01. diabetes mellitus part 1 - prof.askandar
TRANSCRIPT
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
1/40
ASK-SDNC
GARIS BESAR KULIAH UNTUK MAHASISWA SEMESTER-6
DIABETES MELLITUS-I
FAKULTAS KEDOKTERAN UNIVERSITAS AIRLANGGA, SURABAYA
1
2012
16-927-B
Prof. Dr. dr. Askandar Tjokroprawiro Sp.PD, K-EMD, FINASIM
SURABAYA DIABETES AND NUTRITION CENTRE - Dr. SOETOMO TEACHING HOSPITALFACULTY OF MEDICINE AIRLANGGA UNIVERSITY, SURABAYA
Division of Endocrinology and Metabolism Dept. of Internal Medicine
SURABAYA, 05 MARCH 2012
Kuliah DM-I : SLIDE 1 40
dr. Sri Murtiwi Sp.PD, K-EMD, FINASIM
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
2/40
ASK-SDNC
SEJARAH
1550 th SM Penyakit atau "SINDROMA DIABETES", mulai dikenal
di Mesir 1550 SM (The Egyptian Papyrus Ebers)
200 th SM ARETAEUS(Greek Physician) : DIABETES atauSIPHON = FLOW-THROUGH = RUN-THROUGH, berarti
mengalir terus. Sehabis minum banyak, diikuti kencing
banyak. MELLITUS : MADU atau MANIS.
DIABETES MELLITUS = KENCING MANIS.
2
HISTORY (Tattersall 2003) : Polyuric states resembling DIABETESMELLITUS have been described for over 3500 years. The name
DIABETES comes from the Greek word for a SYPHON; the sweet
taste of DIABETIC URINE was recognized at the beginning of the
millenium, but the adjective MELLITUS(honeyed) was only added by
John Rollo in the late 18th century.
Continued
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
3/40
ASK-SDNC
Th. 1909 JEAN d MEYER(Belgia) memberi nama hormon INSULIN
(Latin : Insulina = Island)
SEJARAH3
Th. 1869 PAUL LANGERHANS(Jerman) : timbunan Glukosa
dalam Hepar sebagai Glikogen, dan Hiperglikemia Akut
akibat kerusakan Medulla Oblongata (PIQRE DIABETES).
Th. 1674 THOMAS WILLIS(Inggris), merasakan rasa manis pada
Urine (Abad 5-6 rasa manis ini sudah pernah dilaporkan
oleh Dokter Indian).
Continued
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
4/40
ASK-SDNC
Th. 1921 FREDERIK G. BANTING(Ahli Bedah) dan CHARLES H. BEST(Asisten Student) dari Univertisy of Toronto-Canada
bekerja sama dengan JAMES B. COLLIP(Ahli Biokimia)
dan J.J.R MACLEOD(Ahli Ilmu Faal) menemukan INSULIN.
Mulai digunakan di 11 JANUARI1922, kepada pria umur
14 tahun (nama : LEONARD THOMPSON). The name
INSULIN was coined by MACLEOD
Th. 1954 - 1955
FRANKE dan FUCHS (1954) mulai menggunakan OHO
(Obat Hipoglikemik Oral)atauOAD (Obat Anti Diabetes)
pada manusia. The first oral hypoglycaemic agents
suitable for clinical use were the SULPHONYLUREAS,
developed by Auguste Loubatieres in the early 1940s.
CARBUTAMIDE was introduced in 1955 and
TOLBUTAMIDE in 1957. The biguanide PHENFORMIN
became available in 1959, and METFORMINin 1960
SEJARAH 4
Continued
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
5/40ASK-SDNC
DM TYPE 2 (Tattersall 2003)
INSULIN RESISTANCE and -CELL FAILURE, the fundamental
defects of type 2 diabetes (T2D), have been investigated by many
researchers. The insulin clamp method devised by Ralph
DeFronzo was the first accurate technique for measuring insulin
action. Maturity-Onset Diabetes of the Young (MODY) was describedas a distinct variant of type 2 diabetes by Robert Tattersall in 1974.
5DIABETES MELLITUS
DM TYPE 1 (Tattersall 2003)
THE -CELL DESTRUCTION causing type 1 diabetes (T1D) was
suggested to be autoimmune by Deborah Doniach and GianFranco
Bottazzo in 1979. The significance of chronic lymphocytic infiltration
of the islets (insulitis),first observed by Eugene Opie in 1901, was
highlighted by Willy Gepts in 1965. Andrew Cudworth and John
Woodrow first described the association of type 1 diabetes with
specific HUMANLEUCOCYTE ANTIGENS (HLA).
