chapt17 endocrine

Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.Chapter 17Lecture PowerPointTo run the animations you must be in Slideshow View. Use the buttons on the animation to play, pause, and turn audio/text on or off. Please Note: Once you have used any of the animation functions (such as Play or Pause), you must first click in the white background before you can advance to the next slide.

17-*Endocrine SystemOverview

Hypothalamus and Pituitary Gland

Other Endocrine Glands

Hormones and Their Actions

Stress and Adaptation

Eicosanoids and Paracrine Signaling

Endocrine Disorders

17-*Overview of Cell Communicationsinternal communication is necessary for coordination of cell activities

four mechanisms of communication between cellsgap junctionspores in cell membrane allow signaling from cell to cellneurotransmittersreleased from neuronsparacrine (local) hormonessecreted into tissue fluids to affect nearby cellshormones chemical messengers that travel in the bloodstream

17-*endocrine system - glands, tissues, and cells that secrete hormones

endocrinology the study of this system and the diagnosis and treatment of its disorders

endocrine glands organs that produce hormones

hormones - chemical messengers transported by the bloodstream that stimulate responses in another tissue or organ, often far awayEndocrine System Components

17-*Endocrine Organs

17-*Comparison of Endocrine and Exocrine Glandsexocrine glandsducts carry secretion to an epithelial surface or the mucosa of the digestive tract external secretionsextracellular effects (food digestion)

endocrine glandsno ducts contain dense capillary networks to allow easy uptake of hormones into bloodstreaminternal secretionsintracellular effects such as altering target cell metabolism

17-*Comparison of Nervous and Endocrine Systems (Differences)both serve for internal communicationnervous - both electrical and chemicalendocrine - only chemical

speed and persistence of responsenervous - reacts quickly (1 - 10 msec), stops quicklyendocrine - reacts slowly (hormone release in seconds or days), effect may continue for weeks

adaptation to long-term stimulinervous - response declines (adapts quickly)endocrine - response persists (adapts slowly)

area of effectnervous - targeted and specific (one organ)endocrine - general, widespread effects (many organs)

17-*Communication by the Nervousand Endocrine SystemsFigure 17.2 a-bNeuronNerve impulseNeurotransmitterTarget cellsTarget cells(b) Endocrine system(a) Nervous systemEndocrinecellsHormone inbloodstreamCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

17-*Nervous and Endocrine Systems (Similarities)several chemicals function as both hormones and neurotransmitters

some hormones secreted by neuroendocrine cells (neurons) that release their secretion into the bloodstream

both systems can have overlapping effects on same target norepinephrine and glucagon cause glycogen hydrolysis in liver

systems regulate each otherneurons trigger hormone secretionhormones stimulate or inhibit neurons

17-*Anatomy of Hypothalamusshaped like a flattened funnel

forms floor and walls of third ventricle of the brain

regulates primitive functions of the body from water balance and thermoregulation to sex drive and childbirth

many of its functions carried out by pituitary gland

17-*Pituitary Gland (Hypophysis)suspended from hypothalamus by a stalk infundibulum

size and shape of kidney bean

composed of two structures with independent origins and separate functionsadenohypophysis (anterior pituitary)neurohypophysis (posterior pituitary)

17-*Embryonic Development(a) 4 weeks(b) 8 weeks(c) 16 weeksFuture hypothalamusTelencephalon of brainNeurohypophyseal budHypophyseal pouchPharynxTongueMouthHypothalamusOptic chiasmPosterior lobeAnterior lobeSphenoid bonePharynxPituitary stalkHypothalamusPharynxHypophyseal pouchFuture thyroidglandNeurohypophysealbudCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

17-*Anterior and Posterior PituitaryAnterior pituitary (AP) is anterior 3/4 of pituitarylinked to hypothalamus by hypophyseal portal system primary capillaries in hypothalamus connected to a second set in APhypothalamic hormones regulate AP cells

