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CARBOHYDRATE S

CHARLIE A. CLARION, RMT

3/10/12

OBJECTIVES

At the end of this unit, the student is able to:


Define common terms associated with

carbohydrates; Describe carbohydrates according to composition, classification, chemical properties Discuss the metabolism of CHO in the body Explain the mode of actions of different hormones in the maintenance of blood 3/10/12

TOPICS
Biochemistry
Classification Metabolism

Specimen Considerations Glucose Measurement


Methods Reference Range

Clinical

Significance

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Diabetes Mellitus Hyperglycemia

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Carbohydrates
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Classification
Carbohydrates

are composed of C,

H, O. They are divided into:


Monosaccharide Disaccharide Oligosaccharide Polysaccharide

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Monosaccharides
Cannot

be hydrolyzed into simpler

forms Simple sugars such as glucose, fructose, galactose, ribose, deoxyribose

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Disaccharides

Composed of 2 monosaccharides joined by glycosidic linkage Sucrose: glucose + fructose Lactose: glucose + galactose Maltose: 2 glucose units

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Oligosaccharides
Chaining

of 2-10 sugar units

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Polysaccharides
Made

up of many monosaccharide units such as cellulose, glycogen, and starch

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Carbohydrates
Glycoside

bonds: chaining of

sugars
When

two carbohydrate molecules join, a water molecule is produced When they split, one molecule of water is used to form the individual compound (Hydrolysis)
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Reducing

substances: can reduce

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Metabolism
Primary source of Brain depends on

energy for humans glucose (60-75% of blood glucose level)

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Fate of Glucose
Ingested:

starch and glycogen

Acted upon by salivary amylase and

pancreatic amylase to dextrins and disaccharides (lactose, sucrose, maltose) Maltase: breaks down maltose to 2 glucose units Lactase: lactose to glucose and galactose Sucrase: sucrose to glucose and fructose
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Fate of Glucose
Glucose

(inside the cell) shunted into three possible metabolic pathways (glucose-6-phosphate)
Embden-Myerhof Pathway Hexose monophosphate pathway Conversion of glucose to glycogen

(glycogenesis)

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a. Embden Myerhof Pathway


Glucose

converted to glucose-6phosphate (ATP) catalyzed by hexokinase 3-C molecules of pyruvic acid TCA acetyl-CoA (aerobic) (32 ATPs) 2ATPs (no oxygen) lactic acid

Anaerobic
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b. Hexose Monophosphate Shunt


Glucose-6-phosphate

6-

phosphogluconic acid
Formation

of ribose-5-phosphate and

NADPH
(RBC lacking mitochondria, thus, no

TCA cycle)

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c. Glycogenesis
Glucose-6-phosphate

phosphate uridine diphosphoglucose glycogen (glycogen synthase) muscles

glucose-1-

Liver,

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Terms
Glycolysis Metabolism of glucose molecule to pyruvate or lactate for the production of energy Gluconeogen Formation of glucose-6esis phosphate from noncarbohydrate sources Glycogenolysi Breakdown of glycogen to s glucose for use as energy (glucose-6-phosphatase in liver; none in the liver) Glycogenesis Conversion of glucose to 3/10/12 glycogen for storage

Regulation of Blood Glucose Levels


Liver
glycolysis gluconeogenesis glycogenesis glycogenolysis

Brief fasting: glycogenolysis Longer than 1 day fasting:

(liver)

gluconeogenesis
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Hormones secreted by the endocrine pancreas that regulate glucose homeostasis


Hormones Site of Action Production in the islets of langerhans Insulin Beta Cells Stimulate glycogenesis, glycolysis, and lipogenesis Decreases glycogenolysis [HYPOGLYCEMIC] Increases glycogenolysis and gluconeogenesis [HYPERGLYCEMIC] Inhibits insulin and a glucagon

Glucagon

Alpha Cells

Somatosta Delta Cells


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Other hormones
Adrenal

Glands

Epinephrine: increases glucose

(stress)

Inhibits insulin secretion Increases glycogenolysis Promotes lipolysis

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Glucocorticoids: increases glucose Decreases intestinal entry into the cell Increases gluconeogenesis Increases glycogenolysis