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
6/40ASK-SDNC
Data DM Di RS Pendidikan Dr. Soetomo (Hospital Data)(19642011)
JUMLAH DM TERDAFTAR DI POLI ENDOKRINOLOGI RSU Dr. SOETOMOSurabaya 19642010 (Selama 46 Tahun)
Dari 133Pasien terdaftar pada tahun 1964menjadi 35717pd th 2010(46 tahun)
meningkat 268x lipat, dengan pertambahan pasien baru rerata +110DM pertahun
6
: 133 px
: 1061
: 15381: 16567
: 2914
: 22029
: 26406: 27824
: 5654
: 8222
: 10278
: 11475
: 12608
: 13818
: 19039
: 20366
: 17667 : 29394
: 31457
: 33636
: 35606
: 37704: 39875: 9150
: 42149
: 43264
: 45536
19901991
1986
1987
1988
1989
1964
1970
1975
1980
19841985
1995
19961997
1992
1993
1994
1998
1999
2000
2001
20022003
2004
2005
2006
2007
2008
2009
MANUAL
ELECTRONIC
: 33157
: 328622010 : 35717
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
7/40ASK-SDNC
%0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0
Commulative Prevalence of CVD : +82%(in line with Dyslipidemia)
30 million in USA(FELDMAN, et al 1994)
Tjokroprawiro 1993 (Revised : 2002) ADA 2005-2010
CHRONIC DIABETIC COMPLICATIONS AND PROVIDED INFORMATION
DIABETIC ORAL MANIFESTATIONS : 1075%
GINGIVITIS AND PERIODONTIS ARE MOST PREVALENT
CHD : "THE WINDOW OF MACROANGIOPATHY"RETINOPATHY : "THE WINDOW OF MICROANGIOPATHY"MICROALBUMINURIA (30-299 mg/day = ACR) :IS REFERRED TO AS HAVING INCIPIENT NEPHROPATHY
MICROANGIOPATHY : RETINOPATHY, NEPHROPATHY, NEUROPATHY, MACROANGIOPATHY : CHD, STROKE, PVD
67.0Dyslipidemia
51.4Symptomatic Neuropathy50.9Erectile Dysfunction
27.2Retinopathy25.5Joint Manifestation
16.3Cataract12.8Pulmonary Tbc12.1Hypertension (WHO,1983)
10.0CHD5.7CLINICAL NEPHROPATHY
4.2Stroke3.8Cellulitis - Gangrene
3.0Symptomatic Gall Stone
Based on JNC7, 2003 : + 32%
7
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
8/40ASK-SDNC
(McCarty & Zimmet 1994, Provided : Tjokroprawiro 1989-2012)
DIFFERENCES IN RATES (%) OF T2DM IN MAJOR ETHNIC GROUPS
LOWEST REPORTED RATES
(Hispanic) Central Mexico 5.6
(Micronesian) Rural Kiribati 4.3
(Polynesian) Rural Western Samoa 4.0
(European) Poland 3.5
(Asian Indian) Rural India 2.7(Melanesian) Rural Fiji 1.9
(Oriental) Rural Chinese 1.6
Indonesia (East Java) :
- Urban-Surabaya (Adimasta et al 1980)1.43
- Rural (Tjokroprawiro et al 1989) 1.47
Suspect MRDM : + 21% of DM in Rurals
African Rural Tanzania 1.2(Arab) Rural Tunisia 1.2
- Urban-Surabaya (Pranoto et al 2006) 6.0%
8
HIGHEST REPORTED RATES
(Asian Indian) Fijian Island 22.0
(Micronesian) Urban Kiribati 14.6
(Arab) Oman 14.2
(Hispanic) US Mexican
14.1
(Oriental) Mauritian Chinese 13.1
(Polynesian) Urban Western Samoa 10.6
(African) US African American 10.3
(European) Southern Italy 10.2
(Melanesian) Urban Fiji 8.5
Prevalence Rates of Small Populations :Pima Indians 50.3% Nauru 41.3%
Manado : 8-10% Surabaya : 6.0%
Rates are age-standardized to Segi's world population for ages 30 to 64.
Prevalence rates of smaller populations such as the Pima Indians in North America (50.3),
Pacific Islanders of Nauru (41.3) & Australian Aborigin (22.5) have not been included.
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
9/40ASK-SDNC
Global Diabetes Statistics(Diabetes Atlas IDF 2003, Provided : Tjokroprawiro 2004-2012)
4% Prevalence of DM, Netherlands, 2003
20% Prevalence of DM, UAE, 2003
30% Prevalence of DM, Nauru, 2003
104,800 Number of Children with TIDM, Southeast Asia, 2003
430,000 Number of Children with TIDM, Worldwide, 2003
194,000,000 Number of People with DM, 2003333,000,000 Predicted number of People with DM, 2025
314,000,000 Number of People with IGT, 2003; No Data for IFG
472,000,000 Predicted Number of People with IGT, 2025THE ROLES OF
METFORMIN
28% Proportion of DM attributable to weight gain, Southeast Asia Males, 200380% Proportion of DM attributable to weight gain, Western Europe Males, 2003
9
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
10/40ASK-SDNC
IDF Regions and Global Projections of the Number of People with Diabetes (20-79 years) : 2011 and 2030
IDF, Diabetes Atlas 5thEdition-2011, Provided : 2012
10
The 21thWorld Diabetes Congress : Dubai, 5-8 December 2011
2011 2030 INCREASEREGION MILLIONS MILLIONS %
Africa 14.7 28.0 90%
Middle East and Noth Africa 32.8 59.7 83%
South-East Asia 71.4 120.9 69%
South and Central America 25.1 39.9 59%
Western Pacific 131.9 187.9 42%
North America and Caribbean 37.7 51.2 36%
Europe 52.6 64.0 22%
World 366.2 551.8 51%
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
11/40ASK-SDNC
The TOP 10 COUNTRIES of People with Diabetes (20-79 Yrs)IDF 2009(IDF Diabetes Atlas 4thEdition-2009, Illustrated : Tjokroprawiro 2012)
NO.
