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Laboratory Diagnosis in

Diabetes Mellitus - Pitfalls


Ruland DN Pakasi
Dept of Clinical Pathology Fac of Medicine, Hasanuddin University
Hasanuddin University Teaching Hospital
Makassar
Diabetes Mellitus

Definition
Refers to a group of disorders of abnormal carbohydrate
metabolism
common the clinical finding of hyperglycemia.
relative or absolute impairment in insulin secretion, along with
varying degrees of peripheral resistance to the action of
insulin.
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Diabetes Mellitus 1. Type 1
2. Type 2
Types and Classification
3. Gestational Diabetes
4. Specific types of diabetes
5. Associated with endocrinopathies

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Type 1

Diabes Mellitus Type 2

Types and Classification Gestational Diabetes

Specific types of
diabetes

Associated with
endocrinopathies

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Type 1

Diabes Mellitus Type 2


immune mediated,
Gestational Diabetes results in an
Types and Classification
absolute insulin
Specific types of deficiency
diabetes

Associated with
endocrinopathies

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Type 1

Diabes Mellitus Type 2


relative insulin
deficiency due to
Types and Classification Gestational Diabetes abnormalities of
both insulin
Specific types of
secretion and
diabetes
insulin action
Associated with
endocrinopathies

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Type 1 diagnosed during
pregnancy.
2% of patients
Diabes Mellitus Type 2 with gestational
diabetes remain
Types and Classification Gestational Diabetes diabetic after
delivery.
Specific types of 40 % of the
diabetes patients will
develop overt
Associated with diabetes within 15
endocrinopathies years, mostly type
2, but occasionally
type 1.

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Type 1 a. Genetic defects of
beta cell function
b. Genetic defects in
Diabes Mellitus Type 2
insulin actionc.
c. Diseases of the
Types and Classification Gestational Diabetes exocrine pancreas,
such as pancreatitis,
Specific types of trauma,
diabetes pancreatectomy,
neopla-sia, cystic
Associated with fibrosis (CF),
endocrinopathies hemochromatosis,
fibrocalculous
pancreatopathy

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Type 1

Diabes Mellitus Type 2


a. Endocrinopathies (e.g.
Types and Classification Gestational Diabetes Cushings syndrome
b. drugs (i.e., cortices
Specific types of teroids)
diabetes c. or chemicals

Associated with.

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Diabes Mellitus
The clinical onset of diabetes can be
Who Should be Suspected?
acute or insidious, depending both on
the degree of insulin deficiency as well as
on the intercurrent level of physiologic
stress

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Patients with the following symptoms
and signs should be tested:
1. Classic symptoms of hyperglycemia, such as
Diabes Mellitus thirst, polyuria, weight loss, visual blurring
2. Serendipitous finding of hyperglycemia or
Who Should be Suspected? known impaired glucose tolerance
3. Complications of diabetes, such as
proteinuria, neuropathy, cardiovascular
complications, and retinopathy

4. Evidence of dehydration, orthostatic


hypotension, confusion, or coma

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In the absence of specific symptoms:
Routine screening for type 1 DM is not
recommended, since there is no accepted
treatment for the asymptomatic phase of
Diabes Mellitus type 1 DM
Screening for Diabetes Mellitus For type 2 DM, ADA recommended
screening for diabetes or prediabetes
all adults
BMI 25 kg/m2
and one or more additional risk factors
for diabetes
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For type 2 DM, ADA recommended screening for
diabetes or prediabetes
all adults
BMI 25 kg/m2
Diabes Mellitus and one or more additional risk factors for
diabetes
Screening for Diabetes Mellitus Risk factors for diabetes
Age 45 years, Overweight (body mass index 25 kg/m2),
Family history diabetes mellitus in a first-degree relative ,
Habitual physical inactivity , Belonging to a high-risk ethnic or
racial group (e.g., African American, Hispanic, Native American,
Asian American, and Pacific Islander) , History of delivering a
baby weighing >4.1 kg (9 lb) or of gestational DM, Hypertension
(blood pressure >140/90 mm Hg), Dyslipidemia defined as a
serum high-density lipoprotein cholesterol concentration 35
mg/dL (0.9 mM) and/or a serum triglyceride concentration 250
mg/dL (2.8 mM), Previously identified impaired glucose tolerance
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(IGT) or impaired fasting glucoseDecember
(IFG), Polycystic
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ovary
syndrome, History of vascular disease
ADA Criteria for the diagnosis of diabetes
mellitus:
Symptoms of diabetes & a casual plasma
Diabes Mellitus glucose >200 mg/dL
Fasting plasma glucose >126 mg/dL
How to Confirm the Diagnosis
Two-hour plasma glucose >200 mg/dL
(11.1 mM) during an oral glucose
tolerance test (OGTT).
Glycosylated hemoglobin A1c (HbA1c)
6.5%.