Posterior pituitary (PP) is posterior 1/4 of pituitarynerve tissue, not a true glandnerve cell bodies in hypothalamus pass down the stalk as hypothalamo-hypophyseal tract and end in posterior lobehypothalamic neurons secrete hormones that are stored in PP until released into blood

hypothalamic hormones travel in hypophyseal portal system from hypothalamus to anterior pituitary

hormones secreted by anterior pituitary17-*Follicle-stimulating hormoneLuteinizing hormoneThyroid-stimulating hormone (thyrotropin)Adrenocorticotropic hormoneProlactinGrowth hormoneHypophyseal Portal System

17-*Hypothalamic Hormoneseight hormones produced in hypothalamussix regulate the anterior pituitarytwo are released into capillaries in the posterior pituitary (oxytocin and antidiuretic hormone)

six releasing and inhibiting hormones stimulate or inhibit the anterior pituitaryTRH, CRH, GnRH, and GHRH are releasing hormonesPIH inhibits secretion of prolactin, and somatostatin inhibits secretion growth hormone & thyroid stimulating hormone by the anterior pituitary

see Table 17.3 for abbreviations

17-*Hypothalamic Hormones

two other hypothalamic hormones are oxytocin (OT) and antidiuretic hormone (ADH)

both stored and released by posterior pituitary

posterior pituitary does not synthesize them

17-*Histology of Pituitary GlandFigure 17.5 (1)Figure 17.5a (2)Figure 17.5b (3)ChromophobeBasophilAcidophil(b) Posterior pituitaryUnmyelinatednerve fibersGlial cells(pituicytes)(a) Anterior pituitarya: Dr. John D. Cunningham/Visuals Unlimited; b: Science VU/Visuals UnlimitedCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

17-*anterior lobe of the pituitary synthesizes and secretes six principal hormones

two gonadotropin hormones that target gonads1) FSH (follicle stimulating hormone) stimulates secretion of ovarian sex hormones, development of ovarian follicles, and sperm production 2) LH (luteinizing hormone)stimulates ovulation, stimulates corpus luteum to secrete progesterone, stimulates testes to secrete testosteroneAnterior Pituitary Hormones

17-*3) TSH (thyroid stimulating hormone) stimulates secretion of thyroid hormone

4) ACTH (adrenocorticotropic hormone)stimulates adrenal cortex to secrete glucocorticoids

5) PRL (prolactin)after birth stimulates mammary glands to synthesize milk, enhances secretion of testosterone by testes

6) GH (growth hormone)stimulates mitosis and cellular differentiationAnterior Pituitary Hormones

17-*Hypothalamo-Pituitary-Target Organ RelationshipsFigure 17.6GHACTHTSHLiverTRHGnRHCRHHypothalamusAdrenal cortexOvaryTestisThyroidIGFGHRHPRLMammaryglandFat,muscle,boneLHFSHprinciple hormones and target organsCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.Figure 17.6

17-*produced in hypothalamustransported to posterior lobereleases hormones when hypothalamic neurons are stimulated

ADH (antidiuretic hormone)increases water retention, thus prevents dehydration

OT (oxytocin)released during sexual arousal and orgasmpromotes feelings of sexual satisfaction and emotional bonding between partnersstimulates labor contractions during childbirthstimulates flow of milk during lactationpromotes emotional bonding between mother and infantPosterior Pituitary Hormones

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17-*

Control of Pituitary Secretion

rates of secretion are not constantregulated by hypothalamus, other brain centers, and feedback from target organs

Hypothalamic and Cerebral Controlanterior lobe control - releasing hormones and inhibiting hormones from hypothalamusin cold weather, pituitary stimulated by hypothalamus to release TSH, leads to generation of body heat

posterior lobe control - neuroendocrine reflexes neuroendocrine reflex - hormone release in response to nervous system signalssuckling infant stimulates nerve endings hypothalamus posterior lobe oxytocin milk ejection

17-*Control of Pituitary: Feedback from Target Organsnegative feedback -increased target organ hormone levels inhibits release of hormones positive feedback - stretching of uterus increases OT release, causes contractions, causing more stretching of uterus, etc. until deliveryTRHTSHTarget organsThyroid hormoneStimulatory effectInhibitory effect234156++++Negative feedbackinhibition--Figure 17.7Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

