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Interpretasi Klinis Hasil

Laboratorium pada Pasien


Diabetes Mellitus
Hermina Novida
Pusat Diabetes dan Nutrisi Surabaya
Divisi Endokrin-Metabolik-Diabetes
Departemen 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 disini
adalah 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 jika
didapatkan keluhan klasik.
4. Pemeriksaan HbA1c > 6,5% dengan menggunakan metode
High-Performance Liquid Chromatography (HPLC) yang
terstandarisasi oleh National Glycohaemoglobin
Standarization 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

Diabetes
Prediabetes
Normal

HbA1c (%)

Glukosa
Darah Puasa
(mg/dL)

Glukosa Plasma 2
jam setelah TTGO
(mg/dL)

> 6,5

> 126

> 200

5,7-6,4

100-125

140-199

< 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.
Kelompok
risiko
tinggi
hasil
pemeriksaan
4. Riwayat
dengan
bayi dBengan
B >4 kg atau
GDM.
5. H
glukosa
pipertensi (140/90
lasma normal msmHg)
ebaiknya diulang setiap 3
HDL <35 mg/dL dan atau trigliserida >250 mg/dL.
tahun 6.
(7. E),
Wanita dengan sindrom polikistik ovarium.
kecuali
kelompok
8. pRada
iwayat
prediabetes. prediabetes pemeriksaan
9. tOiap
besitas berat,
akantosis
diulang
1 tahun
(E). nigrikans.
10. Riwayat penyakit kardiovaskular.

Usia >45 tahun tanpa faktor risiko di atas.

Kadar Glukosa Darah Sewaktu dan Puasa Sebagai Patokan


Penyaring dan Diagnosis DM di Indonesia
Bukan
DM
Plasma vena
Kadar glukosa
darah sewaktu Darah kapiler
(mg/dL)
Kadar glukosa Plasma vena
darah
puasa
(mg/dL)
Darah kapiler

Belum Pasti
DM

DM

<100

100-199

200

<90

90-199

200

<100

100-125

126

<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 school self-
monitoring of blood glucose ( SMBG).
SMBG is recommended for all insulin-treated patients.
Intensive glycemic control can decrease microvascular
complications 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):
Sebelum makan
2 jam sesudah makan
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) apabila
pasien terkontrol baik secara konsisten
Pemantauan glukosa darah pada pasien yang mendapat terapi insulin,
ditujukan juga untuk penyesuaian dosis insulin dan memantau
timbulnya hipoglikemia(E)
Tes lebih sering dilakukan pada pasien yang melakukan aktivitas
tinggi, pada keadaan krisis, atau pada pasien yang sulit mencapai
target terapi (selalu tinggi, atau sering mengalami hipoglikemia), juga
pada saat perubahan dosis terapi

o
o
o

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., 033.3 mmol/L (0600
mg/dL).
In 1987, ADA recommended a goal of total error (user plus
analytical) of <10% at glucose concentrations of 1.722.2
mmol/L (30400 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 nonglucose
sugars.

Keton Testing
The ketone bodies acetoacetate (AcAc), acetone, and -hydroxybutyric
acid (HBA) 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 HBA 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
HBA 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 perubahan
terapi 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 atau
yang tidak mencapai sasaran terapi (E).
Untuk kondisi tertentu seperti anemia, hemoglobinopati, riwayat
transfusi darah 2-3 bulan terakhir, kondisi-kondisi yang mempengaruhi
umur eritrosit dan gangguan fungsi ginjal maka HbA1c tidak bisa
dipakai 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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