Podcast
Questions and Answers
What is a life-threatening condition that can occur due to severe insulin deficiency?
What is a life-threatening condition that can occur due to severe insulin deficiency?
What is the typical range for bicarbonate (HCO3) levels at presentation in diabetic ketoacidosis?
What is the typical range for bicarbonate (HCO3) levels at presentation in diabetic ketoacidosis?
Which of the following best describes the metabolic disturbances occurring in diabetic ketoacidosis?
Which of the following best describes the metabolic disturbances occurring in diabetic ketoacidosis?
What role does insulin play in the context of fasting and ketosis?
What role does insulin play in the context of fasting and ketosis?
Signup and view all the answers
Which of the following is NOT a typical presenting symptom of diabetic ketoacidosis?
Which of the following is NOT a typical presenting symptom of diabetic ketoacidosis?
Signup and view all the answers
How does the body utilize fatty acids during prolonged fasting?
How does the body utilize fatty acids during prolonged fasting?
Signup and view all the answers
What is the significance of the fruity odor associated with fasting and diabetic ketoacidosis?
What is the significance of the fruity odor associated with fasting and diabetic ketoacidosis?
Signup and view all the answers
What happens to the pH level in severe diabetic ketoacidosis?
What happens to the pH level in severe diabetic ketoacidosis?
Signup and view all the answers
What does a Urinary Albumin Excretion Rate (AER) indicate in a diabetic patient?
What does a Urinary Albumin Excretion Rate (AER) indicate in a diabetic patient?
Signup and view all the answers
What is primarily measured to estimate the Glomerular Filtration Rate (GFR) in clinical practice?
What is primarily measured to estimate the Glomerular Filtration Rate (GFR) in clinical practice?
Signup and view all the answers
In patients with diabetes, what happens to the Glomerular Filtration Rate (GFR) over time?
In patients with diabetes, what happens to the Glomerular Filtration Rate (GFR) over time?
Signup and view all the answers
What risk factors are associated with the presence and quantity of urinary albumin in diabetic patients?
What risk factors are associated with the presence and quantity of urinary albumin in diabetic patients?
Signup and view all the answers
For which HbA1c range is the Relative Risk for diabetic kidney disease mostly negligible?
For which HbA1c range is the Relative Risk for diabetic kidney disease mostly negligible?
Signup and view all the answers
How does the Relative Risk for diabetic conditions change with HbA1c values increasing beyond 75 mmol/l?
How does the Relative Risk for diabetic conditions change with HbA1c values increasing beyond 75 mmol/l?
Signup and view all the answers
Which of the following conditions can lead to a raised anion gap in metabolic acidosis?
Which of the following conditions can lead to a raised anion gap in metabolic acidosis?
Signup and view all the answers
What is the physiological response to metabolic acidosis involving bicarbonate?
What is the physiological response to metabolic acidosis involving bicarbonate?
Signup and view all the answers
What is a symptom of severe diabetic ketoacidosis related to volume status?
What is a symptom of severe diabetic ketoacidosis related to volume status?
Signup and view all the answers
How does acidosis affect potassium levels in extracellular fluid?
How does acidosis affect potassium levels in extracellular fluid?
Signup and view all the answers
Which of the following is NOT a characteristic of Kussmaul's respirations?
Which of the following is NOT a characteristic of Kussmaul's respirations?
Signup and view all the answers
What primarily drives volume contraction in diabetic ketoacidosis?
What primarily drives volume contraction in diabetic ketoacidosis?
Signup and view all the answers
Which electrolyte disorder is commonly masked by elevated plasma potassium levels in diabetic ketoacidosis?
Which electrolyte disorder is commonly masked by elevated plasma potassium levels in diabetic ketoacidosis?
Signup and view all the answers
What triggers diabetic ketoacidosis and hyperosmolar hyperglycemic state?
What triggers diabetic ketoacidosis and hyperosmolar hyperglycemic state?