OFCASES(M
ILLIONS)
0
10
20
30
40
50
60
INDIA
*50.8
1
CHINA
*43.2
2
USA
*26.8
3
RUSSIAN
FEDERATION
*9.6
4
BRAZIL
*
7.6
5
GERM
*7.5
6
PKTAN
*7.1
7
JAPAN
*7.1
8
MEXICO
*6.8
10INA
9
*
7.0
11
*) Number of People with Diabetes (20-79 Years): in Million
DM-by IDF
2009
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
12/40ASK-SDNC
The TOP 10 COUNTRIES of People with Diabetes (20-79 Yrs)IDF 2011(IDF Diabetes Atlas 5thEdition-2011, Illustrated : Tjokroprawiro 2012)
12
NO.
OFCASES(MILLIONS)
0
1020
30
40
5060
70
80
90
BRAZIL
5
*12.4**
9.72
EGYPT
9
*7.3**
15.16
RUSSIAN
FEDERATION
4
*12.6**
11.54
USA
3
*23.7
**10.94
**) Diabetes National Prevalence (%)
*) Number of People with Diabetes (20-79 Years) : in Million
INA
10
**4.73
*7.3
CHINA
1
**9.29
*90.0
INDIA
2
*61.3
**8.31
BANGLA
DESH
8
*8.4
**9.58
MEXICO
7
*10.3
**14.85
JAPAN
6
*10.7
**11.20
Germany and Pakistan : Out of the TOP TEN
Bangladesh and Egypt : Newcomers of the TOP TEN
DM-by IDF2011
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
13/40ASK-SDNC
CATEGORIES OF INCREASED RISK FOR DIABETES (IRD = PREDIABETES*) : ADA 2012
(Summarized : Tjokroprawiro 2011-2012)
NORMAL : A1C < 5.7 %
1 FPG 100 mg/dl to 125 mg/dl: IFGPREDIABETES
2 2-h PG 140 mg/dl to 199 mg/dl in the 75 g OGTT: IGT PRE DIABETES
3
THE TERM PRE-DIABETESMAY BE APPLIED IF DESIRED
HbA1c5.76.4% : IRD or PREDIABETES
* For all Three tests, risk is continuous extending below the lower limit of the
range and becoming disproportionately greater at higher ends of the range
13
(IRD = PREDIABETES*)
ADA = American Diabetes Association
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
14/40ASK-SDNC
STANDARDS OF MEDICAL CARE IN DIABETES ADA-2012CLASSIFICATION OF DIABETES MELLITUS
(ADA-2012, Added by KONSENSUS PERKENI-2011 and SURABAYA-1986)
Drug-or CHEMICAL-INDUCED (such
Genetic Defects of -CELL FUNCTIONGenetic Defects in INSULIN ACTIONDiseases of the Exocrine Pancreas(such as Cystic Fibrosis-Related Diabetes
= CFRD)
as in-the TREATMENT of AIDS orafter ORGAN TRANSPLANTATION)
D
ABC
DM Variation : DM Type X (Tjokroprawiro et al, 1991)LADA (Tuomi et al 1993)DM 1.5 (Zimmet 1993
I TYPE 1 DIABETES* (Results from -cell destruction, usually leading to absolute insulin deficiency)
II TYPE 2 DIABETES*
III OTHER SPECIFIC TYPES OF DIABETES due to other causes, e.g. :
IV GESTATIONAL DIABETES MELLITUS (GDM) : DM diagnosed during Pregnancy
14
InfectionsUncommon form of Immune-mediated Diabetes
Other Genetic Syndromes associated withDiabetes
EndocrinophathiesEF
GH
Based on PERKENI 2011 & Surabaya (E-I) :
A. Immune Mediated
B. Idiopathic
(Results from a progression Insulin Secretory Defect on the background of
Insulin Resistance)
MRDM (Surabaya 1986)I
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
15/40ASK-SDNC
CRITERIA for the DIAGNOSIS of DIABETES: PERKENI 2011, ADA 2012
(Summarized : Tjokroprawiro 2011-2012)
HbA1c> 6.5 % by NGSP Certified and Standardized to DCCT Assay
(NGSP : The National Glycohemoglobin Standardization Program)
1 HbA1c> 6.5 %
4 RANDOM PLASMA GLUCOSE > 200 mg/dl in Patients with :
CLASSIC SYMPTOMS of HYPERGLYCEMIA or HYPERGLYCEMIC CRISIS
2 FPG > 126 mg/dl FASTING means NO CALORIC INTAKE > 8 Hours
3 2-h PG > 200 mg/dl during OGTT (WHO, GLUCOSE LOADING 75g)
15
or
or
or
PERKENI 2011, ADA 2012
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
16/40ASK-SDNC
Criteria for Testing for Diabetes in Asymptomatic Adult Individuals
(Standards of Medical Care in Diabetes - ADA 2012)
A Testing should be considered in all adults who are OVERWEIGHT(BMI >25 kg/m2*, Indonesia: >23 kg/m2)and WHO HAVE ONE OR MORE ADDITIONAL RISK FACTORS :
16
PHYSICAL INACTIVITY1
First-degree Relative with Diabetes2
High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian
American, Pacific Islander)3
WOMEN who delivered a baby weighing >9 lb or who were diagnosed with GDM4HYPERTENSION (blood pressure >140/90 mmHg or on therapy for hypertension)5
