[TG] : 5 in mg/dL or [TG] : 2.2 in mmol/dL

 not valid if: 1.[TG] > 400mg/dL 2.Chylomicrons present

 3. b-VLDL --> Type III dyslipidemia (rare)

Fridewald equation

LDL =

LDL= Total Cholesterol - HDL - TG/5

 not valid if: TG > 400mg/dL,Chylomicrons present,

 Type III dyslipidemia

Lipid Disorders

 Phenotypes  and Lipoproteins increased

 I

 IIa and IIb

Chylomicrons

 b- region (II) LDL (II L's) + VLDL (IIb)

LDL and VLDL --> major apolipoprotein?

HDL --> major apolipoprotein?

Apo B (bad cholesterol)

 Apo A₁ --> ( a-region)

Total Cholesterol mg/dL

 - desirable

 - high

< 200

> 240

LDL mg/dL

- optimal

 - borderline

 - high

< 100

 130 -159

 160 - 189

HDL mg/dL

 Low

 High

 < 40

 > 60

LDL Targets - Risk groups

 - CHD or equivalents

 - 2 or >2 major risk factors

 - < 2 major risk factors

< 100 mg/dL

 < 130 mg/dL

 < 160 mg/dL

Enzymatic reactions--> dye product

--> spectrophotometry

Lipid Disorders: Phenotypes  and Lipoproteins increased

III, IV, V

IDL ( intermediate - 1-5 = 3)

 VLDL (IV)  pre b-region

 V = I + IV  = VLDL + Chylomicrons

Chylomicrons

-Electrophoretic mobility

-Major lipid / Protein %

-Apolipoprotein

Origin

TG / 1%

B-48, A-1,C, E

VLDL

-Electrophoretic mobility

-Major lipid / Protein %

-Apolipoprotein

pre-b ("V for beta")

TG / 8%

B-100, C, E

IDL

-Electrophoretic mobility

-Major lipid / Protein %

- Apolipoprotein

pre-b/b

Cholesterol / 15%

B-100, E

LDL

-Electrophoretic mobility

-Major lipid / Protein %

- Apolipoprotein

b

Cholesterol / 20%

B-100

HDL

-Electrophoretic mobility

-Major lipid / Protein %

- Apolipoprotein

a

Cholesterol / 50%

A-1, C, E ("ACE")

Eruptive xanthomas, pancreatitis

Cholesterol +, TG +++

DDx

Familial LPL deficiency - Phenotype I

Familial hypertriglyceridemias IV / V

Pancreatitis

Cholesterol +, TG +++

Dx

Familial apo C-II deficiency

Phenotype I / V

Tendinous xanthomas, premature atherosclerosis

Cholesterol +++, TG nml/ +

Familial hypercholesterolemia (IIa) --> most common 1^ocause of hypercholesterolemia <-- LDL Rc deficiency

autosomal dominant

Eruptive xanthomas, premature atherosclerosis

Cholesterol +++, TG +++

DDx

Apolipoprotein E deficiency - Phenotype IIb

Familial dysbetalipoproteinemia - III

Premature atherosclerosis

Cholesterol + , TG +

Familial combined hyperlipidemia

II or IV

Predominant hypertriglyceridemia

--> most common 2^o cause

Low Cholesterol, TG nml - increased, absent HDL & A-1

Tonsils, lymph nodes, vasculature, spleen --> cholesterol esters

Dx?

Pregnancy: Relative Gluc intolerance

Cause?

Measurement of Insulin

Assay? Endogenous vs exogenous Insulin

Gluc measurement

Assay?

Enzymatic: glucose oxidase / hexokinase --> G6PD

--> plasma

Point of care testing

Un-calibrated whole blood Gluc compare with Gluc_plasma

HgbA_1c reflects Gluc control in the past-----?

why?

nonenzymatic: Gluc + HgbA --> HgbA_1c ~ RBC-t_1/2

= 60d --> younger RBCs little > 50%

=>HgbA_1c ~ Gluc control in past 1 month

< 6% Shortened Red cell survival - hemolytic anemias,

Hemoglobinopathies

fructosamine --> 2-3wks

Moderade and gradual drop in Gluc_serum 

Altered mental status

Dx:

Sweating,palpitations,tachycardia,nervousness

Dx

"Reactive" hypoglycemia --> profound and rapid

<--hormonal response

Hypoglycemic symptoms, [Gluc]_plasma< 45mg/dL, relief of symptoms with Gluc, [Insulin]_absolute=nml

Dx?

Insulinoma/Nesidioblastosis

Insulin: Gluc > 180

Renal impairement

--> cleared by the Kidney

"c=child=kid"

Hypoinsulinemic hypoglycemia

- low [beta-OH-butyrate]

causes?

nonketotic=> insulin-like activity

Autoimmune, liver failure, stavation

Patient with insulinoma

What other test should be ordered?

c-peptide

proinsulin

Type I DM - frequency

Antibodies?

10% common in childhood

Auto-Ab--> anti-GAD65, anti-ICA512, anti-IAA

Fasting Gluc_plasma

- DM

- Impaired fasting Gluc (pre-diabetes)

>125 mg/dL

99 - 126 mg/dL

Criteria for + 100gram OGTT in pregnancy

Any 2 of: >95mg/dL fasting, >180 @1hr, > 155 @2hr

>140 @ 3hr

Goal of therapy in diabetic patients?

What test?

HgbA_1c < 7%

--> should not be used in pregnancy

DM Patient: difficulty to maintain glycemic control

What other test?

Magnesium

--> hypomagnesemia--> complicate glycemic control

DM I Pt with polyuria,polydipsia, nauseaa and abdominal pain, hyperglycemia, metabolic acidosis.

Dx?

early DKA

late--> altered breathing (Kussmaul resp) --> altered mental status -->coma

Major serom ketones?

Measurement technique?

¹Acetone, ²acetoacetic acid, ³b-hydroxybutyrate

Nitroprusside, semi-quantitative method

DKA: [¹⁺²] ~ 20%, [³] ~ 80%

[Na⁺]_serum = initially low <-- urinary losses

[K⁺]_serum = initial elevated --> transcellular shifts and urinary losses => [K⁺]_{total decreased}

Hyperglycemic hyperosmolar nonketotic coma

DM II

Pt: Insulin resistance, central obesity, dyslipidemia, hypertension, increased CRP, PAI-1.

Dx?

Metabolic syndrome (syndrome X)

--> accelerated atherosclerosis

PAI-1 =plasminogen activator inhibitor -1