I- INTRODUCTION :
Word “Diabetes “means : “pass through” referring to the strong polyuria that characterizes the disease ; sweet because the urine taste sweet (* diabetes insipidus)
Diabetes mellitus is a major public health problem worldwide since recent epidemiological estimates identified near 366 million diabetic across the globe in the & rsquo; year 2011 and forecasts for 2030 revolve around 552 million according to the & rsquo; IDF (International Diabetes Federation).
Prevalence of diabetes in Algeria: 8,5 at 9,5 % (up & rsquo; to 12%) ,1 unrecognized diabetes 1 known diabetes.
II- DEFINITION :
Diabetes is "a group of metabolic diseases characterized by chronic hyperglycemia, resulting & rsquo; a production shortfall of & rsquo; insulin (insulinocarence relative or absolute) or & rsquo; an abnormality of & rsquo; insulin action (insulinorésistance) in target tissues (foie, muscles, fat tissue) or usually d & rsquo; an entanglement of two mechanisms.
This chronic hyperglycemia is ultimately associated with specific organ complications particularly affecting the eyes, kidneys, nerves ,or nonspecific affecting the heart and blood vessels. ».
III- DIAGNOSTIC CIRCUMSTANCES :
1- functional signs :
- Syndrome polyuro-polydipsique : he is > 3L/24h, with nocturia, (glucose > 1,80 gr / l).
- Polyphagie : it is less frequent, observed especially early in the disease.
- emaciation : Contrast with polyphagia, linked to insulin deficiency.
- Asthenia : d & rsquo; variable intensity, it is physical, psychological and sexual.
2- Lucky find :
C & rsquo; is & rsquo; T2DM the prerogative.
- At & rsquo; & rsquo opportunity; laboratory tests : under DS screening, pregnancy, or d & rsquo; a diabetogenic treatment, preoperative…
3- At & rsquo; & rsquo opportunity; complication :
aquamarine (acidocétose )or chronic (diabetic retinopathy or nephropathy ;IDM,AVC, infection ),especially kind 02.
IV- DIAGNOSTIC CRITERIA :
The latest review by the & rsquo; WHO 1998, after the publication of & rsquo; ADA (American Diabetes Association) in 1997, consider for the diagnosis of diabetes ( threshold & rsquo; emergence of retinopathy) three situations :
1- Symptoms of diabetes ( polyurie, polydipsie, emaciation) and glucose (on venous plasma) >2g /I (11,1 m mol/l) n & rsquo; any time of day.
2- Blood glucose young > l,26g/l(7mmol/l) at 02 occasions,( on venous plasma also).
3- Blood sugar 2 hours after glucose 75g (test & rsquo; hyperglycemia caused oral "OGTT") > 2g/l (ll,lmmol / L.
D & rsquo; other hand, Diagnostic criteria for moderate abnormalities in glucose tolerance and have, increased cardiovascular risk ,and a risk of & rsquo; progression to diabetes mellitus :
1- l & rsquo; search in glucose :
Glucose young< 1,26g/l
Blood Sugar 2 hours after OGTT =(1,40 – 2) g/l
2- moderate hyperglycemia in young :
Glucose young : 1,10 – 1,26 g / l Glucose 2 hours after OGTT :<1,40 g / l The normal subject :
Glucose young <1,10g/l
Blood Sugar 2 hours after OGTT<1,40 g/l
- AMONG PREGNANT WOMEN : the definition of gestational diabetes is different :
– FPG for all the pregnant women in the first quarter (or s & rsquo; there are gestational DT FR):
- pledge >0.92g/l, c & rsquo; is gestational DT
- pledge<0.92 g/l, make an OGTT between 24-28SA in women who have risk factors (to see further).
– Gestational diabetes is defined when & rsquo; one threshold value is exceeded :
GAJ : 0,92 g/l, glucose lh : l,8g/l, Glucose 2 hours : 1,53 g/l.
