投影片 1

Transcription

1 論 糖尿 理 年 念 糖尿 1

2 雷 Age 52 years Family Hx Mother Personal Hx (+)DM 5 years Type (+)Hypertension C.V.A. Hyperlipidemia (+)smoking (-)alcohol drinking (+)exercise mins 2 / 2

3 ( ) History 罹 糖尿 年 93 年 療 Aspirin(100mg) 1 Qd Persantin 1 Tid Nifepine Sustained(20mg) 1 Bid Tenormin(100mg) 0.5 Bid Doxaben(2mg) 1 HS Mevacor(20mg) 1 Qd Euglucon(5mg) 1 Qd Amaryl(2mg) 2 Qd 糖尿 3

4 糖尿 BH cm BW 68 Kg (IBW 64 Kg) BP 136/84 mmhg PR 78 Monofilament Normal Tuning Fork Normal Foot Ulcer NO 9/13 4

5 AC sugar (mg/dl) PC sugar (mg/dl) HbA1C(%) 6.1 T.Chol. (mg/dl) 178 T.G. (mg/dl) 265 LDL-C (mg/dl) 109 HDL-C (mg/dl) 24 GPT (U/L) 14 BUN (mg/dl) / 52.8 Cr. (mg/dl) / 5.1 Urine Protein BP (mmhg) 170/90 130/80 136/84 Hgb (gm/dl)

6 率 糖尿 糖尿 罹 率 率 糖尿 女 女 6

7 20 yrs DM ESRD 1.Type I DM 30-40% 2.Type II DM 15-20% 7

8

9

10

11 Microalbuminuria 24 hours collection mg/dl spot collection (preferred method) ug/1mg CRE 11

12 Plasma proteins albumin globulin α1,α2,ß1,ß2,γ fibrinogen 12

13 Urine Urine protein <100mg/dl come from shed tubular cell 13

14 14

15 Permeability of the glomerular capillaris Neutral substances 4 nm freely filtered 8 nm = 0 Albumin = 7 nm Glomerular basement membrance laminer negatively charged circulating albumin negatively charged 15

16 16

17 Glomerula lesion : thickening of glomerular basement membranes Mesangial matrix expansion Arteriolosclerosis Glomerular filtration defects glomerular permeability 50% hypertension 17

18 18

19 19

20 20

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 Proteinuria markedly reduced survival increased risk of cardiovascular disease almost have diabetic retinopathy 28

29 Albuminuria (Proteinuria ) H.T. CHF Prostate disease Infection Exercise Fever Hyperglycemia Pyuria Hematuria 29

30 Mainstay of therapy DM Nephropathy reducing H.T. and glomerular pressure Dietary protein restriction 0.8 g/kg aggressive lipid management strict glucose control 30

31 31

32 32

33 33

34 34

35 35

36 Diabetic Nephropathy Risk Factors Duration HbA1c level H.T. Hyperlipidemia Smoking Strong family history 36

37 DM Nephropathy Treatment Strict glycemic control (before microalbuminuria) 39% microalbuminuria DDCT type I DM 54% overt albuminuria UKPDS type II DM 24% microalbuminuria 33% overt albuminuria 37

38 Strict blood pressure control reducing albumin excretion slowing the decline in renal failure BP 130/80 proteinuria BP 125/75 microalbuminuria 38

39 Blood pressure control extremely important drug-specific benefit in diabetic nephropathy ACEI type I DM ARBs type II DM 39

40 ACEI hyperkalemia cough renal insufficieay ARBs Calcium channel blocker nondihydropyridine class 1.Dihydropyridine Adalat 2.benzothiazepine Diltiazem(Herbesser) 3.pheylalylaia Verapanoil 40

41 41

42 42

43 43

44 microalbuminuria 0.8g/kg/day overt nephropathy 0.8g/kg/day (10% of the daily caloric intake) 44

45 Lipid control LDL 100 mg/dl 45

46 DM Nephropathy poor tolerance for uremia protein wasting H.T. difficult to control atherosclerosis increase cardiovascular mortality 46

47 DM and hemodialysis mone frequent complications Hypotension (autonomic neuropathy, loss of reflex tachycardia) mone difficult vascular access accelerated progression of retinopathy survival is shorter Atherosclerosis (leading cause of death on dialysis) Hyperlipidemia (should be treatment aggressively) 47

48 DM Nephropathy Asymptomatic bacteriuria / pyelonephritis 2 in diabetic woman autonomic bladder dysfunction impaired organ perfusion, glycosuria Papillary necrosis 1/2 case Renal artery stenosis Hyperkalemia because insulin deficiency, metabolic acidosis, reduced GFR 48

49 Dialysis / organ transplantation mortality is higher in diabetic 49

50 50

51 行 糖 料 不 拉 不 51

52 龍茶 柳 糖 龍茶 52

53 量 量 量 不 量 不 類 量 不 量 不 量 不 糖 量 量 不 53

54 量 IBW (kg) 68kg 量 類 12 類 0 14% 52g(0.8g/kg of IBW) 30% 50g 類 56% 210g 類 3 類 3 類 1 類 7 54

55 糖尿 易 量 55

56 理 56

57 理 料»» 降 糖 便» 不 便» 不 料»CVA H/T DM 年 93 年» DM» 行 57

58 理 行 療 念 療 行 療 便 類 練 糖 狀 理 58

59 理 療 行 糖 59

60 聆