17-*Growth HormoneGH has widespread effects on the body tissuesespecially cartilage, bone, muscle, and fat

induces liver to produce growth stimulantsinsulin-like growth factors (IGF-I or IGF-II)stimulate target cells in diverse tissuesprotein synthesis increases lipid metabolism increases provides energy for growing tissuescarbohydrate metabolism makes glucose available for glycogen synthesis and storageelectrolyte balance

17-*Growth Hormone

bone growth, thickening, and remodeling influenced, especially during childhood and adolescencesecretion high during first two hours of sleepcan peak in response to vigorous exerciseGH levels decline gradually with agelack of protein synthesis contributes to aging of tissues and wrinkling of the skin

17-*Pineal Glandpineal gland - attached to roof of third ventricle beneath the posterior end of corpus callosum

after age 7, it undergoes involution (shrinkage)

may synchronize physiological function with 24-hour circadian rhythms of daylight and darknesssynthesizes melatonin from serotonin during the night

may regulate timing of puberty in humans

seasonal affective disorder (SAD) occurs in winter or northern climates depression, sleepiness, irritability and carbohydrate craving

17-*Thymusplays a role in three systems: endocrine, lymphatic, and immune

bilobed gland in the mediastinum superior to the heart

important in immune defense

secretes hormones that affect immune activityThyroidThymusHeartTracheaDiaphragmLiver(a) Newborn(b) AdultCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.Figure 17.8 a-b

17-*Thyroid Gland Anatomy

Butterfly-shaped

secretes thyroxine (T4: 4 iodine atoms) and triiodothyronine (T3)increases metabolic rate, O2 consumption, heat production (calorigenic effect), appetite, growth hormone secretion, alertness and quicker reflexes

parafollicular (C or clear) cells secrete calcitonin with rising blood calcium stimulates osteoblast activity and bone formationFigure 17.9aInferior thyroid veinIsthmus(a)ThyroidcartilageThyroidglandTracheaSuperior thyroidartery and veinCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

17-*Parathyroid Glandsusually four glands partially embedded in posterior surface of thyroid gland

secrete parathyroid hormone (PTH)increases blood Ca2+ levelspromotes synthesis of calcitriolincreases absorption of Ca2+ decreases urinary excretionincreases bone resorption

Figure 17.10aThyroid glandEsophagusTrachea(a)Pharynx(posterior view)ParathyroidglandsCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display. John Cunningham/Visuals Unlimited

Adrenal glandKidneyAdrenal cortexAdrenal medulla(a)(b)Connectivetissue capsuleAdrenal cortexAdrenal medullaZonaglomerulosaZonafasciculataZonareticularisSuprarenal veinAdrenal Glandsmall gland that sits on top of each kidneyadrenal cortex and medulla formed by merger of two fetal glands with different origins and functions17-*Figure 17.11Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

17-*Adrenal Medullaadrenal medulla inner core, 10% to 20% of gland

has dual nature: endocrine gland and sympathetic ganglion of sympathetic nervous systemwhen stimulated, releases catecholamines (epinephrine and norepinephrine) and a trace of dopamine directly into the bloodstream

effect is longer lasting than neurotransmittersincreases alertness and prepares body for physical activity mobilize high energy fuels, lactate, fatty acids, and glucoseincreases blood pressure, heart rate, blood flow to muscles, pulmonary air flow and metabolic ratedecreases digestion and urine production

17-*Adrenal Cortexsurrounds adrenal medulla and produces more than 25 steroid hormones called corticosteroids or corticoids

secretes 3 classes of steroid hormonesmineralocorticoidsglucocorticoidssex steroids

17-*Categories of Corticosteroidsmineralocorticoidsregulate electrolyte balancealdosterone stimulates Na+ retention and K+ excretion, water is retained with sodium by osmosis, so blood volume and blood pressure are maintained

glucocorticoidsregulate metabolism of glucose and other fuelsespecially cortisol, stimulates release of fuels into bloodhelps body adapt to stress and repair tissuesanti-inflammatory effect can become immune suppression in long-term use

sex steroidsandrogens sets libido; large role in prenatal male developmentestradiol small quantity, but important after menopause for sustaining adult bone mass