- L & rsquo; HEMOGLOBIN GLYCATED (HBAlc) : as a diagnostic criterion??:
L & rsquo; HbAlc is diabetes mellitus monitoring means ; it is used as a criterion diagnosis of diabetes mellitus in some countries (United States ; Canada ) using a standardized assay HPLC method (haut performance liquid chromatography ; HbAlc between 5.7 %-6.5% carbohydrate intolerance ;>6.5% = diabetes) which is the reference method ; something that is not in Algeria , where assay methods vary from & rsquo; one laboratory to another ;it n & rsquo; is possible to retain this setting as a diagnostic criterion for diabetes mellitus.
V- CLASSIFIED ETIOLOGICAL DIABETES :
Diabetes is defined by the pathophysiological entities indicating the need
vital or non-insulin-treatment (distinguishes Diabetes Type 1 other types).
A- diabetes Type 1 :
B- Diabetes Type 2 :
(Spectre variable, d & rsquo; a resistance & rsquo; action of & rsquo; predominant insulin with insulin secretory deficit relative, a predominant insulin secretory deficit with resistance to & rsquo; action of & rsquo; insulin.)
C- Other specific types of diabetes :
a- Genetic defects of cell function P :
- Chromosomes 12 HNF – 1 a ( FASHION 3)
- Chromosome 7, glucokinase (FASHION 2)
- Chromosome 20, HNF – 4 a ( FASHION 1)
- Mutation of the & rsquo; mitochondrial DNA
b- Genetic defects of & rsquo; action of & rsquo; insulin :
- Type A insulin resistance
- Syndrome de Rabson-Mendenhall
- lipoatrophy diabetes
c- pancreatic diabetes :
- trauma / pancreatectomy
- Pancreatic cancer
- Cystic fibrosis
- pancreatitis fibrocalculeuse
d- Endocrinopathies :
- Syndrome de Cushing
e- Diabetes induced by drugs or toxic :
- Vacor (raticide)
- nicotinic acid
- thyroid hormones
- thiazide diuretics
f- Infections :
- congenital rubella
g- rare forms of diabetes linked to a disease of the immune system :
- «Stiff man » syndrome (Syndrome of "& rsquo; stiff man" )
- Antibodies directed against the receptor & rsquo; insulin
h- Other genetic syndromes s & rsquo; d & rsquo accompanying sometimes; D-diabetes Gestational Diabetes
WE- CLINICAL DIABETES :
1- DIABETES TYPE 1 :
old names : juvenile diabetes, lean diabetes, ketotic diabetes,insulin-dependent diabetes, diabetes is insulin-dependent 5 at 10 % diabetes .
A- reminders : etiopathogeny – pathophysiology :
selective and irreversible destruction of beta cells by autoimmune phenomena leading to complete deficiency of insulin. The factors triggering the autoimmune reaction are unknown (environmental factors :virus, toxic, bovine albumin, which will act on with genetic predisposition + abnormalities of the immune system of the & rsquo; individual ).
The practical consequences :
- a drying up of secretion & rsquo; insulin: l & rsquo; Insulin is vital.
- the presence of markers of & rsquo; autoimmunity that & rsquo; can be assayed.
- the presence of markers of genetic background (HLA).
B- the clinical picture :
* field :
AGE : all ages especially the & rsquo; child, l & rsquo; & rsquo and teenager, young adult (less of 30 years).
THE WEIGHT : is usually normal.
HISTORY : in 15% cases, DS family history of type 1 especially in siblings.
SEASON : slightly more common in autumn and winter.
* Clinical signs :
- The beginning is brutal rule 'thunderbolt from a clear sky "), marked by the cardinal signs:
– un syndrome polyuro polydipsique intense
– increasing asthenia
– a massive and rapid weight loss, worrying parents
– sometimes blurred vision that can s & rsquo; accentuate the early days of the & rsquo; insulin.
- If these signs are neglected, in days or weeks onset of ketosis signs with :
– digestive disorders such as nausea, vomiting, anorexia, diarrhea and abdominal pain (simulating an abdominal surgical emergency)
– disorders of consciousness (clouding or coma)
– signs of dehydration with hypotension.
– Kussmaul breathing breath with characteristic d & rsquo; acetone
- This form s & rsquo; observed especially in young patients where & rsquo; spontaneous ketoacidosis remains the discovery mode as usual.