Other hormones
Anterior

Pituitary Glands

GH: increases glucose; Released when

hypoglycemic, inhibited by increased glucose level


Decreases entry of glucose into the cells Increases glycolysis

ACTH: increases glucose; released when

cortisol is decreased

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Promotes glycogenolysis Promotes gluconeogenesis

Other hormones
Thyroid

Gland

Thyroxine: increases plasma glucose Increases glycogenolysis Gluconeogenesis Increases intestinal absorption of glucose

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Insulin
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Functions
Stimulates

glucose uptake in the cell

Glycogenesis: liver, muscles Lipogenesis: abdomen, gluteus,

breasts
inhibits glucose production in insulin-

sensitive tissues (liver, skeletal muscles, fats)


Increased

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glucose: release of insulin

Molecular Characteristics
Peptide

hormone having a mass of approximately 5000 daltons


21 amino acid A

chain 30 amino acid B chain

linked together by disulfide bonds

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Site of Production
Beta

cells as proinsulin (65-80%)

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Mechanism of Insulin Production


Proinsulin

insulin and C-peptide (enzymatic cleavages)


Primary cleavage proinsulin 65, 66 split proinsulin (PC2 proprotein convertases) proinsulin 32, 33 split proinsulin (PC3/PC1 proprotein convertases) Secondary cleavage carboxypeptidase H des 64,65 split proinsulin 31,32 split proinsulin.

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Mechanism of Insulin Production


Small

amount of des 31, 32 is cosecreted with insulin in adults In healthy infants and preterm neonates, however, proinsulin and 32,33 split proinsulin concentrations are higher
Elevated

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proinsulin (intact and partially processed) levels are seen in the following.

Clinical Significance of Changes in Insulin Levels


Disease

states occur when insulin and glucose concentrations are found to be inappropriate with each other. Below are the effects of the changes in insulin level. Insulin deficiency (absolute or relative)

DM

Increased insulin secretion Insulin resistant patients Increased insulin with decreased glucose level suggests inappropriate secretion or 3/10/12 administration of insulin

Clinical Significance of Changes in Insulin Levels


Unregulated excessive insulin

secretion

insulinomas decreased glucose (<50 mg/dL) elevated insulin and proinsulin levels Hypoglycemic symptoms

Shakiness Palpitations Diaphoresis Confusion

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C-Peptide
Measured

in conjunction with insulin and blood glucose to help indentify cause of hypoglycemia
C-peptide and insulin are secreted in

equimolar amounts in the portal vein ratio in serum: 5:1 to 15:1 molar concentration of C-peptide in blood > insulin due to hepatic clearance of insulin
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Relationship of Cpeptide and insulin levels Insulin Conditions C-Peptide


Insulinoma Increased Increased

Insulin Treatment Type I DM


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Increased

Decreased

Absolute deficiency

Decreased

Other uses of C-peptide measurement


follow

up evaluations after pancreatectomy and after pancreatic transplant Renal Failure


C-peptide and proinsulin are primarily

degraded by the kidneys Elevated levels [renal failure]

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Interferences in measurement of insulin, C-peptide and proinsulin


Hemolysis
Insulin falsely decreased C-peptide less affected Proinsulin- less affected

Insulin

antibodies

Insulin falsely increased or falsely

decreased in immunoassays

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Glucagon
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Functions
stimulates

glucose production

mediated by generation of cyclic

adenosine monophosphate (cAMP)

regulates

hepatic :

Glycogenolysis Gluconeogenesis Ketogenesis

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Proglucagon and its products


Proglucagon is produced by: Pancreatic alpha cells 15-20% L cells of distal small bowel

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Glucagon
results

from differential processing of proglucagon

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GLP-1 (glucagon-like peptide)


formed from proglucagon functions as incretin:
stimulates insulin secretion after a meal

other

functions

suppression of glucagon and lipase

secretion inhibition of gastric emptying stimulation of somatostatin

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Clinical Significance of Differences in Glucagon


Glucagon

deficiency results in

Increased glycemic fluctuations Difficulty in recovering from

hypoglycemia

Excessive

glucagon increase

Glucagonemias Fasting glucagon level is >120pg/mL,

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with levels ranging from 900 to 7800 pg/mL

Clinical Significance of Differences in Glucagon


Mild

elevations

Cirrhosis Diabetes Cushings syndrome Acromegaly Pancreatitis Renal insuffiency Patients with multifunctional

neuroendocrine tumors

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SOMATOSTATIN
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Function
inhibits

both insulin and glucagon secretion and secretion of other hormones

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Site of Production
Delta cells 5 to 10%

of islets of Langerhans

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Clinical significance of differences in somatostatin secretion


Increased

level

Somatostatinoma Medullary thyroid cancer Small cell lung cancer Pheochromocytoma

Somatostatin

is rarely measured in clinical practice and has a very short half-life.

