2. interpretasi klinis hasil laboratorium pada pasien
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Interpretasi Klinis HasilLaboratorium pada Pasien
Diabetes Mellitus
Hermina Novida
Pusat Diabetes dan Nutrisi SurabayaDivisi Endokrin-‐Metabolik-‐DiabetesDepartemen Ilmu Penyakit Dalam
FK Unair-‐RSUD Dr. Soetomo Surabaya
Introduction
• Multiple laboratory tests are used to diagnose and manage patients with diabetes mellitus
• Diabetes mellitus is a group of metabolic disorders of carbohydrate metabolism in which glucose is underutilized and overproduced, causing hyperglycemia.
• Classification :-‐ Type 1 DM-‐ Type 2 DM-‐ Gestasional DM-‐ Other specific types
Diagnosis DM (Perkeni, 2015)
1. Pemeriksaan glukosa plasma puasa ≥ 126 mg/dL, puasa disiniadalah kondisi tidak ada asupan kalori minimal 8 jam.
2. Pemeriksaan glukosa plasma > 200 mg/dL 2 jam setelah tes toleransi glukosa oral (TTGO) dengan beban 75 gram glukosa.
3. Pemeriksaan glukosa plasma sewaktu > 200 mg/dL jikadidapatkan keluhan klasik.
4. Pemeriksaan HbA1c > 6,5% dengan menggunakan metodeHigh-‐Performance Liquid Chromatography (HPLC) yang terstandarisasi oleh National GlycohaemoglobinStandarization Program (NGSP).
Recommendation (NACB, 2011)
• RECOMMENDATION: WHEN GLUCOSE IS USED TO ESTABLISH THE DIAGNOSIS OF DIABETES, IT SHOULD BE MEASURED IN VENOUS PLASMA A (high).
• RECOMMENDATION: WHEN GLUCOSE IS USED FOR SCREENING OF HIGH-‐RISK INDIVIDUALS, IT SHOULD BE MEASURED IN VENOUS PLASMA B (moderate).
• RECOMMENDATION: PLASMA GLUCOSE SHOULD BE MEASURED IN AN ACCREDITED LABORATORY WHEN USED FOR DIAGNOSIS OF OR SCREENING FOR DIABETES Good Practice Point (GPP).
WHO criteria for interpreting 2-‐h OGTT
Diabetes Care, 2011
Interpretasi Tes Laboratorium untuk Diagnosis Diabetes dan Prediabetes
HbA1c (%)Glukosa
Darah Puasa(mg/dL)
Glukosa Plasma 2 jam setelah TTGO
(mg/dL)
Diabetes > 6,5 > 126 > 200
Prediabetes 5,7-‐6,4 100-‐125 140-‐199
Normal < 5,7 < 100 < 140
Perkeni, 2015
Kelompok Risiko Tinggi
• Kelompok dengan berat badan lebih (Indeks Massa Tubuh [IMT] ≥23 kg/m2) yang disertai dengan satu atau lebih faktor risiko sebagai berikut:
1. Aktivitas fisik yang kurang.2. First-‐degree relative DM 3. Kelompok ras/etnis tertentu.4. Riwayat dengan bayi BB >4 kg atau GDM.5. Hipertensi (≥140/90 mmHg)6. HDL <35 mg/dL dan atau trigliserida >250 mg/dL.7. Wanita dengan sindrom polikistik ovarium.8. Riwayat prediabetes.9. Obesitas berat, akantosis nigrikans.10. Riwayat penyakit kardiovaskular.
• Usia >45 tahun tanpa faktor risiko di atas.
Kelompok risiko tinggi dengan hasil pemeriksaan glukosa plasma normal sebaiknya diulang setiap 3 tahun (E), kecuali pada kelompok prediabetes pemeriksaan diulang tiap 1 tahun (E).