- At the & rsquo; mature adult: Table less dramatic
– the start is less abrupt * less marked symptomatology
– a slow evolution without ketosis
– answering (at least initially)the TRT and simulating oral T2D
- This entity is called type II diabetes 1 d & rsquo; slow evolution or "slow DID" or LADA ( Latent Autoimmune Diabetes in the Adults ).
C- the balance sheet :
* metabolic balance :
- l & rsquo; hyperglycemia is frank, in general > at 2 your 3g / I can reach very high values simulating hyperosmolar coma.
- glycosurie massive.
- ++++ of ketones in the blood and especially in urine. L & rsquo; & rsquo existence; a spontaneous ketosis sign virtually insulin dependent diabetes character.
- in severe: metabolic acidosis with decreased blood pH and bicarbonate and water, electrolyte disorders (hyponatremia, Hypokalemia or hyperkalemia false).
– lipid abnormalities in type & rsquo; hypertriglyceridemia.
* hormonal :
determination of & rsquo; insulin and C peptidémie : usually collapsed.
In practice, these assays are not essential to the diagnosis of & rsquo; a type DS 1.
- immunological assessment
– genetic background: presence in 90 at 95 % of type DS 1 Caucasians of & rsquo; HLA DR3 class II and / or DR4 .
* l & rsquo; autoimmunity :
presence & rsquo; AC directed against cell components p. The most important are :
– self antiinsuline antibody or IAA : present in half of type DS 1 before all insulin therapy.
- anti protein tyrosine phosphatase antibody ( IA-2)
- islet cell antibodies Langerhans or ICA (Islet Cells Antibodies) : they are present in 90 % typel DS of the & rsquo; children under 15 years at diagnosis. Their rate decreases with & rsquo; diabetes seniority .
- anti glutamate decarboxylase antibody & rsquo; glutamic acid (anti GAD 65) : present in 50 at 80% of type DS 1 recently discovered. Their positivity increases with & rsquo; age. They persist several years after diagnosis ++++.
- This immunological n & rsquo balance sheet is not necessary in current practice in the diagnosis of type DS 1 d & rsquo; especially as only specialized laboratories can realize.
- It is essential to differentiate the two subtypes
– the type DS 1 autoimmune: positive immunological assessment.
– the type DS 1 idiopathic( the rarest) without markers.
– And also differentiate type DT 1 of MODY diabetes
- L & rsquo; another advantage of this balance relates to diabetes type 2 : Indeed, the & rsquo; UKPDS showed that 12% labeled diabetes type 2 had one or more antibodies : antiGAD ( 9,8%), ICA ( 5,8%). In reality, it s & rsquo; were type diabetes 1 d & rsquo; slow evolution or LADA.
* stock of complications :
- is useless at diagnosis. The earliest complication is diabetic retinopathy (RD) which appears 3 at 5 years after.
- Search d & rsquo; infection (l & rsquo; ECBU, TLT…) is systematic at diagnosis and each time & rsquo; there is a glycemic unexplained.
D- Evolution :
* spontaneous evolution :
In the absence of insulin treatment, l & rsquo; evolution is, after d & rsquo; a variable time, to the & rsquo; ketoacidosis and death.
* response to treatment :
favors on insulin,dose d & rsquo; insulin for the & rsquo; glycemic vary & rsquo; one patient to another.
when the diagnosis was early and that & rsquo; insulin therapy was intensive, diabetes may go into remission ( " honeymoon ").
Forgiveness d & rsquo; a type DS 1 is the possibility of suspending the & rsquo; insulin while the & rsquo; glycemic normal rest with diet alone or in combination with oral antidiabetic.
This remission is temporary, for several months 2 or 3 years.
Acute Complications Possible type & rsquo; treatment-induced hypoglycemia (they are the price of & rsquo; good metabolic control).