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SPECIMEN CONSIDERATION
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Specimen Used
Whole blood Plasma Serum CSF (60-75% Pleural fluid Urine

of blood glucose)

Plasma/serum

10-15% > whole

blood Capillary blood 7% > venous blood 3/10/12

Special Considerations
Glucose

metabolism occurs in unprocessed specimens in the following conditions:


At room temperature the rate of

metabolism is 7 mg/dL/hr Storage at 4 deg C will cause a loss of approximately 2 mg/dL/hr


Bacterial
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contamination and leukocytosis

1. 2. 3. 4.

Serum Specimen
Serum

Appropriate for glucose analysis if serum is separated from cells within 30 minutes Sodium fluoride preservative should be added to specimen, if serum is in contact with cells for longer than 30 minutes, to prevent glycolysis In serum specimens without bacterial contamination or leukocytosis, results are still acceptable even if separation is delayed for up to 90 minutes When refrigerated, serum or plasma glucose remains stable for 48 hours

is separated from cells within 30 minutes Greater than 30 minutes use NaF
Serum

specimens without bacterial contamination or leukocytosis


results are still acceptable even if

separation is delayed for up to 90 minutes

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Whole blood
Give

decreased glucose reading compared to plasma by 10-15%


Percentage difference vary with the

hematocrit of the patient


When

refrigerated, 2mg of sodium fluoride/mL of whole blood prevents glycolysis for up to 48 hours

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GLUCOSE MEASUREMENT METHODS


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GLUCOSE MEASUREMENT METHODS


Copper Reduction Method O-Toluidine Method Enzymatic
Glucose Oxidase Glucose Dehydrogenase Hexokinase

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1. Copper Reduction Method


glucose

= reducing sugar

Folin-Wu Method Nelson-Somogyi

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Folin-Wu Method
Oldest

method

Cu2+ (glucose in serum) Cu+ Phosphomolybdic acid (PMA) (Cu+) Mo (BLUE)

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Nelson-Somogyi
Cu2+

(glucose in serum) Cu+ acid (AMA) (Cu+)

Arsenomolybdic

Mo

(BLUE)

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2. O-Toluidine Method
Dubowski

Method

most sensitive method Carcinogenic


Glucose + O-Toluidine (boil w/ Acetic acid) Glycosylamine (GREEN)

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3. Enzymatic
Most

glucose measurements employ enzymatic methods: SPECIFICITY

Glucose Oxidase Glucose Dehydrogenase Hexokinase

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Glucose Oxidase
Spectrophotometric

-D-glucose + O2 (glucose oxidase) Dgluconolactone + H2O2 Gluconolactone + H2O Gluconic acid H2O2 + chromogen O2 receptor (O-dianisidine; 4 amino-phenazine; O-toluidine) (peroxidase) colored chromogen + H2O (BLUE) Disadvantage: this reaction is inhibited by high 3/10/12 concentrations of uric acid, vitamin C, bilirubin,

Reaction)

Assay (Trinders

Glucose Oxidase
Electric

Current Assay

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i. -D-glucose + 2[Fe(Cn6)]3- + H2O (glucose oxidase) D-gluconic acid + 2[Fe(Cn6)]4- + 2H+ 2[Fe(Cn6)]4- 2[Fe(Cn6)]3- + 2e Disadvantage: this system is affected by partial pressure of

Glucose Oxidase
ii. -D-glucose + O2 (glucose oxidase) D-gluconolactone + H2O2 H2O2 2H+ O2 + 2e- (combi of GOD and Clark Electrode Method)
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Glucose Dehydrogenase
Spectrophotometric

assay: glucose is reduced to form a chromophore


Problem can oxidize beta glucose molecules (65%) cannot oxidize alpha glucose molecules (35%) [MUTAROSE]

-D-glucose (mutarose) beta-Dglucose


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Glucose Dehydrogenase
Electric

