & an excess of glucagon (prod by alpha cells)
-Insulin deficiency=hyperglycemia, ketonemia
-Excess glucagon
-Elevated blood glucose levels fail to suppress the production of glucagon.
-Both hormones cause the full metabolic syndrome
Type I DM S/S
-Affects metab of fats, AA, carbs
-Glucose accumulates in blood, spills into the urine, renal threshold for glucose is exceeded
-Protein & fats break down d/t lack of insulin, result: wt loss
-Initial S/S (acute): 3 P's, wt loss, fluctuations in blood gluc levels
-Ketoacidosis: dec metab of fats & AA->high level of circulating ketones->pH drops (met acid)->Acetone (volatile form of ketones) is blown off (breath: sweet fruity odor)
-Sometimes diabetic coma first S/S
Type I Treatment
-Goal: avoid high & low levels of gluc & insulin
-Indiv planning: age, type of dz, activity level
-Combo of insulin, meal planning, exercise
-HBA1C: dx, monitor effect of txt, prev complications
-Islet cell transplantation
-Pancreas transplant (w/ end stage renal failure)
Type II DM
Risk: Gender (F), Age (40), Race (NA, Blk, Hsp), Metabolic syndrome, genetics (beta, insulin), environmental factors, Family Hx, Obesity/BMI
Cause: unknown
*MODY: autosomal dominant, 6 types (specific mutation in critical enzyme involved in beta cell fxn or insulin axn)
*Cellular resistance: Insulin resistance inc w/ obesity
Dec. beta cell responsiveness to plasma glucose levels (islet dysfunction)
Abnorm glucagon secretion
Alt in insulin receptor
Amyloid deposits=islet cell destruction (age, degree of dz)
Fat in nonadipose tissue (ectopic fat)
Fatty infiltration of liver (nonalcoholic steatohepatisis) can result in hepatic failure & cirrhosis d/t overnutrition
Amylin
Hormone co-secreted w/ insulin by beta cells
Deficiency in Type I diabetes
S/S of Type II DM
Nonspecific
Overweight, hyper lipidemic
Onset: slow, insidious
Pruritus, recurrent infxn, visual changes, paresthesias
Txt of Type II DM
-Goal: restore euglycemia (norm blood glucose levels), correct metabolic disorders
-Diet (Dec caloric intake, sat fat, high fiber diet
-Dec wt=dec in insulin resistance & improve gluc tolerance
-Oral hyperglycemic agents
-Exercise
-Insulin therapy (when other meds fail to restore b.s.)
Gestational DM
glucose intolerance during pregnancy
Risk: family hx DH, race, adv maternal age (>25), prior hx, polycystic ovary syndrom, overwt,
-Aggressive txt
Acute Complications of DM-Hypoglycemia
*** Hypoglycemia (insulin shock, insulin rxn)
-d/t dec b.g. (45-60) & neurogenic rxns
-S/s: pallor, tremor, anxiety, tachycardia, palpatations, diaphoresis, HA, dizziness, irritability, gatigue, poor judgement, confusion, visual disturb., hunger, seizures, coma
-Txt: replace glucose
-Prevention: Indv txt, b.g. monitor, education
*** Diabetic ketoacidosis
-d/t dec insulin & inc counterreg hormones (catecholamines, glucagon, GH)/ Hepatic glucose production increases & periferal usage decreases/Fat is mobilized/ Stimulated Ketogenesis
-Freq peaks in adolescence

Dawn phenomenon
Acute Complications of DM- HHNKS
** Hyperosmolar hyperglycemic nonketotic syndrome
-uncommon, High mortality rate
-elderly w/ comorbities (infxn, CV, Renal dz)
-poor glucose control->high serum glucose (>500mg/dL) & high serum osmotic pressure (dehydration, low blood V, low perfusion rates
-Txt: fluid & electrolyte resuscitation & strict control of serum glucose levels
Acute Complications of DM-Somogyi phenomenon
Somogyi phenomenon
-Hypoglycemia followed by rebound hyerglycemia
-Rise in b.g. d/t counterregulatory hormone (epi, GH, corticosteroids) stimulated by hypoglycemia (produce gluconeogenesis).