Kadar Glukosa Darah Sewaktu dan Puasa Sebagai PatokanPenyaring dan Diagnosis DM di Indonesia
Bukan DM
Belum Pasti DM
DM
Kadar glukosadarah sewaktu(mg/dL)
Plasma vena <100 100-199 ≥ 200
Darah kapiler <90 90-199 ≥ 200
Kadar glukosadarah puasa(mg/dL)
Plasma vena <100 100-125 ≥126
Darah kapiler <90 90-99 ≥100
Glucosemeter• Portable meters for the measurement of blood glucose
concentrations are used in three major settings:1) in acute-‐ and chronic-‐care facilities, including intensive care units (ICUs);2) in physicians’ offices; 3) by patients at home, work, and schoolà self-‐monitoring of blood glucose ( SMBG).
• SMBG is recommended for all insulin-‐treated patients. Intensive glycemic control can decrease microvascularcomplications in individuals with type 1 or type 2 diabetes.
• The role of SMBG in individuals with type 2 diabetes has generated considerable controversy.
Prosedur Pemantauan SMBG (Perkeni, 2015)
• Tergantung dari tujuan pemeriksaan tes dilakukan pada waktu (B):o Sebelum makano 2 jam sesudah makano Sebelum tidur malam• Pasien dengan kendali buruk/tidak stabil dilakukan tes setiap hari• Pasien dengan kendali baik/stabil sebaiknya tes tetap dilakukan secara
rutin. Pemantauan dapat lebih jarang (minggu sampai bulan) apabilapasien terkontrol baik secara konsisten
• Pemantauan glukosa darah pada pasien yang mendapat terapi insulin,ditujukan juga untuk penyesuaian dosis insulin dan memantautimbulnya hipoglikemia(E)
• Tes lebih sering dilakukan pada pasien yang melakukan aktivitastinggi, pada keadaan krisis, atau pada pasien yang sulit mencapaitarget terapi (selalu tinggi, atau sering mengalami hipoglikemia), jugapada saat perubahan dosis terapi
Glucosemeter
• Patients should be instructed in the correct use of glucose meters, including quality control.
• Important variables that may influence the results of bedside glucose monitoring include changes in hematocrit, altitude, environmental temperature or humidity, hypotension, hypoxia and high triglyceride concentrations, and various drugs.
• Most meters are inaccurate at very high or very low glucose concentrations.
Glucosemeter
• Manufacturers claim reportable concentration ranges as large as 33.3 mmol/L (600 mg/dL), e.g., 0–33.3 mmol/L (0–600 mg/dL).
• In 1987, ADA recommended a goal of total error (user plus analytical) of <10% at glucose concentrations of 1.7–22.2 mmol/L (30–400 mg/dL). In addition, the ADA proposed that values should differ by ≤15% from those obtained by a laboratory reference method.
• A revised performance goal, published in 1996 , was for a total analytical error of <5%.
Gestasional Diabetes Mellitus (GDM)
• GDM has been defined as any degree of glucose intolerance with onset or first recognition occurring during pregnancy.
• Risk assessment for GDM should be undertaken at the first prenatal visit.
• Women with clinical characteristics consistent with a high risk of GDM (marked obesity, personal history of GDM, glycosuria, or a strong family history of diabetes) should undergo glucose testing as soon as feasible.
• If they are found not to have GDM at that initial screening, they should be retested between 24 and 28 weeks of gestation.
Screening and Diagnosis GDM
ADA, 2015
Urinary Glucose
• RECOMMENDATION: SEMIQUANTITATIVE URINE GLUCOSE TESTING IS NOT RECOMMENDED FOR ROUTINE CARE OF PATIENTS WITH DIABETES MELLITUS.
• Urine glucose provides no information about blood glucose concentrations below the renal glucose threshold [10 mmol/L (180 mg/dL)].
• Urine glucose also cannot distinguish euglycemia and hypoglycemia.• The strips use the glucose oxidase reaction. They are subject to
numerous interferences, including numerous drugs and nonglucosesugars.
