Classification of diabetes(ADA-1997) Type 1 (beta-cell destruction, usually leading to absolute insulin deficiency) Autoimmune Idiopathic Type 2 (may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with or without insulin resistance) Other specific types Gestational diabetes** Other specific types Genetic defects of beta-cell function Genetic defects in insulin action Diseases of the exocrine pancreas Endocrinopathies Drug- or chemical-induced Infections Uncommon forms of immune-mediated diabetes Other genetic syndromes sometimes associated with diabetes Pathology Type 1 DM ：inflammation of pancreas Type 2 DM ：amyloidosis of pancreas Large vessel ：atherosclerosis Kidney ：diffuse or nodular glomerular sclerosis Retina ：arteriolar sclerosis 、microaneurysm 、exudates 、new vessel formation Nerve ：axon degeneration 、myelinolysis Pathophysiology Abnormalities in metabolism Carbohydrate ：anabolism ，catabolism 、utilization Lipid ：anabolism ，catabolism ，ketoplasia protein ：anabolism ，catabolism ，glyconeogenesis Clinical Presentation WHO plasma glucose guideline Comparison of type 1 and type 2 DM type1 DM type2 DM Usual age of onset <30 years >40years Mode of onset acute chronic weight normal overweight or obesity or weight loss symptoms polyuria,polydipsia, similar but usually weight loss less severe presentation Acute complications often few Chronic complications Large vessel disease less then type 2 DM leading cause of death Renal disease leading cause of death 5% 10% Insulin and c-peptide low or lack peak value delayed ,high or deficiency Immune marker usually + usually - Therapy insulin dependence oral antidiabetic agents are available Chronic complications Macrovascular disease Microangiopathy Diabetic retinopathy Diabetic renal disease Diabetic neuropathy Diabetic dermatopathy Infection Mechanism of complications Activation of polyol （or sorbitol ）pathway Formation of non-enzyme saccharification products Change of hemodynamics Activation of PKC Microangiopathy theory Hyperglycemia is the essential reason for diabetic complications DCCT Diabetes Control and Complications Trial UKPDS United Kingdom Prospective Diabetes Study UKPTS ：results HbA1c 0 .9% ，（intensive therapy vs routine therapy ）Intensive therapy group: diabetis associated complications 12% ，and the fatalness of microvascular complications 25% 。It cannot evidently reduce the incidence of great vessel disease ,such as miocardial infarction and strock . Most stimulating findings ：Biguanides can prevent or slow the onset and/or progression of diabetic complications in overweight patients Tight control of hypertension can prevent or slow the onset and/or progression of diabetic complications by 24% （144/82mmHg vs 154/87mmHg ），stroke by 44% ，microvascular complications by 37% 。Epidemiology of diabetes Macrovascular disease Diabetics are easy to get atherosclerosis Monckeberg’s sclerosis 41.5 ％Intimal arteriosteogenesis 29.3 ％Coronary heart disease 、cerebrovascular disease ：24 times Risk of miocardial infarction ：10 times Risk of stroke : 3.8 times ，especially in women Risk of lower limb amputation ：15times ，fatalness Hypertension in DM Diabetic retinopathy －leading course of new cases of blindness Pathogeny ：state of illness 、course of disease 、age of onset <5 years ：eyeground disease is not common <10 years ：50 ％eyeground disease <20 years ：80 90 ％eyeground disease Classifications (China) Background retinopathy Ⅰmicroaneurysms 、dots of hemorrhages Ⅱyellow and white hard exudates , haemorrhages Ⅲwhite soft exudates , haemorrhages spots Proliferative retinopathy Ⅳnew vessel formation 、haemorrhage into the vitreous Ⅴnew vessel formation and fibrosis Ⅵretinal detachment Diabetic nephropathy DN is the leading cause of ESRD (end-stage renal disease) Almost 40 ％of Type 1 DM died of uremia Incidence of DN in type 2 DM is about 20 ％In EU ，DN accounts for 1/3 of dialysis and kidney transplantation cases In China, DN also accounts for quite a lot of dialyses and kidney transplantations