Signup and view all the answers
Which of the following is NOT a chronic complication stemming from microvascular disease in diabetes?
Which of the following is NOT a chronic complication stemming from microvascular disease in diabetes?
Signup and view all the answers
What is a key modification to minimize the risk of chronic complications in diabetes?
What is a key modification to minimize the risk of chronic complications in diabetes?
Signup and view all the answers
Which hormone's increase is primarily involved in the promotion of gluconeogenesis?
Which hormone's increase is primarily involved in the promotion of gluconeogenesis?
Signup and view all the answers
Which condition is characterized by an increase in counterregulatory hormones to insulin?
Which condition is characterized by an increase in counterregulatory hormones to insulin?
Signup and view all the answers
Which microvascular complication is known to be the leading cause of blindness in diabetic patients?
Which microvascular complication is known to be the leading cause of blindness in diabetic patients?
Signup and view all the answers
What is the result of severe ketosis in terms of acid-base balance?
What is the result of severe ketosis in terms of acid-base balance?
Signup and view all the answers
Which lifestyle modification has the least impact on reducing the risks associated with diabetes complications?
Which lifestyle modification has the least impact on reducing the risks associated with diabetes complications?
Signup and view all the answers
In the context of diabetes, which of the following does NOT contribute to relative insulin deficiency?
In the context of diabetes, which of the following does NOT contribute to relative insulin deficiency?
Signup and view all the answers
What is the primary metabolic effect of increased lipolysis in the context of diabetes?
What is the primary metabolic effect of increased lipolysis in the context of diabetes?
Signup and view all the answers
Which of these complications is NOT classified under chronic complications associated with diabetes?
Which of these complications is NOT classified under chronic complications associated with diabetes?
Signup and view all the answers
Study Notes
Monitoring Diabetes Mellitus
- Diabetes complications monitored include acute (Diabetic Ketoacidosis - DKA) and chronic (Renal, Atherosclerotic/dyslipidaemia)
- Laboratory investigations and self-monitoring are used to monitor diabetes
Diabetic Ketoacidosis
- Diabetic Ketoacidosis (DKA) occurs when the body's ability to compensate for insulin deficiency fails
- DKA is a life-threatening condition caused by severe insulin deficiency
- Key features of DKA include:
- Hyperglycaemia (usually >25 mmol/L)
- Ketosis (usually > 3 mmol/L)
- Metabolic acidosis
- Volume depletion and shock
- Electrolyte disturbances
- Additional symptoms of DKA:
- Abdominal pain, nausea, vomiting
- Variable mental status from drowsiness to coma
Normal Fasting Ketosis
- In the fasting state, lack of insulin increases lipolysis, releasing fatty acids
- Fatty acids are metabolised for energy (beta-oxidation) in most tissues, except the brain
- Liver oxidizes fatty acids into ketone bodies (acetoacetate & β-hydroxybutyrate) used as an energy source by the brain
- After 3-4 days of fasting, ketone bodies provide 30-40% of the body's energy
- Acetoacetate decarboxylates to acetone, causing a fruity breath odor
Ketosis in Diabetes
- Untreated T1DM mimics the fasting state due to severe insulin deficiency, leading to ketosis
- Excessive ketone production can be detected in urine (ketonuria) & blood (ketonemia)
- Acetone produces a characteristic fruity breath odor
Ketoacidosis in Diabetes
- Elevated ketone levels (ketoacids) cause metabolic acidosis
- Blood pH decreases (below 7.0 in severe cases, normal range 7.35-7.45)
- Bicarbonate levels fall (below 10 mmol/L, normal range 22-29 mmol/L)
- Compensatory hyperventilation (Kussmaul's respirations) occurs to remove CO2
Raised Anion Gap Metabolic Acidosis
- The anion gap is a simple diagnostic tool for metabolic acidosis
- Anion gap = Na+ - (CI¯ + HCO3¯)
- In DKA, the anion gap can be 20-40 mmol/L (normal range 8-16 mmol/L)
Diabetic Ketoacidosis (DKA)
- Occurs in approximately 25% of Type 1 Diabetes Mellitus (T1DM) patients at presentation.