-Excess carb intake may result in rebound hypoglycemia
Acute Complications of DM-Dawn Phenomenon
-Early morning rise in b.g. w/ no hypoglycemia @ night
-r/t nocturnal elevations of GH , dec metabolism of glucose by muscle & fat
~Inc clearance of plasma insulin
-Txt: managmt of time & dose of insulin admin
Chronic Complications of DM-
1.) Diabetic Neuropathies
2.) Microvascular dz (retinopathy, nephropathy)
3.) Macrovascular dz (coronary artery dz, stroke, peripheral vascular dz
4.) Infection
Metabolic alterations (hyperglycemia)
Txt: strict control of blood glucose
-Shunting of glucose into the polyol pathway, activation of protein kinase C, overproduction of reactive oxygen species (oxidative stress), production of advance glycation end products or nonenzymatic glycosylation of proteins
Nonenzymatic glycosylation
reversible attachmt of glucose to AA, lipid, NA w/o enzyme
Advanced glycosylation endproducts (AGE's)
result from attachmt of glucose + proteins=tissue injury?
Hyperglycemia & the polyol pathway
Polyol pathway-metabolic pathway for glucose metabolism (vs insulin glucose transport) ex. kidneys, RBCs, blood vessels, eyelense, nerves
-W/ Hyperglycemia, glucose is shunted to this pathway & converted to Sorbitol (a polyol) by aldose reductase/ then Fructose by sorbitol dehydrogenase=accumulation of sorbitol=Increase Intracellular osmotic pressure, attracts H2O->Cell injury
-Ex. Lens of eye, swellling w/ visual changes & cataracts
-Ex. Nerves, interfers w/ ion pumps, damages, Schwann cells, disrupts nerve conduxn
-Ex. RBCs become swollen & stiff & interfere w/ perfusion
Protein kinase C
PKC
intrecellular signaling proteins that inappropriately activate in different tissues d/t hyperglycemia
-Lead to: insulin resistance, production of extracellular matrix & cytokines, vascular cell proliferation, Inc contractility, & Inc. Permeability
-Can cause: microvasc, macrovasc, & neurologic complications
-Txt?=Ruboxistaurin, selective PKCB inhibitor
Diabetic neuropathies
Cause: metabolic & vascular issues r/t hyperglycemia
-Nerve degeneration & delayed conduxn d/t glycosylation end products & Increased polyols
=damage to somatic & periph cells=neuropathies
Microvascular dz
thickened basemt membrane, endothelial hyperplasia, thrombosis, & pericyte degeneration
-Dec tissue perfusion & hypoxia
Diabetic retinopathy
Cause: retinal ischemia d/t vessel changes & RBC aggregation, GH, Activation of PKC
-Severity related to age & duration
-Macular edema, hard exudates, microaneurysms, hyperglycemia, sorbitol accumulation, dehydration of the lens
Diabetic nephropathy
-Leads to end stage renal dz
-Cause: AGE's, polyol pathway, glucose toxicity, PKC
HTN, proteins,
-nephrons thicken and slowly become scarred over time
-Microalbuminuria: proteinuria, decreased plasma oncotic pressure, fluid overload, anasarca (general body edema), HTN
Macrovascular disease
proliferation of fibrous plaques in the arterial wall & elevated lipid levels
Due to AGE attaching to blood vessel walls, leading to atherosclerosis
CAD
High LDL & triglycerides, low HDL, platlet abnorm's, endothelial cell dysfunction
Inc platelet adhesion & dec fibrinolysis promote thrombus formation
Peripheral vascular dz
+ osteomyelitis or gangrene & amputation
Inc Risk for Infection
1.)The senses: Dec vision d/t retinal changes & Dec touch d/t neuropathy
2.)Hypoxia: glycosated hemoglobin in RBCs blocks release of O2 to tissues
3.) Pathogens: bacteria love glucose (energy to grow)
4.) Blood Supply: Vascular changes=dec blood supply=Dec WBCs
5.) White cells: Impaired function (abnorm chemotaxis & defective phagocytosis)