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Fasting 2-hour Glycosylated
Category plasma plasma hemoglobin
glucose glucose A1C
<100 mg/dL <140 mg/dL
Normal <5.7%
(5.6 mM) (7.8 mM)
Diabes Mellitus Impaired
100125 mg/dL
fasting
(5.65.9 mM)
How to Confirm the Diagnosis glucose
Impaired
140199 mg/dL
glucose
(7.811.0 mM)
tolerance
Increased 126 mg/dL
5.7 6.4%
risk (7.0 mM)
200
Diabetes
mg/dL(11.1 6.5%
mellitus mM)

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Diabes Mellitus
Glycated
Laboratory Test A1C level of
hemoglobin
(A1C) test
6.5 % on two Diabetes
type 1 & type 2 diabetes separate tests

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IfA1c not
consistent
Pregnancy
Diabes Mellitus Uncommon Hb

Laboratory Test
Fasting blood Random blood
type 1 & type 2 diabetes sugar test sugar test

100 and 125 126 mg/dL on


200 mg/dL
mg/dL 2 separate tests suggests
considered diabetes diabetes.
prediabetes diagnosed

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If type 1 DM
suspected
Diabes Mellitus

Laboratory Test
C Peptide Urine: Keton
type 1 & type 2 diabetes

low in people normal or


with type 1 high in type 2 Low insulin
diabetes diabetes

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at high risk of at average risk of
Diabes Mellitus gestational diabetes gestational diabetes
test for diabetes at screening test for
Laboratory Test the first prenatal gestational diabetes
Gestational Diabetes visit. during 2nd
trimester
typically between
24 and 28 weeks

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at high risk of at average risk
GD of GD

Initial glucose challenge test


Diabes Mellitus 130 to 140 mg/dL =considered normal

Laboratory Test > 140 mg/dL =higher risk of gestational


diabetes
Gestational Diabetes

Follow-up glucose tolerance testing

2 of the 3 blood sugar readings >normal


will be diagnosed with gestational diabetes.

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Primary test to screen for prediabetes: A1c

Diabes Mellitus A1C 5.7 - 6.4 % A1C < 5.7 %

Laboratory Test
PreDiabetes PreDiabetes Normal

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Primary test to screen for prediabetes: A1c

If the A1C test isn't


Diabes Mellitus available
pregnant or Hb variant
Laboratory Test
Oral glucose
PreDiabetes Fasting blood
tolerance
sugar test
test.

<100 to 125 mg/dL


= PreDiabetes/ 140 to 199 mg/dL =
Impaired Fasting PreDiabetes/ Impaired
Glucose Glucose Tolerance

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23

a likely mistake or an unforeseen or


problem in unexpected or
situation surprising difficulty
Pitfalls
Tems
hidden or
covered pit for use
unsuspected
as a trap.
danger

factors that interfere in


laboratory tests process,
either in pre- or analytically
phaseLeading to
misinterpretation of the
result

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stress serum
Glucose Test
glucose level.

Pitfall trauma, general


anesthesia, infection,
burns, myocardial infarct

Caffeine increased levels

I.V dextrose, which is quickly


converted to glucose.
increased glucose levels.

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Drugs that may cause


Glucose Test increased levels
anti-depressants, -adrenergic blocking
Pitfall agents, corticosteroids, estrogens,
glucagon, soniazid, lithium,
phenothiazines, phenytoin, salicylates,
and triamterene.

Drugs that may cause


decreased levels

acetaminophen, alcohol, -
glucosidase, insulin, biguanides,
clofibrate, disopyramide, gemfibrozil,
pentamide, mooamine oxidase
inhibitors, pentamidinse, sulfonylureas,
thiazolidinediones.
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Glucose Test
Glucose strips

Pitfall
Capillary vc Vein
Whole blood vs plasma/serum
Capillary 10-15%

Hematocrit

>55%: decrease glucose level


<55%: increase glucose level
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Delayed seperating
Glucose Test
serum
Glucose level 3-5/hrs at T
Pitfall

O2 content/altitude

highO2 :false high Glu


>1000 m false high glu

Exersice, emotion etc

Increase glu level


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Glucose:
Pitfall Monohydrate or
Oral Glucose Anhydrous?
Tolerance Test

75 g of glucose anhydrate C6H1206 (or


82-5 g of glucose monohydrate
C6H1206.H20).confusing on what kind
of sugar should be using 75 g of
anhydrous or monohydrous glucose,.

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Smoking
Pitfall
Glucose, may increase the blood
postprandial test glucose level

small snack or candy


glucose level will be
falsely elevated.

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not able to eat the


Pitfall
entire test meal
levels will be falsely
Glucose, decreased.
postprandial test
vomits some or all of
the meal
levels will be falsely
decreased.
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Prior diet of >150 g of carbohydrate daily,


no alcohol, and unrestricted activity for 3
days before test.
Pitfalls Test in morning after 1016 hours of
fasting.
Oral Glucose No medication, smoking, or exercise
Tolerance Test (remain seated) during test.
(OGTT) Certain drugs should be stopped several
weeks before the test (e.g., oral diuretics,
oral contraceptives, and phenytoin).
Loading dose of glucose consumed
within 5 minutes

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Prolonged exposure of urine


sample to room temperature
Pitfall lower glucose results due
micro-bial contamination and
Urine glucose glycolysis.
tests
Specific gravity >1.020 and
increased pH causes reduced
sensitivity and falsely low
glucose levels.

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