HDL CHOLESTEROL level 250 mg/dL
(2.82 mmol/L)6
WOMEN with PCOS7
A1C >5.7%, IGT, or IFG on PREVIOUS TESTING8
OTHER CLINICAL CONDITIONS associated with INSULIN RESISTANCE (e.g.,severe obesity, acanthosis nigricans)
9
HISTORY of CVD10
B In the absence of the above criteria, TESTING for DIABETES SHOULD BEGIN at AGE 45 YEARS
C IF RESULTS are NORMAL, testing should be REPEATED at LEAST at 3-YEAR INTERVALS, withconsideration of more-frequent testing depending on initial results (e.g., those with prediabetes should be
tested yearly) and risk status.
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
17/40ASK-SDNC
PELAKSANAAN TES TOLERANSI GLUKOSA ORAL (TTGO)(Perkeni-2006, ADA-2007, Tjokroprawiro 2006-2012)
1 3 hari sebelumnya makan karbohidrat cukup
3 Puasa semalam 10-12 jam (minimal 8 jam)
4 Diperiksa Glukosa Darah Puasa
5 Diberikan glukosa 75 gram, dilarutkan dalam air 250 ml,diminum dalam waktu 5 menit.
6 Berpuasa kembali sampai pengambilan darah untuk 2 jam
sesudah minum larutan glukosa tersebut selesai
7 Diperiksa Glukosa Darah 2 (dua) jam sesudah beban Glukosa
17
Kegiatan Jasmani seperti yang biasa dilakukan2
8 Selama permeriksaan, pasien yang diperiksa tetap
istirahat dan tidak merokok; boleh minum air putih
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
18/40ASK-SDNC
Langkah-langkah Diagnostik DM dan Gangguan Toleransi Glukosa
(KONSENSUS PERKENI 2011)
GDP = Glukosa Darah Puasa
GDS = Glukosa Darah Sewaktu
GDPT = IFG = Glukosa Darah Puasa Terganggu
TGT = Toleransi Glukosa Terganggu
KELUHAN KLASIK (-)KELUHAN KLASIK DIABETES (+)
KELUHAN KLINIK DIABETES
D I A B E T E S M E L L I T U S TGT GDPT NORMAL
- Evaluasi Status Gizi
- Evaluasi Penyulit DM
- Evaluasi Perencanaan Makan
Sesuai Kebutuhan
- Nasihat Umum
- Perencanaan Makan
- Latihan Jasmani
- Berat Idaman
- Belum Perlu Obat Penurun Glukosa
GDP
GDSatau
GDP
GDSatau
>126
>200
200
200
100-125
140-199
TTGO
GD 2 Jam
>200 140-199 < 140
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
19/40ASK-SDNC
PRACTICAL TOOL FOR INSULIN RESISTANCE AND -CELL FUNCTION(Mathews et al 1985, Falutz et al 2002, Summarized : Tjokroprawiro 2005-2012)
HOMA-R and HOMA-BUseful in Daily Practice
:1
2 FOLLOW-UP OF TREATMENT
RATIONALE TREATMENT
HOMA-B-Cell Function
: (N: 70150%)20 x Fasting Insulin (U/ml)
FPG (mmol/l) 3.5
HOMA-RInsulin Resistance
: (N: < 4.0)Fasting Insulin (U/ml) x FPG (mmol/l)
22.5
19
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
20/40ASK-SDNC
PREVALENCE OF IR IN SELECTED METABOLIC DISORDERS(Bonora 1998, Summarized and Illustrated : Tjokroprawiro 2006-2012)
4 HYPERTENSION
IFG & IGT2
URIC ACID 7
LOW HDL-C 6
3 The MetS
HYPER-CHOL 8
1stPhase and
IR in LiverIFG = Impaired Fasting Glucose
1stPhase and
IR in PeripheryIGT = Impaired Glucose Tolerance
IR = INSULIN RESISTANCEIR = INSULIN RESISTANCE
DISORDERS
METABOLIC
SEQUENTIALPREVALENCES OF IR
in
20
HYPERTRIGLYCERIDAEMIA
5
T2DM
1
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
21/40ASK-SDNC
1. DM TIPE-1 (DMT1) : FROM -CELL DESTRUCTION TOABSOLUTE INSULIN DEFICIENCY
PROGREESSIVE INSULIN SECRETORY DEFECT ("AIR") ON THE BACKGROUND OF I.R.2. PATOFISIOLOGI DM TIPE-2 (DMT2) :
*SEKRESI INSULIN :1 FIRST PHASE (ACUTE) = "AIR" : 0-5 menit
2SECOND PHASE
GABUNGAN IR + IMPAIRED "AIR" T2DM
IR : INSULIN RESISTANCE"AIR" : ACUTE INSULIN RESPONSE (FIRST PHASE)
21
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
22/40ASK-SDNC
MACAM DM DI PRAKTEK SEHARI-HARI(Rangkuman : Tjokroprawiro 1993-2012)
BBR 1.1
>
Dx Dugaan :Gejala mendadakInsulin DependentAnak, atau Dewasa
(
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
23/40ASK-SDNC
1 DIABETES MELLITUS
2 RETINOPATI DIABETIK HARUS : POSITIF
3 PROTEINURIA yang positif tanpa penyebab lain, atau
selama 2 kali pemeriksaan dengan interval 2 minggu
apabila penyebab lain (misalnya infeksi) sudah teratasi.