Current Assay

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Glucose + pyrroloquinoline quinine (PQQ) (glucose dehydrogenase) gluconolactone PQQH2 PQQH2 + 2[Fe(CN6)]3- PQQ + 2[Fe(Cn6)]4- + 2H+

Hexokinase
Measures

both alpha and beta

glucose Catalyzes phosphorylation of glucose + ATP

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Hexokinase
Spectrophotometric

Assay

Glucose + Mg ATP (hexokinase) glucose6phosphate + Mg ADP Glucose-6-phosphate + NAD(P) (glucose6-phosphate dehydrogenase) 6phosphogluconolactone + NAD(P)H + H+ (colored)
Note: 3/10/12

This is the generally accepted

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CLINICAL SIGNIFICANCE
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Clinical Significance
Hyperglycemia Hypoglycemia Insulinoma

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Hyperglycemia
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Hyperglycemia
Increase WHY?
Normally, in hyperglycemic state, insulin

in plasma glucose levels

is secreted by cells of Islets of Langerhans of pancreas


Absolute or relative deficiency of hormone Increase production of other hormones affecting glucose metabolism

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Diabetes Mellitus

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Diabetes Mellitus
A

group of diseases in which blood glucose levels are elevated due to deficiency in insulin secretion or due to abnormal insulin action or both. Plus manifestations of hyperglycemic state

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Tests used to Diagnose Diabetes


Fasting

blood glucose (6-8 hours

fasting) 2-hour post-prandial OGTT


Ingest at least 150g of carbohydrates 3 days prior to testing Fast the night prior to testing Challenged orally with 75g glucose Should not eat, drink tea, coffee or alcohol; vigorously exercise, or smoke during the test Venous blood preferably collected in gray-top 3/10/12 tubes

Criteria Used to Diagnose DM


Random

Blood Glucose > 200 mg/dL + DM symptoms Blood Glucose > 126 mg/dL

Fasting

OGTT

with a 2-hour postload (75g glucose load) level > 200 mg/dL

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Impaired Glucose Metabolism

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Impaired Glucose Metabolism


refers

to a condition where in the glucose homeostasis the serum glucose levels are not high enough to be classified as diabetes for classification
Fasting Blood Glucose >110mg/dL (6.1

Criteria

mmol/L) but < 126mg/dL (7.0mmol/L) OGTT after 2 hours >140mg/dL (7.8mmol/L) but less than 200 mg/dL 3/10/12 (11.1 mmol/L)

Impaired Glucose Metabolism


Predisposing Factors Occur commonly in insulin-resistant individuals, a majority later develop overt DM Abdominal obesity Hypertension Elevated uric acid level Dyslipidemia (decreased HDL, increased triglycerides, increased LDL) This insulin-resistant state is also

referred to as Syndrome X

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Classification of DM

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Type 1 DM

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Type 1 DM
Represents

approx. 10% to 20% of

all DM Cellular-mediated, autoimmune destruction of insulin producing beta cells in the pancreatic islets causing absolute insulin deficiency childhood and adolescence

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Type 1 DM
Genes

associated with HLA-DR/DQ on chromosome 6 Trigger:


viral infection toxin exposure stress

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Type 1 DM

Markers of beta cell destruction


Islet cells antigen 512 autoantibodies

(ICA512) Glutamic acid decarboxylase antibodies (GAD 65) Insulin autoantibodies (IAA) Tyrosine phosphatase-like protein antibodies (IA-2) or insulinoma associated antigen-2 and 2 autoantibodies (IA-2A and IA-2A)

Note: used in the familial studies where it was found out that at least 2 of these 3/10/12

Type 1 DM

Laboratory findings:
low insulin and C-peptide levels

Untreated

type 1 DM can develop:

Ketoacidosis (insulin therapy is required)

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Type 2 DM

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Type 2 DM
Individual

develops resistance to insulin with an insulin secretory defect, resulting to relative insulin deficiency (not absolute)

Most common type of DM Adult onset seldom results to DKA milder symptoms than type 1 But likely to go to hyperosmolar coma,
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macrovascular and microvascular coma

Type 2 DM
Risk factors: Obesity Sedentary lifestyle Lack of physical exercise Family history Advanced age Ethnicity (African-American, Latinos, Native

Risk factors: screening every three years

Americans, Asian Americans, and Pacific Islanders)

