Klinisk kemisk diagnos.k

Transkript

1 Klinisk kemisk diagnos.k Introduk.on Johan Malm professor/överläkare i klinisk kemi inst f transla.onell medicin Lunds universitet Skånes universitetssjukhus Malmö

2 Man, 63 år söker inkommer med ambulans.ll med akut bröstsmärta sedan 3.mmar.digare frisk inga mediciner

3 smärtpåverkad blodtryck 165/95 kallsveig

4 Hb, LPK, TPK EKG troponin glukos Na K Ca krea.nin ASAT, ALAT blodgaser po2, pco2 koagula.onsstatus

5 *Smärtlindring *An.- ischemisk behandling *Trombosbehandling *Sviktbehandling *Arytmibehandling

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7 Dag 3 blir pat. medvetslös och avlider trots återupplivningsförsök.

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9 Handläggning av pa.ent Anamnes Fysikalisk undersökning Differen.aldiagnoser Utredning tex lab, röntgen Diagnos Terapi Utvärdering

10 En majoritet av medicinska beslut baseras på laboratoriemedicinska resultat

11 Laboratoriemedicin klinisk kemi klinisk mikrobiologi klinisk patologi klinisk immunologi och transfusionsmedicin klinisk gene.k arbets- och miljömedicin vårdhygien biobank

12 Vem arbetar inom laboratoriemedicin? biomedicinska analy.ker kemister ingenjörer läkare gene.ker administra.v personal

13 Varifrån kommer proven? vårdcentraler sjukhus privatprak.ker övriga

14 Olika sek.oner inom klinisk kemi allmänkemi hematologi farmakologi och toxikologi koagula.on endokrinologi molekylärbiologi pa.entnära diagnos.k (POCT, point of care tes.ng) proteiner

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17 Provtagningsmaterial blod urin likvor (CSF, cerebrospinalvätska) annan vätska eller vävnad

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19 Speciella provtagningsföreskriaer fasteprov glukos, triglycerider morgonprov järn, kor.sol

20 Vad är normalt?

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22 Acute Myocardial Infarc.on End result of luminal narrowing of coronary arteries Reduc.on of blood supply Reduc.on of O 2 supply

23 Risk factors Older age Male gender Cigarede smoking Hypercholesterolemia Diabetes High blood pressure Obesity

24 Pathophysiology Result of Atherosclerosis disease affec.ng arterial blood vessels It is a chronic inflammatory response in the walls of arteries, deposi.on of lipoproteins (plasma proteins that carry cholesterol and triglycerides). forma.on of mul.ple plaques within the arteries.

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34 Hur diagnos.seras hjär.nfarkt?

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39 man, 54 år söker på vårdcentral har insulinbehandlad diabetes problem med kroniska sår

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41 dagliga såromläggningar intensifierad glukoskontroll blir ini.alt bädre

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43 diabetes mellitus

44 The Interna.onal Diabetes Federa.on Diabetes Atlas, 5th ed

45 The Interna.onal Diabetes Federa.on Diabetes Atlas, 5th ed

46 The Interna.onal Diabetes Federa.on Diabetes Atlas, 5th ed

47 The Interna.onal Diabetes Federa.on Diabetes Atlas, 5th ed

48 Type 1 diabetes in the young The Interna.onal Diabetes Federa.on Diabetes Atlas, 5th ed

49 4.6 million deaths due to diabetes in % of all- cause mortality 48% in people under 60 The Interna.onal Diabetes Federa.on Diabetes Atlas, 5th ed

50 Prevalence (%) by region and age and sex The Interna.onal Diabetes Federa.on Diabetes Atlas, 5th ed

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54 Ac.on of Insulin on Cell Metabolism

55 Ac.on of Insulin on Carbohydrate, Protein and Fat Metabolism facilitates the transport of glucose into muscle and adipose cells, facilitates the conversion of glucose to glycogen in the liver and muscle s.mulates protein synthesis s.mulates lipogenesis

56 What goes wrong in diabetes?

57 Type I Diabetes Cell

58 Type I Diabetes Low or absent endogenous insulin Dependent on exogenous insulin for life Onset generally < 30 years 5-10% of cases of diabetes Onset sudden Symptoms: 3 P s: polyuria, polydypsia, polyphagia

59 Type I Diabetes Gene.c component to disease

60 Type II Diabetes

61 Type II Diabetes Insulin levels may be normal, elevated or depressed Characterized by insulin resistance, diminished.ssue sensi.vity to insulin, and impaired beta cell func.on (delayed or inadequate insulin release) Oaen occurs >40 years

62 Type II Diabetes Risk factors: family history, sedentary lifestyle, obesity and aging Controlled by weight loss, oral hypoglycemic agents and/or insulin

63 Gesta.onal diabetes (graviditetsdiabetes) } Glucose intolerance during pregnancy. } More common among obese women. } Requires treatment to avoid complica.ons in the infant. } Aaer pregnancy, 5-10% have type 2 diabetes. } Women who have had gesta.onal diabetes % develop diabetes in the next 5-10 years.

64 Labtester vid diabetes B- glukos B- HbA1c Urins.cka U- albumin

65 HbA1c glucose (green) HbA1c (red).me

66 Labtester vid diabetes B- glukos B- HbA1c Urins.cka U- albumin

67 Hur diagnos.seras diabetes?

68 WHO 2006

69 Glucose concentra.on

70 Diabetes Complications Cardiovascular disease Coronary Heart disease (CHD) Stroke Peripheral arterial disease (PAD)/amputation) Eye disease (retinopathy) Kidney disease (nephropathy) Liver disease Nerve disease (neuropathy) All cause mortality risk

71 Avoiding Diabetes Complications Blood glucose control HbA1c Treat cholesterol profiles to targets Treat blood pressure to target <130/<80

72 Type 1 Diabetes Microvascular Complications Relative Risk Retinopathy Nephropathy Neuropathy Microalbuminuria A1C (%) Skyler J. Endocrinol Metab Clin North Am. 1996;25:243 DCCT Research Group. N Engl J Med. 1993;329:977

73 Cardiovascular Disease Risk: Stroke 2 to 4 times higher Heart Disease 2 to 4 times higher ~75% of diabetes patients have high blood pressure (hypertension) ~75% of people with diabetes have a dyslipidemia (cholesterol disease)

74 Peripheral Arterial Disease Blockage of arteries in legs Contributing factor to amputations in diabetes: ~60% of lower limb amputations occur in people with diabetes Amputation rate is 10 times higher in diabetes

75 Diabetic Nephropathy Characterized by proteinuria Prevalence 15-40% in type 1 Prevalence 5-20% in type 2 Associated with risk of CVD

76 Nephropathy - Screening Microalbumin

77 microalbumin

78 Nephropathy - Screening Microalbumin and serum creatinine screening

79 crea.nine

80 Nephropathy- Screening Microalbumin and serum creatinine screening HbA1c BP s <130/<80, weight reduction, lipid control, tobacco cessation

81 Diabetic Eye Disease Cataracts Macular edema Glaucoma

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84 Diabetic Neuropathy Diabetic Peripheral Neuropathy Autonomic Neuropathy

85 Diabetic Neuropathy