(Kriteria ND 1989) : DM, Retinopati Diabetik, Kreatinin Darah
>2.5 mg/dl, Proteinuria 1 (satu) kalipemeriksaan tanpa adanya
penyebab proteinuria lain.
DIAGNOSIS DAN KLASIFIKASI NEFROPATI DIABETIK(Kriteria Surabaya 1985 dan 1989)
Atau
TIGA PERSYARATAN DIAGNOSIS NEFROPATI-DIABETIK (ND) :
23
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
24/40
ASK-SDNC
MNT : Medical Nutrition Therapy or Diet. Treatment : B2, B3, Be(Types of MNT), OAD(Oral Agents for Diabetic), INS(Insulin)
B2 & B3-Diets (Pre-HD Phase) : With Specific Composition plus Low K+
& Na+
, Protein 0.6-0.8 g/kg BW( 10% of Daily Cal.). Be-Diet (HD-Phase) : Low K+& Na+, Protein 1-1.2 g/kg BW/day, etc*) Diabetic Diets for DN are supplemented with Low Vit C, Folic Acid, Vit B6, Vit B12, GlutamineS
** THE FORMULA OF GFR MEASUREMENT RELY ON A STABLE SERUM CREATININE CONCENTRATION
B2*) 1 Micro/Macro Alb eGFR > 90 (N) B2, OAD, INS - ? -
B2*) 2 Macro Alb. eGFR 60-89 (< 2.5) B2, OAD, INS > 5 years
B2*) 3 Macro Alb. eGFR 30-59 (2.5-4) B2, OAD, INS > 2 years
5 Be, INS, HD
ESDN TransplantationBe*) Macro Alb. eGFR < 15 (> 10) 2-5 Months
4a eGFR 15-29 (4-8) B3, INS, Pre HD4b eGFR 15-29 (8-10) Be, INS, HD
B3*)Macro Alb. 4-18 Months
Be*)
(1986)Type Stage
Life ExpectancyeGFR (mL/min)**Micro/MacroAlbuminuria
MNT = DIET
OAD - INSSC (mg/dl)
eGFR ( )(mL/min.)
o (140-Age) x Body Weight (Kg)
Plasma Creatinine (mg/dl) x 72=
eGFR ( )(mL/min.)
(140-Age) x Body Weight (Kg)
Plasma Creatinine (mg/dl) x 72=+
ox 0.85
The Formula of CockroftGault : eGFR (estimated GFR); SC = Serum Creatinine
SURABAYA CLASSIFICATION OF DIABETIC NEPHROPATHY (DN)-2005Nefropati Diabetik St. 2 (Serum Kreatinin 1.5 2.5 mg/dl : Rendah Protein dan Batasi KTT)
Nefropati Diabetik St. 3 & 4 (Serum Kreatinin > 2.5 mg/dl : Rendah Protein dan Pantang KTT)
(Tjokroprawiro 2004, Yogiantoro et al 2004) KTT : Kacang, Tahu, Tempe
24
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
25/40
ASK-SDNC
STAGES OF CHRONIC KIDNEY DISEASE : CKD(National Kidney Foundation-Levey et al 2003; Position Statement ADA 2012)
STAGE DESCRIPTIONGFR (MDRD)
(mL/min/1.73 m2)
1 KIDNEY DAMAGE*)
withNORMAL or GFR >90
2KIDNEY DAMAGE*)with
MILDLY GFR60-89
5 KIDNEY FAILURE
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
26/40
ASK-SDNC
THE FORMULA OF COCKROFTGAULT : eGFR (estimated GFR)SC = SERUM CREATININE eGFR CREATININE CLEARANCES
eGFR ( )
(mL/min.)
o=
(140-AGE) X BODY WEIGHT(Kg)
PLASMA CREATININE(mg/dl) x 72
=(140-AGE) X BODY WEIGHT(Kg)
PLASMA CREATININE(mg/dl) x 72
eGFR ( )(mL/min.)