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Type 2 DM
Characteristics of type 2 DM patients: Most are obese Insulin-resistant Impaired peripheral glucose utilization Decreased glucose transport in muscle and

adipose tissues Inappropriately high hepatic glucose production Undiagnosed for many years

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Type 2 DM

Mechanisms involved in the development of type 2 DM


As a compensatory mechanism for glucose

These mechanisms usually lead to progressive cell failure and decreased insulin production contributing to increased insulin deficiency. This is the reason why some type 2 DM require insulin 3/10/12 therapy, in contrast to others whose diabetes can still

tolerance, the pancreas has to secrete extra insulin In the event that the pancreas becomes incapable of increasing its insulin secretion impaired glucose homeostasis or type 2 DM develops Hyperglycemia is also toxic to the cells of the pancreas, disrupting cell function and impairing insulin secretion.

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Other Specific Types of DM

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Gestational Diabetes Mellitus

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Gestational Diabetes Mellitus

Any degree of glucose intolerance with the onset or first recognized during pregnancy (>20 weeks AOG)

Causes: Metabolic hormonal changes Increased perinatal Macrosomia Hypoglycemia Hypocalcemia 3/10/12

complications:

Gestational Diabetes Mellitus


Screening

Tests for Gestational

Diabetes
Screening using 50-g oral glucose

load

After 1 hour > 140 mg/dL (7.8 mmol/L) OGTT (75 g glucose load)

OGTT

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Fasting: 105 mg/dL One hour: 190 mg/dL 2 hours: 165 mg/dL 3 hours: 145 mg/dL

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Pathophysiology

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Pathophysiology
1. Insulin deficiency (absolute/relative) 2. Hyperglycemia Hyperosmolar state Glucosuria Polyuria 3. Hyperosmolar state Polydipsia Polyuria 4. Less ATP Decreased energy Polyphagia 5. Gluconeogenesis (weigth loss) ketone bodies (blood and urine) LIVER fail accumulation of ketones DKA 6. DKA Kussmaul Kien Breathing CO2 7. Hyperosmolar state Brain Confusion 8. Glucose cannot be utilized by brain ketogenesis deplete Confusion
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Signs and Symptoms


Polydipsia (excessive thirst) Polyphagia (increased food intake) Polyuria (excessive urine production) Rapid weight loss Hyperventilation (Kussmaul-Kien

breathing) Mental confusion Possible loss of consciousness


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Long term effects: Retinopathy blindness Cataract Peripheral neuropathy Autonomic neuropathy Poor wound healing Amputation Nephropathy ESRD CVD atherosclerosis, hypertension Immunocompromised
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Review
Type I DM IDDM Insulin deficiency <10% of DM Juvenile onset Non-obese Type II DM NIDDM Insulin resistance >90% DM Adult onset Obese

Prone to DKA Seldom DKA Tx: insulin administration Diet, exercise, oral hypoglycemic agent, seldom insulin 3/10/12

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Measures of Glycemic Control

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Glycosylated Hemoglobin (HgbA1C)


Preferred test used to assess glycemic control Index of average blood glucose: two to three months (RBCs life span 120 days)
Principle:

HgbA1c is formed irreversibly through a 2-step nonenzymatic reaction


First reaction: rapid, reversible, dependent

on ambient glucose concentration

Product: aldimine or Schiffs base

Second reaction: aldimine slowly undergoes

Amadori rearrangement and is converted to stable

3/10/12 Product: ketoamine, glycosylated hemoglobin

Glycosylated Hemoglobin (HgbA1C)


Methods used to measure HgbA1c; Cation-exchange chromatography Electrophoresis Isoelectric focusing Colorimetry Immunologic methods

condition associated with shortened RBC survival, such as hemolysis or acute blood 3/10/12 loss, will lower HgbA1c level

Any

Glycosylated Hemoglobin (HgbA1C)


Individuals without diabetes have HgbA1c levels between 4-6%. Correlation of HgbA1c and average glucose levels is as follows:

Blood Glucose (mg/dL) 120 150 180 210 240 270 300 330 360 3/10/12

HgbA1c (%) 6 7 8 9 10 11 12 13 14

Fructosamine Assay
Assay

used to asses glycemic control over a short period of time (3-6 weeks) serum protein

Glycated

Fructosamine

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also results from nonenzymatic glycation (Maillard Reaction) between glucose and amino acid of protein

Fructosamine Test Levels and Glucose Control


Test Value Under 265 265-280 280-300 320-340 Over 350
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Indication Normal fructosamine level Excellent bloodglucose (sugar)control Good bloodglucose (sugar)control Fair bloodglucose (sugar)control Poor bloodglucose (sugar)control

Fructosamine Assay
Disadvantages: Result is affected by changes in the

level of serum proteins.