Bile ductDuodenumTail of pancreasHead ofpancreas(a)(b) Pancreatic isletPancreaticductsBeta cellDelta cellAlpha cell(c)Pancreatic isletExocrine acinusc: Ed Reschke17-*Pancreasexocrine digestive gland and endocrine cell clusters (pancreatic islets) found inferior and posterior to stomach.Figure 17.12 a-cCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

17-*Pancreatic Hormones1-2 million pancreatic islets (Islets of Langerhans) produce hormonesother 98% of pancreas cells produce digestive enzymes insulin secreted by B or beta () cellssecreted during and after meal when glucose and amino acid blood levels are risingstimulates cells to absorb these nutrients and store or metabolize them lowering blood glucose levelspromotes synthesis of glycogen, fat, and proteinsuppresses use of already-stored fuelsinsufficiency or inaction is cause of diabetes mellitus

17-*Pancreatic Hormonesglucagon secreted by A or alpha () cellsreleased between meals when blood glucose concentration is fallingin liver, stimulates release of glucose into the circulation raising blood glucose levelin adipose tissue, stimulates fat catabolismglucagon also released to rising amino acid levels in blood, promotes amino acid absorption

17-*Pancreatic Hormones

somatostatin secreted by D or delta () cellspartially suppresses secretion of glucagon and insulin inhibits nutrient digestion and absorption which prolongs absorption of nutrients

pancreatic polypeptide secreted by PP cells (F cells)inhibits gallbladder contraction and secretion pancreatic digestive enzymes

gastrin secreted by G cellsstimulates stomach acid secretion, motility and emptying

17-*Hormones and the Pancreashyperglycemic hormones raise blood glucose concentrationglucagon, growth hormone, epinephrine, norepinephrine, cortisol, and corticosterone

hypoglycemic hormones lower blood glucoseinsulin

17-*The Gonadsovaries and testes are both endocrine and exocrineexocrine product whole cells - eggs and spermendocrine product - gonadal hormones mostly steroids

ovarian hormonesestradiol, progesterone, and inhibin

testicular hormonestestosterone, weaker androgens, estrogen and inhibin

17-*Histology of Gonadsfollicle - egg surrounded by granulosa cells and a capsule (theca)Granulosa cells(source ofestrogen)Egg nucleusEggOvary(a)Theca100 m Manfred Kage/Peter Arnold, Inc.Figure 17.13aCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.(b)Interstitial cells(source oftestosterone)Connective tissuewall of tubuleGerm cellsSeminiferoustubuleBlood vesselsTestisSustentacularcells50 mFigure 17.13b Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display. Ed Reschke

17-*Ovarysecrete estradiolafter ovulation, the remains of the follicle becomes the corpus luteumsecretes progesterone for 12 days following ovulationfollicle and corpus luteum secrete inhibin

functions of estradiol and progesteronedevelopment of female reproductive system and physique including adolescent bone growthregulate menstrual cycle, sustain pregnancyprepare mammary glands for lactation

inhibin suppresses FSH secretion from anterior pituitary

17-*Testesmicroscopic seminiferous tubules produce spermtubule walls contain sustentacular cellsinterstitial cells lie in clusters between tubules

testicular hormonestestosterone and other steroids from interstitial cells (cells of Leydig) nestled between the tubulesstimulates development of male reproductive system in fetus and adolescent, and sex drivesustains sperm production

inhibin from sustentacular (Sertoli) cellslimits FSH secretion in order to regulate sperm production

17-*Endocrine Functions of Other Organsskinkeratinocytes make cholecalciferol using UV from sun

liver involved in the production of at least five hormonesconverts cholecalciferol into calcidiolsecretes angiotensinogen (precursor for BP regulation)secretes 15% of erythropoietin (stimulates bone marrow) hepcidin promotes intestinal absorption of ironsource of IGF-I that controls action of growth hormone

kidneys plays role in production of three hormonesconverts calcidiol to calcitriol, the active form of vitamin D secrete renin that converts angiotensinogen to angiotensin Iproduce 85% of erythropoietin