+o x 0.85
Other FORMULA : MDRD(Modification of Diet in Renal Disease)
(Summarized : Tjokroprawiro 2010-2012)
26
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
27/40
ASK-SDNC
THE MDRD FORMULA (MODIFICATION OF DIET IN RENAL DISEASE)
SC = SERUM CREATININE eGFR CREATININE CLEARANCES
186 x (SC)1.154x (AGE)0.203 x (0.742) x (1.212 IF BLACK/ASIA)
eGFR (MDRD) for FEMALE
186 x (SC)1.154x (AGE)0.203x (1.212 IF BLACK/ASIA)
eGFR (MDRD) for MALE
27
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
28/40
ASK-SDNC
DEFINITION OF ABNORMALITIES IN ALBUMIN EXCRETION
(ADA 2006, Provided : Tjokroprawiro 2006 2012)
NORMAL < 30 < 20 < 30
MACRO ALBUMINURIA
CLINICAL ALBUMINURIA>300 >200 >300
ANY TWO OF THREE SPECIMENS COLLECTED WITHIN A 3-6 MONTH PERIOD
30 - 29930 - 299 20 - 199MICRO ALBUMINURIA
Eight Causesof
Elevated AER
1 Excercise within 24 h, 2 Marked Hyperglycemia, 3 Marked Hypertension,4 Infection, 5 Fever, 6 CHF
28
24-h COLLECTIONTIMED COLLECTION
(mg/24 h) (g/min)CATEGORY Spot Collection : ACRg/mg Creatinine
Easiest to Carry Out
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
29/40
ASK-SDNC
3 LATIHAN FISIK: * PRIMER(1.02 jam sesudah makan)* SEKUNDER(Pagi dan Sore sebelum mandi)
*) SUDAH DIKERJAKAN OLEH PUSAT DIABETES DAN NUTRISI
RSUD DR. SOETOMO FK UNAIR PADA TH 1989 DAN 1991
PENTALOGI-TERAPI DIABETES MELLITUS(Askandar Tjokroprawiro 1983-2012)
1 PENYULUHAN(tentang DIABETES MELLITUS)
2 POLA MAKAN= PM(DIET ATAU TERAPI NUTRISI MEDIS = TNM)
5 CANGKOK PANKREASPusat Diabetes dan
Nutrisi(1989, 1991)
Sel Beta : pada Tikus*)
Total : pada Anjing*)
OBAT HIPOGLIKEMIK ORAL (OHO) OHO = OAD
INSULIN4
OBAT ANTI DIABETES (OAD)
29
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
30/40
ASK-SDNC
NUTRITION IN DIABETES MELLITUSClinical Experiences : Tjokroprawiro 1978-2012
DIABETIC DIETSMEDICAL NUTRITION THERAPY
(MNT) P.E.N. P-P.E.N.
PAR ENTERAL NUTRITION ( "SONDE" )
E1, E2, E3, E4, E5, E6
:08.00
:14.00:20.00
INSULIN
E1
E3E5
:11.00
:17.00:23.00
NO INSULIN
E2
E4E6
ORAL NUTRITIONSince 1978 ENTERAL NUTRITIONSince 1995
PAR ENTERAL NUTRITION = P.E.N.
Since 1993
PERIPHERAL PPAR PENTERAL ENUTRITION N
Ten Principlesof
P-P.E.N. in DM
30
21Types of Diabetic Diets
at Dr. Soetomo Hospital
From the B-Diet 1978
to
The B1-L 2004
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
31/40
ASK-SDNC
THE 6-E (E-1 UP TO E-6) REGIMEN OF ENTERAL NUTRITION FOR DIABETICS
("TUBE FEEDING" "SONDE")(Clinical Experiences : Tjokroprawiro 1995-2012)
Hospital Formula : E1,E3,E5 Pharm. Formula : E2, E4, E6: Sites of MUFA
ENTERAL- 1
(E-1)08.00 am
ENTERAL- 4
(E-4)05.00 pm
ENTERAL- 5
(E-5)08.00 pm
ENTERAL- 3
(E-3)02.00 pm
ENTERAL- 2
(E-2)11.00 am
ENTERAL- 6
(E-6)11.00 pm
1 6 Times/day 2 Started at 08.00 am 3 3-Hour Interval
TIMING OF INSULIN INJECTION : 30 MIN. BEFORE OR PRECISELY on E1 ,E3 ,E5
EXAMPLE : DIANERAL(D) OR HOSPITAL FORMULA
1
DIANERAL
INSULIN
6
MUFA or D
2
MUFA or D
4
MUFA or D
3
DIANERAL
INSULIN
5
DIANERAL
INSULIN
31
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
32/40
ASK-SDNC
The Diet-B 1978 (Revised TNM-2002) : The Mother - Diet
Prospective Study (1978) and Clinical Experiences (1978-2011)(Tjokroprawiro 1978-2012; TNM = Terapi Nutrisi Medik)
*) Diet-B : 68% CHO 12% Protein 20% FATs Prospective-Cross Over Design (1978)
SAFA 5% PUFA 5% PS = 1.0 MUFA 10% Chol.