Not be performed: serum albumin < 3mg/dL

Affected by high uric acid and bilirubin

levels Heparin affects the test Monthly monitoring in order to obtain information similar to performing HgbA1C (2-3 months)
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Indications of Fructosamine Assay


Rapid changes in diabetes treatment Diabetic pregnancy Shortened RBC life span: hemolytic

anemia Abnormal forms of hemoglobin: sickle cell anemia

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HYPOGLYCEMIA

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HYPOGLYCEMIA
low plasma glucose levels usually overnight plasma glucose

of less than 45mg/dL (2.5 mmol/L) + associated group of symptoms that are relieved by ingestion of food or carbohydrates
Occur
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when:

inappropriately elevated levels of

Classic Symptoms of hypoglycemia: all related to CNS


Increased hunger Confusion Unconsciousness Headaches Dizziness Nausea and vomitting Seizures Nightmares Blurred vision Diaphoresis

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Classification of Hypoglycemic Disorders

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1. Patient appears healthy


a. No coexistent disease
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Drugs (ethanol, salicylates, haloperidol) Insulinoma Islet hyperplasia/nesidioblastosis Persistent hyperinsulinemic hypoglycemia of infants Noninsulinoma pancreatogenous hypoglycemia syndrome Familial hypoglycemia from insulin, sulfonylurea or repaglinide Severe exercise Ketotic hypoglycemia

1. Patient appears healthy (cont)


b. Compensated coexistent disease

Drugs (disopyridine; B-adrenergic blocking agents; dispensing error) Sulfhydryl or thiol-containing drugs with autoimmune insulin syndrome Unripe akee fruit (hypoglycins A and B) and undernutrition

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2. Patient appears ill


a. Drugs

Pentamidine Pneumocystis carinii pneumonia Propoxyphene (cerebral malaria) Topical salicylates (renal failure) Sulfamethoxazole and trimethoprim (renal failure)

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2. Patient appears ill (cont)


b. Predisposing illness

SGA infant Beckwith-Weidemann Syndrome Erythroblastosis fetalis Infant of DM mother Glycogen storage disease Defects in amino acid and fatty acid metabolism Reyes syndrome

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2. Patient appears ill (cont)


Hospitalized

patient

Total parenteral nutrition and insulin therapy Questran interference with glucocorticoid absorption Shock

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Insulinoma/Islet Cell Hyperplasia

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Insulinoma/Islet Cell Hyperplasia


Presents with hypersecretion of insulin Healthy appearing individuals documented hypoglycemia + no coexistent disease or ingestion of potential hypoglycemic drug Diagnostic:
72-hour prolonged supervised fasting: to identify

insulin-mediated hypoglycemia

Note: Insulin administration and sulfonylurea or repaglinide, a short acting insulin secretagogue treatment can mask hyperinsulin secretion, thereby proper diagnosis needs to be performed

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Criteria for diagnosis of insulinoma during hypoglycemia


Plasma

insulin level that is either:

Proinsulin: > 5 pmol/L C-peptide: > 200 pmol/L B-hydroxybutyrate: < 2.7 mmol/L Good plasma glucose response to 1mg

> 6uU/mL (by RIA) > 3uU/mL (by immunochemiluminometric assay)

of IV glucagon (> 25 mg/dL glucose rise) during hypoglycemia


These values SUGGEST insulinoma in the presence of negative sulfonylurea screening

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INBORN ERRORS OF CARBOHYDRATE METABOLISM


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INBORN ERRORS OF CARBOHYDRATE METABOLISM


FRUCTOSE METABOLISM GALACTOSE METABOLISM GLYCOGEN METABOLISM

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FRUCTOSE METABOLISM

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General Considerations

Fructose is abundant in most diets and is present in Western diets of up to 110 g/day intermediates are essential to glycolysis and gluconeogenesis

Frustoce

almost zero level fasting state Lab: difficult to measure Specificity: gas, liquid, and thin layer

chromatography

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Clinical Syndromes of Fructose Metabolism