E- Diabetes Type 1 associated with d & rsquo; other autoimmune diseases :
In 4 at 10% cases the type DS 1 s can & rsquo; d & rsquo associate with, other autoimmune diseases are the most common endocrinopathies (Graves' disease, thyroiditis d & rsquo; Hashimoto, adrenal insufficiency) vitiligo, pernicious anemia, celiac disease, chronic autoimmune hepatitis etc.…
F- Prediabetes Type 1 :
Search immunological markers and HLA typing to screen predisposed to diabetes type 1, especially among siblings of the sick, most often to answer the & rsquo; parental concern.
No markers n & rsquo; has an absolute predictive value.
THE DIABETES LADA :
LADA : Latent Autoimmune Diabetes of Adults,( intermediate diabetes or diabetes 1,5) KEY CRITERIA :
- age > 30 years
- absence of & rsquo; ketoacidosis at diagnosis
- time between diagnosis and the power insulin > 06 month
- presence & rsquo; anti GAD antibodies 65
9,3% type diabetes 2 had antibodies antiGAD.
TWO TYPES OF DIABETES LADA
LADA type 1 : it has the characteristics of type diabetes 1( age < 40 years, normal weight, no associated pathologies ( HTA, dyslipémies ) "Signs of & rsquo; insulinocarence without signs & rsquo; insulin resistance"
LADA type 2 : it has the characteristics of & rsquo; diabetes type 2(age > 40 years ,android obesity,possible association with hypertension or dyslipidemia "signs d & rsquo; insulin resistance without insulinocarence"
2- TYPE OF DIABETES 2 :
old names : maturity onset diabetes, diabetes mellitus, nonketotic diabetes, non-insulinodependant diabetes. C & rsquo; is the form of the most common : 90 at 95 %.
A- L & rsquo; pathogenesis is unknown : Heredity + environmental factors
a- Heredity :
- greater frequency in some populations: Indian PIMA
- the family nature of the disease. The risk is 40% When & rsquo; was a diabetic ascending, 100 % in monozygotic twins.
polygenic disease: the mode of transmission and the genes are still unknown.
b- Environmental factors :
- l & rsquo; obesity :60 at 80 % at diagnosis or were obese. C & rsquo; is & rsquo; android type of obesity that predispose to type DS 2 (insulinorésistance).
- physical inactivity : regular physical activity Protection Factor.
- nutritional factors : a high calorie diet encourages the development of & rsquo; a DS via the & rsquo; obesity. At & rsquo; reverse malnutrition protein-calorie s & rsquo; d & rsquo sometimes accompanies, a particular form of DS.
In type DS 2, there is a reduction in the mass of beta cells but insufficient to explain the occurrence of & rsquo; diabetes.
L & rsquo; hyperglycemia results from two usually associated anomalies: quantitative and qualitative abnormalities of & rsquo; insulin as well as & rsquo; an abnormality of & rsquo; action periphery of & rsquo; insulin or insulin.
insulin deficiency : with reduction of cell mass (3, disappearance of the early peak of & rsquo; insulin
Insulinorésistance : with the liver decreased glucose uptake and an increase in gluconeogenesis.
In adipose tissue : decrease in glucose uptake, increased lipolysis,
At the muscle level : decrease in glucose uptake, and decreased production of glycogen
B- The diagnosis :
a- field :
- l & rsquo; age : mature adult over 40 years and its frequency increases with & rsquo; age.
- l & rsquo; obesity : 60 at 80 % of type DS 2 have been or are obese. C & rsquo; is above the & rsquo; android type of obesity (assessed by waist circumference) that predisposes to diabetes.
- l & rsquo; heredity: family history of diabetes (siblings ascendants, collateral) and d & rsquo; obesity.
- l & rsquo; & rsquo combination with, other cardiovascular risk factors :
HTA in essential rule,lipid abnormalities in type & rsquo; hypertriglyceridemia and & rsquo; hypoHDL-emia well as & rsquo; hyperinsulinism.
This set of co-morbidity makes the metabolic syndrome & rsquo; insulin resistance, which predisposes to ischemic cardiovascular complications.
b- Diagnostic circumstances :
large clinical latency and insidious development for many years( on average 10 years).
for a diagnosed case, there is a case unknown d & rsquo; where & rsquo; importance of routine screening.
diversity of circumstances of discovery :
- often absent cardinal signs. When they exist, they are moderate in general, often overlooked by the patient.