Keton Testing
• The ketone bodies acetoacetate (AcAc), acetone, and β-‐hydroxybutyricacid (βHBA) are catabolic products of free fatty acids.
• Measurements of ketones in urine and blood are widely used in the management of patients with diabetes as adjuncts for both diagnosis and ongoing monitoring of DKA.
• Reference intervals for βHBA differ among assay methods, but concentrations in healthy individuals who have fasted overnight are generally <0.5 mmol/L.
• Patients with well-‐documented DKA [serum CO2 <17 mmol/L, arterial pH <7.3, plasma glucose >14.9 mmol/L (250 mg/dL)] generally have βHBA concentrations >2 mmol/L.
Interpretation of Urinary Keton Testing
• The presence of positive urine ketone readings in a patient with known diabetes or not but who presents with typical symptoms of hyperglycemia suggests the possibility of impending or established DKA.
• Patients with alcoholic ketoacidosis will have positive urine ketone readings, but hyperglycemia is not usually present.
• Positive urine ketone readings are found in up to 30% of first morning urine samples from pregnant women (with or without diabetes), during starvation, and after hypoglycemia
HbA1c
• RECOMMENDATION: HbA1c SHOULD BE MEASURED ROUTINELY IN ALL PATIENTS WITH DIABETES MELLITUS TO DOCUMENT THEIR DEGREE OF GLYCEMIC CONTROL A (moderate).
• Principally on the basis of the DCCT results, the ADA has recommended that a primary goal of therapy be an HbA1c value <7% (53 mmol/mol).
• For selected individual patients, more-‐stringent targets could be suggested, such patients might include those with a short duration of diabetes, a long life expectancy, and no significant cardiovascular disease .
• Conversely, higher HbA1c goals should be chosen for patients with a history of severe hypoglycemia, a limited life expectancy, advanced microvascular or macrovascular complications, or extensive comorbid conditions.
HbA1c (Perkeni, 2015)
• HbA1c merupakan cara yang digunakan untuk menilai efek perubahanterapi 8-‐12 minggu sebelumnya.
• HbA1c diperiksa paling sedikit 2 kali dalam 1 tahun pada pasien yang mencapai sasaran terapi dan yang memiliki kendali glikemik stabil. (E), dan 4 kali dalam 1 tahun pada pasien dengan perubahan terapi atauyang tidak mencapai sasaran terapi (E).
• Untuk kondisi tertentu seperti anemia, hemoglobinopati, riwayattransfusi darah 2-‐3 bulan terakhir, kondisi-‐kondisi yang mempengaruhiumur eritrosit dan gangguan fungsi ginjal maka HbA1c tidak bisadipakai sebagai alat evaluasi
Glycated Albumin
• GA dapat digunakan untuk menilai indeks kontrol glikemik yang tidak dipengaruhi oleh gangguan metabolisme hemoglobin dan masa hidup eritrosit seperti HbA1c.
• Proses metabolik albumin terjadi lebih cepat daripada hemoglobin dengan perkiraan 15 – 20 hari sehingga GA merupakan indeks kontrol glikemik jangka pendek.
• Beberapa gangguan seperti sindrom nefrotik, pengobatan steroid, severe obesitasdan gangguan fungsi tiroid dapat mempengaruhi albumin yang berpotensi mempengaruhi nilai pengukuran GA.
• Nilai konversi HbA1c terhadap glycated albumin sebagai berikut:HbA1c = 0,245 x GA + 1,73
• Nilai Rujukan : 11-‐16%
Pemeriksaan Laboratorium Lainnya
• Profil lipid pada keadaan puasa: kolesterol total, High Density Lipoprotein (HDL), Low Density Lipoprotein (LDL), dan trigliserida.
• Tes fungsi hati• Tes fungsi ginjal: Kreatinin serum dan estimasi-‐GFR• Tes urin rutin• Albumin urin kuantitatif• Rasio albumin-‐kreatinin sewaktu.
Summary Diagnostic Criteria of DM
Am. Fam. Physician, 2010
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