Fructokinase deficiency Fructose-bisphoshonate

Abnormalities of three different enzymes involved in its metabolism:


aldolase

deficiency Fructose-1-6-bisphosphonate deficiency

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Fructokinase deficiency
Clinically:
Fructosuria NOT associated with any

short-term or long term complications Fructosemia following an oral or IV fructose load

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Fructose-bisphosphonate aldolase deficiency


Three isoenzymes and deficiency characteristics: Isoenzyme A Isoenzyme B Isoenzyme C

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Isoenzyme A
Seen:
embryonic tissue adult muscles

Manifestations:
mental retardation short stature hemolytic anemia abnormal facial expression
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Isoenzyme B

Seen: adult liver kidney intestines Manifestation: hereditary fructose intolerance most frequent error of fructose metabolism) Symptoms after ingestion of fructose, sucrose, and sorbitol

Complications are either acute or chronic Acute: poor feeding, failure to thrive, hypoglycemia, vomiting Chronic: hepatomegaly with hepatic dysfunction, kidney 3/10/12 damage, retinal damage, and death

Isoenzyme C
Predominantly

seen in nervous

tissue

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Fructose-1-6bisphosphonate deficiency
impairment of gluconeogenesis In infants: life-threatening episodes of lactic In older individuals, episodes occur: after prolonged fasting after depletion of glycogen store during periods of physiologic stress
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acidoses hypoglycemia

Long

fever and fructose exposure

term course is benign if

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GALACTOSE METABOLISM

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General Considerations
Lactose:

in milk

major carbohydrate found

Deficiency of three enzymes: Galactokinase galactose-1-phosphate uridyl

transferase UDP galactose-4-epimerase

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These enzymes are essential for: conversion of galactose to glucose

Galactosemia
autosomal

recessive genetic

disorder infant cannot digest lactose partially metabolized galactose extremely toxic to
brain, liver, and kidneys

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Newborn screening tests for Galactosemia


Total Galactose Test/ Bacterial Assay Beutler Fluorescent Test Hill Test

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Total Galactose Test/ Bacterial Assay


Paigen Screen

Test

elevated galactose and galactose-1-phosphate coli : grows in the presence of galactose or galactose-1-phosphate

E.

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Beutler Fluorescent Test


Used

to screen galactokinase and galactose-1-phosphate uridyl transferase levels measures NADPH production which is coupled with fluorescence

Test

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Reactions involved are


Galactose + ATP (galactokinase) galactose-1-phosphate + ADP Galactose-1-phosphate + UDP glucose (galactose-1-phosphate uridyl transferase) UDP-galactose + glucose1phosphate Glucose-1-phosphate (phosphoglucomutase) glucose-63/10/12

Hill Test
Fluorometric

assay for galactose

levels Fluorescence: visible only when total galactose is increased (> 8-10 mg/dL)

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Characteristics of the Different Enzyme Deficiencies

Galactose-1-phosphate uridyltransferase deficiency


Elevated galactose and galactose-1-

phosphate Neonates prone to E. coli sepsis, liver dysfunction with hepatomegaly and cataracts Central nervous system disease and primary ovarian dysfunctions are complications of this deficiency even if individuals are screened and treated with galactose-free diet 3/10/12

Characteristics of the Different Enzyme Deficiencies

Galactokinase deficiency
More benign syndrome Complications: cataracts and

UDP-galactose-4-epimerase

psudotumor cerebri

deficiency syndrome

Leukocyte and RBC-limited

deficiency: without complications Generalized deficiency: resembles galactose-1-phosphate-uridyl transferase deficiency


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GLYCOGEN METABOLISM

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GLYCOGEN METABOLISM
Glycogen

storage diseases

conditions characterized by tissue

dysfunction, which are related to normal function and breakdown of glycogen. Tissues primarily affected

liver muscles

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Glycogen Storage Diseases


Type of Condition Glycogenos is 1a Glucose-6-phosphate 1b deficiency (von Gierkes 1c glycogen storage disease, hepatorenal glycogenosis 1a -1,4-glucosidase (ph 4.0) deficiency 9acid maltase deficiency; generalized glycogenosis; Pompes 1b disease
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Biochemical Reaction Accumulation of normal glycogen in liver and kidney; hyperuricemia Accumulation of normal glycogen in lysosomes of all organs Accumulation of normal glycogen in