Stages of diabetic nephropathy(1) stage I increased kidney DM already filtration diagnosised GFR↑↑enlarged kidneys(B- ultrasonic) GFR>130ml/min Stage II clinically silent phase DM 2 5year GFR ↑20 40 ％renal enlargement ，	 with continued glomerular hypertrophy, hyperfiltration and hypertrophy expansion of the mesangial matrix	 thickening of the glomerular basement membrane resulting in glomerulosclerosis Stage III concealed DN microalbuminuria DM5 10year microalbuminuria 1/5 patients with hypertension (20-200μg/min retinopothy↑,or30 300mg/24h) proteinuria 0.15 0.5g/24h GFR> or =normal Stages of diabetic nephropathy(2) Stage IV Overt Nephropathy DM10 25year albuminuria>300mg/d 60 70 ％patients proteinuria>0.5g/d ，with hypertentio GFR↓(when UAER=100 and edema mg/24h , GER begin to decrease ，about 1ml/min/month) retinopathy ↑↑Stage V end-stage renal disease, ESRD DM15 30 year albuminuria azotemic→uremia GFR< 1/3 of normal Classification of diabetes neuropathy （1）Peripheral neuropathy symmetric multiple peripheral neuropathy sensibility multiple neuropathy numbness type pain type numbness-pain type sensomotor multiple neuropathy acute or sub-acute motor multiple neuropathy asymmetricsingle or multiple periphearal neuropathy member or torso mononeural cranial nerves disease radiculopathy proximal motor neuropathy autonomic neuropathy Autonomic neuropathy diabetic myelopathy diabetic spinal ataxia spinal muscular atrophy Cerebropathy Hypoglycemia cerebropathy diabetic coma cerebrovascular disease Diabetic sensability multiple neuropathy more common in female Average age of onset is 58.7year Course of DM> 15years Symptoms of sense Numbness type ：large medullated fibers Pain type ：little medullated fibers and nonmedullated fibers Numbness-pain type  Nervous symptom examination parasthesia Lower limbs pallesthetic disturbance or dissapear Tendon reflex low or dissappear Sensory staxia Paratrophy symptoms Charcot arthropathy 、ischemic gangrenosis and foot ulcer Diabetic autonomic neuropathy Pupil disease Cardiovascular parafunction Fixed heart rate Postural hypertension Sudden cardiac death Gestrophageal ,diarrhea Neuropathic bladder,erectile failure Abnormal sweating Diagnosis Criteria for diagnosing diabetes FPG Random OGTT plasma glucose 2hPG mmol/L mmol/L mmol/L DM ≥7.0 ≥11.1 ≥11.1 IGR IFG 6.1≤FPG<7.0 IGT 7.8≤FPG<11.1 Normal <6.1 <7.8 Characteristics of new diabetic diagnostic criteria FPG<6.1mmol/L is normal fasting glucose ，OGTT 2hPG<7.8mmol/L is normal glucose tolerance ；Impaired fasting glucose corresponding with impaired glucose tolerance (IFG) ：6.1mmol/L ≤FPG<7.0 mmol/L ；The cutoff value of FPG decline from 7.8mmol/L to 7.0mol/L.the cutoff values of OGTT2hrPG and random plasma glucose level are still 11.1mmol/L ；FPG is the initial screening test of diabetes ，OGTT is not recommended for routine diagnostic use. The diagnoses of Gestational diabetes is not changed Practical problems in diagnosis Symptoms ＋random plasma glucose ≥11.1 mmol/L FPG ：≥7.0 mmol/L OGTT ：2hPG≥11.1 mmol/L Asymtomatic persons tests should be repeated the once latent autoimmune diabetes mellitus in adults （LADA ）Adult onset Symptoms are evident Secretion function of cell is low GADA positive HLA-DQ B chain is non aspartate homozygote Management Goals Good metabolism control （blood sugar 、blood lipid 、HBA1C etc ）Relieve symptoms Keeping good physiologic state and a social life Good quality of live Prevent the development of acute complications of diabetes （hypoglycemia 、DKA 、hyperosmolar nonketotic syndrome 、lactic acidosis ）Preventing the development or delaying the progression of the chronic complications of diabetes Principle of treatment Early Life-long synthesis individual Control actuality of DM in China 26 centers 、3965 patients 28 ％patients measure H bA1c：8.1 2.6%，52％>7.5％FPG：9.2 3.7mmol/L，55%>7.8 mmol/L Determing rate of microalbumin in urine ：20％Principles of medical nutrition theraphy rational control of total calorific value Goal ：Keep ideal body