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
33/40
ASK-SDNC
(Tjokroprawiro, Hari Witarti, Indrawati, Frieda et al, 1999-2007)
SPECIFICATIONS : 3 of 21 DIABETIC DIETS (TNMs) at Dr. SOETOMO HOSPITAL
DIET-G = Diet-H and DIET-KV
Diet-B1 plus 5 Specifications
Diet-G = Diet-H : Gangrene or HeparDiet-B plus 5 Specifications
Diet-KV : Stroke, CAD, POAD
These are able to lowerHomocysteine Level
(Chol. < 300 mg/day)
1 Arginin Content 2 Fiber 25-35 g/day
3 Folate
4 Vit B6
5 Vit B12
Diet-B (% Cal) : 68% Cbh, 20% F, 12% P
These are able to lowerHomocysteine Level
(Chol. < 300 mg/day)
1 Arginin Content 2 Fiber 25-35 g/day
3 Folate
4 Vit B6
5 Vit B12
Diet-B1 (% Cal): 60% CHO, 20% F, 20% P
ARGININ : Atheroprotective via Nitric Oxide (NO)
HOMOCYSTEINE : Oxidative Stress , ADMA
Asymmetric Di Methyl Arginine
(ADMA)
33
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
34/40
ASK-SDNC
DIET-B (1978)* : The Mother Diet
Kbh 68% kal, L 20% kal, Protein 12% kal, Kolesterol < 300 mg/hari,
SAFA 5%, PUFA 5%, MUFA 10%, Rasio PS + 1.0, Serat 25-35 g/hari
INDIKASI :
1 DIABETISI YANG TIDAK TAHAN LAPAR
3 DM LEBIH DARI 10 TAHUN
2 DISLIPIDEMIA(Salah satu atau lebih : TG , HDL , Kol. Tot. , LDL )
* Hasil Disertasi S3 (Askandar Tjokroprawiro 1978)
34
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
35/40
ASK-SDNC
(CHO plus MUFA**)
***)
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
36/40
ASK-SDNC
PEDOMAN DIET-B2, DIET-B3, dan DIET-BeKonsensus : Diabetologi, Nefrologi, Gizi
RSUD Dr. Soetomo - FK Unair Surabaya(Surabaya : 6 April 2002)
FASE PRA-HEMODIALISA : Diet-B2, B3)
1 PRA-HD UMUM Diet-B2Kandungan Protein : 0.6 g/kgBB/hari
2 PRA-HD KHUSUS Diet-B3
Proteinuria > 3 g/hari, atau
Kandungan Protein : 0.8 g/kgBB/hariAlbuminuria Berat (Positif 4 )
(FASE PRA-HD)
DIABETISI FASE HD : Diet-BeKandungan Protein : 1.0-1.2 g/kgBB/hari
Intensivitas MenghambatProgresivitas Gagal Ginjal
Vitamin C Maks. 100 mg,Pantang NSAID, dll
FASE HEMODIALISA : Diet-Be
(FASE HD)
36
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
37/40
ASK-SDNC
PERBANDINGAN GOLONGAN OHO(KONSENSUS PERKENI 2011)
37
Cara kerja utama Efek sampingutama
ReduksiA1C
Keuntungan Kerugian
Sulfonilurea Meningkatkan sekresiinsulin
BB naik,hipoglikemia
1,0-2,0% Sangat efektif Meningkatkan berat badan,hipoglikemia (glibenklamid dan
klorpropamid)
Glinid Meningkatkan sekresi
insulin
BB naik,
hipoglikemia
0,5-1,5% Sangat efektif Meningkatkan berat badan, pemberian
3x/hari, harganya mahal dan
Hipoglikemia
Metformin Menekan produksi
glukosa hati &menambah sensitifitas
terhadap insulin
Dispepsia, diare,
asidosis laktat
1,0-2,0% Tidak ada kaitan
dengan berat badan
Efek samping gastrointestinal,
kontraindikasi pada insufisiensi renal
Penghambat
glukosidasealfa
Menghambat absorpsi
glukosa
Flatulens, tinja
lembek
0.,5-0,8% Tidak ada kaitan
dengan berat badan
Sering menimbulkan efek
gastrointestinal, 3x/hari dan mahal
Tiazolidindion Menambah sensitifitasterhadap insulin
Edema 0,5-1,4% Memperbaiki profilLipid (pioglitazon), berpotensi
menurunkan infark miokard
(pioglitazon)
Retensi cairan, CHF, fraktur,berpotensi menimbulkan infark
miokard, dan mahal
DPP-4 inhibitor Meningkatkan sekresi
insulin, menghambat
sekresi glukagon
Sebah, muntah 0,5-0,8% Tidak ada kaitan dengan berat
badan
Penggunaan jangka panjang tidak
disarankan, mahal