Glycogen Storage Diseases


IIIA to IIIF Amylo-1,6-glucosidase Accumulation of (debracher) deficiency abnormal highly (limit dextranosis; branched, short-chain Forbes disease; Coris glycogen in liver and disease) in some subtypes in skeletal and heart muscles Deficiency of 1,4-Generalized low to glucan branching normal levels of enzyme (Andersens abnormally structured disease; glycogen with long

IV

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Glycogen Storage Diseases


V Muscle phosphorylase deficiency (Mc Ardles Syndrome) VI Liver phosphorylase deficiency (Hers disease)
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Moderate accumulation of normal glycogen in skeletal muscle lowered blood lactate and pyruvate levels in physical activity Lowered acitivity of total liver phosphorylase (phosphorylaseactivating system intact); accumulation of normal glycogen in the liver

Glycogen Storage Diseases


VII Muscle 6-phosphofructokinase phosphofructoki activity in muscle absent or nase deficiency considerably reduced; activity (Taruis in erythrocytes is about 50% disease) of normal; in muscles, high level of glycogen, as well as glucose-6-phosphate and low level of fructose 1,6bisphosphonate VIII Inactive liver Liver phosphorylase is in the phosphorylase inactive form, but the
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Glycogen Storage Diseases


IXa, IXb Liver phosphorylase kinase deficiency Failure to activate phosphorylase in liver and leukocytes; accumulation of normal glycogen in liver Accumulation of normal glycogen in liver and muscles

Deficiency of cAMPdependent protein kinase (HUG) (phosphorylase b 3/10/12 kinase deficiency

Glycogen Storage Diseases


XII Glycogen deposited in the liver (sometimes in kidney), not in muscle; tendency for acidosis; no rise in blood glucose after IV glucagons; aminoaciduria (generalized), glucosuria, phosphaturia, hyperlipidemia, no enzyme defect identified; abnormal galactose metabolism Phosohoglucomutase deficiency (Thomsom) Aglycogenosis
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Accumulation of normal glycogen in the muscle Enzyme defect in the liver, but

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LACTIC ACIDOSIS

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General Considerations

Lactic acidosis accumulation of lactic acid d/t defects in lactic acid metabolism Lactic acid is a dead-end product of glycolysis Can also be formed from pyruvate through enzymatic action of lactate dehydrogenase

Pyruvate + NADH + H+ (lactate dehydrogenase) lactic acid + NAD

Lactic acid is strong acid (pKa = 3.9), so that in physiologic systems it is dissociated into lactate and hydrogen ions

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Classification of Causes of Lactic Acidosis


Hypoxic conditions Nonhypoxic conditions

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Hypoxic Condtions

Oxygen demand is greater than oxygen supply or systemic

Localized Hypoxic

condition mitochondrial respiration not possible inability of the Krebs Cycla to release fully stored energy of fats, carbohydrates and protein (compensatory mechanis) production of energy through substrate phosphorylation (2 ATP) rapid accumulation of lactic acid
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compromised oxygen supply, the cells

Hypoxic Condtions
The

following are selected caused of lactic acidosis that lead to hypoxia


Shock Regional hyperplasia Severe anemia Respiratory failure Carbon monoxide poisoning

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Nonhypoxic Conditions
No

apparent evidence of hypoxia

Mechanism:
interference with normal metabolism of

acetyl-CoA through Krebs Cycle Glycolysis in the absence of Krebs cycle leads to rapid lactic acid accumulation

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Nonhypoxic Conditions
Selected

metabolic causes of lactic acidosis without tissue hypoxia


Out of control DM Liver failure Kidney failure Thiamine deficiency Thiamine deficiency Biguanide

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Lactic Acid Level Determination


Use venous blood Arterial blood: lower values Venipuncture: with minimum tourniquet time without clenching of the muscles Specimen collection tube w/ inhibitors of glycolysis

sodium fluoride and potassium oxalate

specimen must be placed in ice.


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Lactic Acid Level Determination


Lactate

measured enzymatically using lactate dehydrogenase with NADH loss followed spectrophotometrically NV: 0.4 to 2.1 mmol/L lactic acid levels should be suspected when a patient has
elevated anion gap [Na+ - (total CO2 + Cl-)] of

Abnormal

greater than 12
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