- the diagnosis is most often made to & rsquo; & rsquo opportunity; laboratory tests done routinely in patients at risk or when & rsquo; concomitant illness.
- it n & rsquo; is not uncommon that & rsquo; a complication reveals a type DS 2.
– retinopathy with drop in & rsquo; visual acuity.
– cardiovascular pathology : infarct (IDM), gangrene d & rsquo; a member, AVC.
– metabolic complication : hyperosmolar coma especially in the elderly, a non-spontaneous ketoacidosis.
- at d & rsquo; pregnancy
C- The balance sheet d & rsquo; a diabetes Of type 2 :
* A diagnostic purposes :
- glycemia : l & rsquo; fasting hyperglycemia is usually moderate but greater than 1.26 g /1. Sometimes, it is very high above 2,5 or 3g but clinically well tolerated. In many cases, diagnosis n & rsquo; is carried & rsquo that, after an OGTT.
- la glycosurie : it is a function of glucose.
the ketonuria : absent in rule. When it exists, it is usually secondary to infection.
* lipid abnormalities : present in 30 at 40 % cases These abnormalities may be related to the glycemic regressing after normoglycemia or be independent requiring specific processing.
- L & rsquo; hypertriglyceridemia is the most common
- The normal or slightly elevated total cholesterol.
- His often pathological fractions involving an increase in LDL that are small and dense and a decrease in HDL.
* Total complications :
Search chronic degenerative complications systematic dice diagnosis because of the & rsquo; latent disease progression.
This assessment is both clinical and paraclinical with :
+ an ophthalmologic examination comprising : FO a necessary complemented by angiography fluoroscéinique, consideration at the LAF, measurement of & rsquo; visual acuity, measurement of the TO in search of & rsquo; glaucoma.
+ renal balance with :
- Search d & rsquo; proteinuria and d & rsquo; a micro albuminuria
- the dosage of creatinine to assess renal function.
+ cardiovascular ECG assessment looking & rsquo; ischemic heart disease, clinically latent.
+ a neurological assessment : peripheral neuropathy (monofilament….)
+ stock infections : skin ( fungus between the toes) urinary (ECBU)..
D- Evolution :
Diabetes Type 02 is a progressive disease, at diagnosis 50-60% Beta pancreatic cells are already destroyed ; and destruction s & rsquo; accentuated over the years, with progressive depletion of & rsquo; & rsquo insulin until, at a stage of & rsquo; insulinorequerance.
Don for years, obtaining & rsquo; proper glycemic control and the & rsquo; effectiveness of TRT i despite the & rsquo; therapeutic climbing, necessitating the use of the & rsquo; insulin.
We talk & rsquo; Mayor failure to ADO or DT or insulinorequérant insulinonécessitant.
This is suspected to insulinorequerance:
– l & rsquo; & rsquo appearance; chronic metabolic imbalance s / maximum oral TRT.
– signs of & rsquo; insulin deficiency : unexplained w, tendency to spontaneous ketosis.
– Before talking about diabetes requiring insulin, we must rule out other causes of glycemic control as :
- dietary errors; a reduction in & rsquo; habitual physical activity
- taking drugs interfering with glucose metabolism.
- especially a disease intercurrent latent infection.
DIABETE TYPE 02 CETONURIQUE :
Call also like 03 African or relatively frequent in Africa, age between 30-40 years:
– clinical profile of & rsquo; DT 2 robésité and metabolic syndrome ,ATCDS family T2DM …
– But the discovery mode d & rsquo; a DTl:ketosis d & rsquo; spontaneous appearance; puisai doses d & rsquo; & rsquo insulin up; to & rsquo; stop with response to ADO.
– Changes in spurts (ketosis requiring the & rsquo; insulin) remission (stop of & rsquo; s insulin and up / ADO)
3- OTHER SPECIFIC TYPES OF DIABETES :
a- The type of diabetes MODY(Maturity Onset Diabetes of the Young) :
Represents more 2 at 5 % cases of clinically non-insulin dependent diabetes. MODY 2 and MODY 3 are by far the most common.