- Causes: Delayed presentation, inability to respond to thirst, intercurrent illness.
- Life-threatening condition characterized by severe insulin deficiency.
- Characterized by:
- Hyperglycemia (usually >25 mmol/L)
- Ketosis (usually > 3 mmol/L)
- Metabolic acidosis
- Volume depletion & shock
- Electrolyte disturbances
- Additional symptoms: Abdominal pain, nausea, vomiting.
- Variable mental status: Drowsiness to profound lethargy and coma.
Normal Fasting Ketosis
- Occurs in the fasting state when plasma glucose levels drop.
- Pancreas stops producing insulin; Lack of insulin increases lipolysis.
- Release of free fatty acids (FFA) into the bloodstream.
- Fatty acids are metabolized as an energy source for most tissues (fatty acid β-oxidation)
- FFA cannot cross the blood-brain barrier; they are oxidized in the liver to ketone bodies: acetoacetate & β-hydroxybutyrate.
- Ketone bodies are used as an energy source for the brain and other tissues.
- After a 3-4 day fast, ketone bodies provide 30-40% of the body's energy requirements.
- Acetone (from acetoacetate) gives rise to a fruity odour from breath associated with fasting.
Ketosis in Diabetes
- Hormonal milieu is similar to fasting in untreated T1DM; Severe insulin deficiency leads to ketosis.
- Excessive ketone production detected in urine (ketonuria) & blood (ketonemia).
- Acetone produces a fruity odour from breath, similar to normal fasting.
Ketoacidosis in Diabetes
- Markedly elevated levels of ketoacids (acetoacetate & β-hydroxybutyrate) induce metabolic acidosis.
- Low pH; Severe cases fall below 7.0 (RR 7.35-7.45), H+ increases to 100 nmol/L. (Normal 40 nmol/L).
- Acidosis is buffered by converting: HCO3¯ + H+→ H2CO3 → H2O + CO2.
- HCO3 usually falls less than 10 mmol/L at presentation (RI 22-29 mmol/L).
- Compensatory hyperventilation, with slow, deep breaths (Kussmaul's respirations) occurs in an effort to remove CO2.
Raised Anion Gap Metabolic Acidosis
- Anion gap is a diagnostic tool for metabolic acidosis.
- Formula: Anion gap = Na+ - (CI¯ + HCO3¯)
- In DKA, the anion gap may be 20-40 mmol/L (RI <15 mmol/L).
- This is due to the unmeasured anions (β-hydroxybutyrate & acetacetate).
- Other causes of raised anion gap metabolic acidosis:
- Lactic acidosis (secondary to severe dehydration & shock)
- Starvation ketosis
- Alcoholic ketoacidosis
- Uremic acidosis in renal failure
- Toxic ingestions (salicylate, methanol, ethylene glycol)
Volume Status
- Volume contraction is a hallmark of diabetic ketoacidosis.
- Driven by hyperosmolality secondary to hyperglycemia.
- Mild DKA: Osmotic diuresis; H2O moves from intracellular to extracellular space; Partially counterbalanced by polydipsia.
- Severe DKA: Inability to maintain fluid balance; Fluid deficits of 5-10 L are common.
- Hypovolaemic shock: Lactic acidosis, uraemic acidosis; Hypotension; Rapid, weak, thready pulse; Thirst & dry mouth; Cold & mottled skin.
Potassium Disturbance
- Factors raising extracellular fluid (ECF) K+: Shift of K+ to extracellular space due to acidosis (H + exchanged for K+ in ECF); Insulin stimulates Na+/K+ ATPase.
- Factors lowering ECF K+: Increased K+ excretion due to raised plasma K+, secondary hyperaldosteronism, vomiting.
- Commonly N/↑ plasma K+ masks a total body K+ deficiency.