17-*Endocrine Functions of Other Organs heart cardiac muscle secretes atrial and brain natriuretic peptides in response to an increase in blood pressurelowers blood pressure

stomach and small intestine: at least ten enteric hormonescoordinate digestive motility and glandular secretion

adipose tissue secretes leptin - slows appetite

osseous tissue osteocalcin secreted by osteoblastsincreases insulin sensitivity of body tissuesinhibits weight gain and onset of type II diabetes mellitus

placentasecretes estrogen, progesterone and othersregulate pregnancy, development of fetus

17-*Hormone Receptorshormones only stimulate cells that have receptors for them

receptors are protein or glycoprotein molecules: on plasma membrane, in cytoplasm, or in nucleus

receptors act like switches, turning on metabolic pathways when hormone binds to them

usually each target cell has a few thousand receptors for a given hormone

receptor-hormone interactions exhibit specificity and saturationspecific receptor for each hormonesaturated when all receptor molecules are occupied by hormone

17-*Hormone Mode of ActionFigure 17.20BloodTransportproteinFreehormonesBoundhormoneHydrophobichormoneTissue fluidReceptor innucleusSecond-messengeractivationReceptor inplasmamembraneTargetcellHydrophilichormoneCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.hydrophobic hormonespenetrate plasma membrane and enter nucleusact directly on the genesestrogen, progesterone, thyroid hormone act on nuclear receptorstake several hours to days to show effect due to lag for protein synthesis

hydrophilic hormones cannot penetrate target cellmust stimulate indirectly

Enzyme Amplificationhormones are extraordinarily potent chemicalsone hormone molecule can trigger the synthesis of many enzyme molecules very small stimulus can produce very large effect17-*Figure 17.24HormoneActivated enzymesMetabolic productGreat effectSmall stimulusReaction cascade (time)cAMP andprotein kinaseCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

17-*Modulation of Target Cell Sensitivitytarget cell sensitivity adjusted by changing the number of receptors

up-regulation means number of receptors is increasedsensitivity increased

down-regulation reduces number of receptorscell less sensitive to hormonehappens with long-term exposure to high hormone concentrationsFigure 17.25HormoneReceptorResponseLow receptor densityWeak responseIncreased receptor densityIncreased sensitivityStronger response(a ) Up-regulation(b ) Down-regulationHigh receptor densityStrong responseReduced receptor densityReduced sensitivityDiminished responseResponseCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.

17-*Hormone Interactionsmost cells sensitive to more than one hormone and exhibit interactive effects

synergistic effects multiple hormones act together for greater effectFSH and testosterone for sperm production

permissive effectsone hormone enhances the target organs response to a second later hormoneestrogen prepares uterus for action of progesterone

antagonistic effects one hormone opposes the action of anotherinsulin lowers blood glucose and glucagon raises it

17-*Hormone Clearancehormone signals must be turned off when they have served their purpose

most hormones are taken up and degraded by liver and kidneyexcreted in bile or urine

metabolic clearance rate (MCR)rate of hormone removal from the blood

17-*Paracrine Secretionsparacrines - chemical messengers that diffuse short distances and stimulate nearby cells

unlike neurotransmitters, not produced in neuronsunlike hormones, not transported in blood

a single chemical can act as a hormone, paracrine, or even neurotransmitter in different locations

17-*Paracrine Secretions

histamine from mast cells in connective tissue: causes relaxation of blood vessels

nitric oxide from endothelium of blood vessels, causes vasodilation

somatostatin from gamma cells, inhibits secretions of alpha and beta cells

catecholamines diffuse from adrenal medulla to cortex

17-*Endocrine Disordersvariations in hormone concentration and target cell sensitivity have noticeable effects on body

hyposecretion inadequate hormone releasetumor or lesion destroys gland or interferes with its ability to receive signals from another glandhead trauma affects pituitary glands ability to secrete ADHdiabetes insipidus - chronic polyuriaautoantibodies fail to distinguish gland from foreign matter

17-*Endocrine Disorders

hypersecretion excessive hormone releasetumors or autoimmune disorderpheochromocytoma tumor of adrenal medulla secretes excessive epinephrine and norepinephrinetoxic goiter (Graves disease) autoantibodies mimic effect of TSH on the thyroid causing thyroid hypersecretion