We know at present 6 subtypes that share : there are several types which have in common :
- the age of onset in young adults , usually before 25 years.
- autosomal dominant inheritance.
- presence of the disease over several generations
- achieving half siblings.
* FASHION 1 : gene HNF-4 α
* MODY2 : gene glucokinase ++,
* MOD Y3 : gèneHNF-1 a
* MODY4 : genelPF-1
* MODY5 : gene HNF-1 β
* MODY6 : neuro DI gene
b- The Mitochondrial Diabetes :
is a mitochondrial cytopathy to maternal transmission which is characterized by : diabetes mellitus : all aspects
The multi visceral reached with neurosensory signs (Deafness, retinal damage), Neuromuscular signs :
– Le syndrome "MIDD» (Maternally Inherited Diabètes and Deafness) combining : diabetes + sensorineural hearing loss, crosslinked macular dystrophy.
– MERRF syndrome :
– MELAS syndrome : mitochondrial myopathy, encephalopathy, repeated stroke and lactic acidosis.
c- Genetic defects in insulin action :
|1- Type A insulin resistance||2- leprechaunism|
|3- Syndrome de Rabson-Mendenhall||4- lipoatrophy diabetes|
d- pancreatic diabetes :
1- pancreatitis (PCC +++) deficit associated exocrine and endocrine twin deficits ( P and)
|2- trauma / pancreatectomy||3- Pancreatic cancer|
|4- Cystic fibrosis||5- hemochromatosis|
e- endocrinopathies :
|1- acromegaly||2- Syndrome de Cushing|
|3- Glucagonome||4- Phéochromocytome|
|5- Hyperthyroidie||6- Somatostatinome|
|7- aldosteronism||8- Other|
f- diabetes induced by drugs or toxic :
|1- Vacor (raticide)||2- Pentamidine|
|3- nicotinic acid||4- glucocorticoids ++++++|
|5- Thyroid hormones ++++||6- Diazoxide++++++|
|7- AgonistesPadrénergiques||8- thiazide diuretics|
|9- Diphénylhydantoïnes||10- interferon|
g- diabetes related pathology of the immune system :
- «Stiff man » syndrome (Syndrome of "& rsquo; stiff man" )
- Antibodies directed against the receptor & rsquo; insulin (lupus )
h- Other genetic syndromes accompanied by diabetes :
WOLFRAM syndrome or "DID MOAD", Laurence – Moon, Prader Willi
4- DIABETES GESTATIONAL :
Gestational diabetes is defined as impaired glucose tolerance of varying severity occurred or diagnosed for the first time during pregnancy whatever the term, regardless of changes in the postpartum.
During pregnancy , an insulin resistance state with increased insulin requirements occurs mainly in 2nd quarter
The east Associée at diseases-maternal-infantile foeto élevée et peut entrainer des maternal fetal complications in court and information (See table).
|A court terme||A long terme|
|fetal complications||They die in the womb,
|Obesity disorder of glucose tolerance|
|HTA gravidique, preeclampsia, caesarean||Glucose intolerance, Diabetes Mellitus Type 2|
– GAJ>0.92g / l in the first quarter is sufficient for diagnosis (pledge >l,26g / l c & rsquo; is a pre-existing diabetes).
– Otherwise OGTT between about 2H 24-28 SA if risk factors (ingestion of 75g diluted in glucose 250 cc then levy T0 ,TLH you T2h).
– Gestational diabetes is defined when & rsquo; one threshold value is exceeded :
GAJ : 0,92 g/1, glucose lh : l,8g/l, Glucose 2 hours : 1,53 g/1.
And : GAJ >l,26g / l c & rsquo; is a pre-existing diabetes.
Risk factors for gestational diabetes :
– age >35 years
– BMI>25 Kg/m2
– personal history of gestational DT or macrosomia
– history of diabetes in first-degree relatives
VII- CONCLUSION :
Diabetes is a complex disease. There are different types, the most common are the type 1 and type 2 . if the diagnosis of diabetes is most often evident in the type 1, you have to know the & rsquo; evoke and seek in diabetes Type 2 which is often asymptomatic.
Course of Dr A. ZAOUIA – Faculty of Constantine