論 糖尿 理 年 念 糖尿 1
雷 Age 52 years Family Hx Mother Personal Hx (+)DM 5 years Type (+)Hypertension C.V.A. Hyperlipidemia (+)smoking (-)alcohol drinking (+)exercise 30-60 mins 2 / 2
( ) 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 94.08.11. 糖尿 3
糖尿 94.08.11. BH 170.5 cm BW 68 Kg (IBW 64 Kg) BP 136/84 mmhg PR 78 Monofilament Normal Tuning Fork Normal Foot Ulcer NO 9/13 4
94.04.23. 94.05.26. 94.06.30. 94.08.11. AC sugar (mg/dl) 126 196 92 PC sugar (mg/dl) 330 405 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) 36 46 51.6 50 / 52.8 Cr. (mg/dl) 5.8 4.6 5.5 5.8 / 5.1 Urine Protein 2+ 2+ 3+ BP (mmhg) 170/90 130/80 136/84 Hgb (gm/dl) 10.8 11.1 9.8 9.3
率 糖尿 糖尿 罹 率 率 糖尿 女 女 6
20 yrs DM ESRD 1.Type I DM 30-40% 2.Type II DM 15-20% 7
Microalbuminuria 24 hours collection 30-300mg/dl spot collection (preferred method) 30-300ug/1mg CRE 11
Plasma proteins albumin globulin α1,α2,ß1,ß2,γ fibrinogen 12
Urine Urine protein <100mg/dl come from shed tubular cell 13
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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
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Glomerula lesion : thickening of glomerular basement membranes Mesangial matrix expansion Arteriolosclerosis Glomerular filtration defects glomerular permeability 50% hypertension 17
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Proteinuria markedly reduced survival increased risk of cardiovascular disease almost have diabetic retinopathy 28
Albuminuria (Proteinuria ) H.T. CHF Prostate disease Infection Exercise Fever Hyperglycemia Pyuria Hematuria 29
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
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Diabetic Nephropathy Risk Factors Duration HbA1c level H.T. Hyperlipidemia Smoking Strong family history 36
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
Strict blood pressure control reducing albumin excretion slowing the decline in renal failure BP 130/80 proteinuria BP 125/75 microalbuminuria 38
Blood pressure control extremely important drug-specific benefit in diabetic nephropathy ACEI type I DM ARBs type II DM 39
ACEI hyperkalemia cough renal insufficieay ARBs Calcium channel blocker nondihydropyridine class 1.Dihydropyridine Adalat 2.benzothiazepine Diltiazem(Herbesser) 3.pheylalylaia Verapanoil 40
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microalbuminuria 0.8g/kg/day overt nephropathy 0.8g/kg/day (10% of the daily caloric intake) 44
Lipid control LDL 100 mg/dl 45
DM Nephropathy poor tolerance for uremia protein wasting H.T. difficult to control atherosclerosis increase cardiovascular mortality 46
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
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
Dialysis / organ transplantation mortality is higher in diabetic 49
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行 糖 料 不 拉 不 51
龍茶 柳 糖 龍茶 52
量 量 量 不 量 不 類 量 不 量 不 量 不 糖 量 量 不 53
量 IBW 22 1.705 1.705 64(kg) 68kg 64 30-500 1420 1500 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
糖尿 易 量 55
理 56
理 料»» 降 糖 便» 不 便» 不 料»CVA H/T DM 年 93 年» DM» 行 57
理 行 療 念 療 行 療 便 類 練 糖 狀 理 58
理 療 行 糖 59
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