17-*Pituitary Disordershypersecretion of growth hormone (GH)acromegaly - thickening of bones and soft tissues in adultsespecially hands, feet and faceproblems in childhood or adolescencegigantism if hypersecretionpituitary dwarfism if hyposecretion rare since growth hormone is now made by genetically engineered bacteria

Figure 17.27 1-5Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.From Clinical Pathological Conference Acromegaly, Diabetes, Hypermetabolism, Protein Use and Heart Failure in American Journal of Medicine, 20:133, 1986. Copyright 1986 by Excerpta Media, Inc.Age 33Age 16Age 9Age 52

17-*Thyroid Gland Disorderscongenital hypothyroidism (decreased TH)hyposecretion present a birth (formerly cretinism)myxedema (decreased TH)adult hypothyroidismboth treated with oral thyroid hormone

goiter any pathological enlargement of the thyroid glandendemic goiterdietary iodine deficiency, no TH, no feedback, increased TSH stimulates hypertrophytoxic goiter (Graves disease)autoantibodies mimic the effect of TSH on the thyroid causing hypersecretionovergrown thyroid produces functional TH

17-*Endemic GoiterFigure 17.28Copyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display. CNR/Phototake

17-*Parathyroid Disordershypoparathyroidismsurgical excision during thyroid surgeryfatal tetany in 3 - 4 days due to rapid decline in blood calcium level

hyperparathyroidism - excess PTH secretionparathyroid tumor bones become soft, fragile, and deformedCa2+ and phosphate blood levels increasepromotes renal calculi formation

17-*Adrenal DisordersCushing syndrome - excess cortisol secretionhyperglycemia, hypertension, weakness, edemarapid muscle and bone loss due to protein catabolismabnormal fat depositionmoon face and buffalo hump

adrenogenital syndrome (AGS)adrenal androgen hypersecretion (accompanies Cushing)enlargement of external sexual organs in children and early onset of pubertynewborn girls exhibit masculinized genitaliamasculinizing effects on women increased body hair, deeper voice and beard growth

17-*Cushing SyndromeFigure 17.29bCopyright The McGraw-Hill Companies, Inc. Permission required for reproduction or display.(b)From: Atlas of Pediatric Physical Diagnosis, 3/e by Zitelli & Davis, fig 9-17 1997, with permission from Elsevier

17-*Diabetes Mellitusmost prevalent metabolic disease in worlddisruption of metabolism due to hyposecretion or inaction of insulinsymptoms:polyuria (excess urine output), polydipsia (intense thirst) and polyphagia (hunger)revealed by elevated blood glucose, glucose in urine and ketones in the urine

17-*Types of Diabetes MellitusType 1 5 to 10% of cases in USinsulin is always used to treat Type 1hereditary susceptibility if infected with certain virusesautoantibodies attack and destroy pancreatic beta cells

Type 2 90 to 95% of diabeticsproblem is insulin resistance risk factors are heredity, age (40+),obesity, and ethnicity Native American, Hispanic, and Asiantreated with weight loss program and exercise since:increased muscle mass improves regulation of glucoseadipose signals interfere with glucose uptakeoral medications improve insulin secretion or target cell sensitivity

17-*Pathology of Diabetespathogenesis: cells cannot absorb glucose, must rely on fat and proteins for energy needs - weight loss and weaknessfat catabolism increases free fatty acids and ketones in blood ketonuria promotes osmotic diuresis, loss of Na+ and K+, irregular heartbeat, and neurological issuesketoacidosis occurs as ketones decrease blood pHdeep, gasping breathing and diabetic coma are terminal result

17-*Pathology of Diabeteschronic pathology (chronic hyperglycemia)leads to neuropathy and cardiovascular damage from atherosclerosis and microvascular diseasearterial damage in retina and kidneys (common in type I), atherosclerosis leads to heart failure (common in type II)diabetic neuropathy nerve damage from impoverished blood flow can lead to erectile dysfunction, incontinence, poor wound healing, and loss of sensation from area

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chapt17 endocrine

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