Inkretin
analog/mimetik
Meningkatkan sekresi
insulin, menghambat
sekresi glukagon
Sebah, muntah 0,5-1,0% Penurunan berat badan Injeksi 2x/hari, penggunaan jangka
panjang tidak disarankan, dan mahal
Insulin Menekan produksi
glukosa hati, stimulasipemanfaatan glukosa
Hipoglikemi, BB
naik
1,5-3,5% Dosis tidak terbatas,
memperbaiki profil lipid dasangat efektif
Injeksi 1-4 kali/hari, harus dimonitor,
meningkatkan berat badan,hipoglikemia dan analognya mahal
Keterangan :
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
38/40
ASK-SDNC
OBAT HIPOGLIKEMIK ORAL : KONSENSUS PERKENI 2011 * Produk orisinal***** Kadar plasma efektif terpelihara selama 24 jam
Belum beredar di Indonesia38
Golongan Generik Nama Dagang Mg/tab Dosis harian Lama kerja(jam)
Frek/hari Waktu
Glibenclamid Daonil* 2,5-5 2,5-15 12-24 1-2
GlipizidMinidiab 5-10 5-20 10-16 1-2
Glucotrol-XL 5-10 5-20 12-16** 1
Gliklazid Diamicron 80 80-320 10-20 1-2Diamicron-MR 30-60 30-120 24 1Sebelum
Glikuidon Glurenom 30 30-120 6-8 2-3
makan
Glimepirid
Amaryl* 1-2-3-4 0,5-6 24 1
Gluvas 1-2-3-4 1-6 24 1Amadiab 1-2-3-4 1-6 24 1
Metrix 1-2-3-4 1-6 24 1
GlinidRepaglinid Dexanorm 1 1,5-6 - 3
Nateglinid Starlix 120 360 - 3
Tiazolidindion Tidak bergantungPioglitazon
Actos* 15-30 15-45 24 1
jadwal makanDeculin 15-30 15-45 24 1
PenghambatAcarbose
Glucobay 50-100 100-300 3 Bersama suapan
Glukosidase pertamaEclid 50-100 100-300 3
Glumin 500 500-3000 6-8 2-3
BiguanidMetformin
Glucophage 500-850 250-3000 6-8 1-3
Bersama/sesudah
makanMetformin XRGlucophage-XR* 500-750
Glumin-XR 500 500-2000 24 1
Obat Kombinasi
Tetap
Metformin +Glucovance
250/1,25 Total Glibenclamid
maksimal 20 mg/hr
12-24 1-2
Bersama/sesudah
Glibenklamid 500/2,5
makan
500/5Glimepirid + Amaryl-Met
FDC
1/250 2/500 - 2Metformin 2/500 4/1000
Pionix 15-30 15-45 18-24 1
Penghambat DPP-IV Sitagliptin Januvia 25, 50, 100 25-100 24 1
Saxagliptin Onglyza 120 5 24 1
Tidak bergantung
jadwal makan
Vildagliptin Galvus 50 50-100 12-24 1-2
MetforminPionix M
Total Pioglitazone
maksimal 45 mg/hr18-24 1
Pioglitazone + 15/50030/850
MetforminJanumet 1
Sitagliptin +50/100050/500 Total Sitagliptin
maksimal 100mg/hr
Metformin
Galvusmet
2
Vildagliptin +
50/850
50/500 Total Vildagliptin
maksimal 100mg/hr 12-2450/1000
39
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
39/40
ASK-SDNCASK-
MEKANISME KERJA, EFEK SAMPING UTAMA, DAN A1C(KONSENSUS PERKENI 2011, Provided : Tjokroprawiro 2011-2012)
CARA KERJA UTAMA EFEK SAMPING UTAMA PENURUNAN A1C
Insulin Menekan produksi glukosa hati, Hipoglikemia, 1`.5 3.5 %stimulasi pemanfaatan glukosa BB naik
Sulfonilurea Meningkatkan sekresi insulin BB naik, 1.0 2.0 %hipoglikemia
Metformin Menekan produksi glukosa hatiMenambah sensitivitas insulin
Diare, dispepsia, 1.0 2.0 %asidosis laktat
Penghambat Menghambat absorpsi glukosa Flatulens, 0.5 0.8 %
Glukosidase Alfa tinja lembek
Tiazolidindion Menambah sensitivitas terhadap Edema 0.5 1.4 %
(Glitazon) insulin
Glinid Meningkatkan sekresi insulin 0,5-1,5%BB naik,
hipoglikemia
OAD
INSULIN
"Non" 1.13 % (6 minggu)INLACIN Novel Insulin Sensitizer (2011)
39
40
-
5/20/2018 01. Diabetes Mellitus Part 1 - Prof.askandar
40/40
RSUD Dr. SOETOMO
PUSAT DIABETES & NUTRISI SURABAYA (PDNS) :1986-2012 40
PDNS Lt-7
(1200 m2)
RSUD Dr. SOETOMO, 1938 2012 : Bed Capacity 1550
PDNS C St f 8 E t M b 52