- Both hyper- & hypokalaemia can lead to cardiac arrhythmias.
Pathogenesis of DKA and Hyperosmolar Hyperglycemic State (HHS)
- Triggers include stress, infection, and insufficient insulin.
- Absolute insulin deficiency leads to increased lipolysis, increased free fatty acid (FFA) to liver, and increased ketogenesis.
- Counterregulatory hormones: Protein synthesis, proteolysis, gluconeogenic substrates, gluconeogenesis, hyperglycemia, glycosuria, loss of water and electrolytes, dehydration, decreased fluid intake, impaired renal function.
- Relative insulin deficiency leads to increased glycogenolysis and hyperosmolarity.
- These can lead to DKA or HHS.
Chronic Complications
- Long-term management of diabetes aims to minimize risk of chronic complications.
- All main complications stem from effects on the vasculature.
- Microvascular disease: Retinopathy (leading cause of blindness), Nephropathy (leading cause of end stage renal disease), Neuropathy.
- Atherosclerosis: Coronary artery disease, Cerebrovascular accidents, Peripheral vascular disease.
- Modifiable risk factors for chronic complications: Good glucose control, smoking cessation, healthy lifestyle habits (nutrition, exercise), controlling hypertension and managing dyslipidaemia.
DCCT: A1C and Microvascular Complications
- Relative risk for Retinopathy, Nephropathy, Neuropathy, and Microalbumin increases with increasing HbA1c values.
Kidney Disease
- Diabetes is the most common predisposing factor for chronic kidney disease and requiring dialysis.
Diabetic Kidney Disease
- Urinary Albumin Excretion Rate (AER, ACR): Marker of glomerular dysfunction; Indicates albumin leak from damaged glomeruli; Maybe intermittent in T1DM 3-5 years post-diagnosis; Persistent presence indicates risk of CKD, also a risk marker for other microvascular & atherosclerotic diseases.
- Glomerular Filtration Rate (GFR): Reduction in GFR can indicate loss of nephrons in diabetes; Usually estimated based on serum creatinine.
- Other: Kidney Failure Risk Equation (KFRE) predicts kidney replacement therapy risk in CKD stages 3a-5.
CKD Classification
- CKD is classified based on Cause (C), GFR (G) and Albuminuria (A).
Atherosclerotic Disease
- Similar to atherosclerosis in non-diabetics but more extensive and rapidly progressive.
- Insulin resistance and hyperglycemia accelerate atherosclerosis through endothelial cell dysfunction and dyslipidaemia.
Diabetic Dyslipidaemia
- Insulin resistance results in increased FFA release from adipose tissue, conversion of FFA to triglycerides in the liver, repackaging as VLDL, low HDL levels and increased small dense LDL particles, which predispose to atherosclerosis.
- It can be managed through good diabetic control and lipid-lowering drugs (statins).
- Usually monitored using lipid profile parameters.
- Routine tests may not adequately identify patients with proatherogenic small dense LDL particles.
- Inferred by low HDL and elevated triglyceride levels.
Monitoring
Lab Investigations
- HbA1c: Monitors long-term glycaemic control; Assesses therapeutic response, risk of microvascular complications; Screens and diagnoses diabetes; Measures quality of diabetes care; Evaluates new medications; Formal lab and point-of-care testing (POCT not for diagnosis).
Alternatives to HbA1c
- Used when HbA1c is limited due to clinical reasons (e.g., Hgb variants).
- Not standardized, not widely available; Lack of evidence-based clinical decision/limits of cut-points.
- Examples: Fructosamine, glycated albumin.
Self Monitoring: Glucose Monitoring
- Multiple self-monitoring devices are available.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Related Documents
Description
Test your knowledge on monitoring diabetes mellitus including diabetic ketoacidosis (DKA) and its complications. This quiz covers laboratory investigations, self-monitoring techniques, and the physiological changes during fasting. Understand the key features, symptoms, and implications of various diabetic conditions.
