komplikasi kronik diabetes melitus 2010-sorong

7/21/2019 Komplikasi Kronik Diabetes Melitus 2010-Sorong

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KOMPLIKASI KRONIKKOMPLIKASI KRONIK

DIABETES MELITUSDIABETES MELITUS

HIMAWAN SANUSIHIMAWAN SANUSISUBBAGIAN ENDOKRIN DAN METABOLIKSUBBAGIAN ENDOKRIN DAN METABOLIKBAGIAN PENYAKIT DALAM FKUH RS DRBAGIAN PENYAKIT DALAM FKUH RS DRWAHIDIN SUDIROHUSODO MAKASSARWAHIDIN SUDIROHUSODO MAKASSAR


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Komplikasi KronikKomplikasi Kronik

KronikHiperglikemia

Mikrovaskuler Makrovaskuler


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Pancreas

Hyperinslinemia

Hiperglikemia

!lyca"e# pro"ein T$rom%osis

PAI&'

Li(er

HDL

))A

Dyslipi#emia

*LDL +T!,

O%esi"y

Skele"al m

scle

))A

Hyper-lycemia

A#ipocy"es

Li! P "ir#ula$io% &''&

(v

TN)&

Hyper"ension

)i%rino-en

Lipemia

.RP

A#(ance#

!lycosyla"ion

En#pro#c"


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MAKROAN!IOPATIMAKROAN!IOPATI

Pe%!aki$ )a%$u%( Koro%er *P)K+Pe%!aki$ )a%$u%( Koro%er *P)K+ An-ina pek"oris #an in/ark miokar#An-ina pek"oris #an in/ark miokar#

Ma"i men#a#akMa"i men#a#ak

Pe%!aki$ sererovaskulerPe%!aki$ sererovaskulerSeran-an iskemik "ransien"Seran-an iskemik "ransien"

S"rokS"rok

Pe%!aki$ vaskuler ,eri-erPe%!aki$ vaskuler ,eri-er Kla#ikasi in"ermi""enKla#ikasi in"ermi""en

!an-ren!an-ren


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Penyaki" 0an"n- Koroner pa#a

Dia%e"es


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Penyaki" 0an"n- Koroner pa#aPenyaki" 0an"n- Koroner pa#a

Dia%e"esDia%e"es

. An-ina pek"orisAn-ina pek"oris

. In/ark miokar# ak"In/ark miokar# ak"

. Ma"i men#a#ak +Ma"i men#a#ak +suddensudden

cardiac arrestcardiac arrest ,,


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Sekitar 50-75%

kematianpada DM disebabkanoleh

Pen akit antun


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Historical Model of AtherogenesisHistorical Model of AtherogenesisHistorical Model of Atherogenesis

healthy subclinical symptomatic

ThresholdThreshold

DecadesDecades YearsYears--MonthsMonths MonthsMonths--DaysDays

PlaquePlaque

IntimaIntima

MediaMediaLumen

Stable anginaStable angina

Stable plaques withStable plaques with narrowingnarrowing

Simple diagnostic (!"# angiography$Simple diagnostic (!"# angiography$

%are MI%are MI

asy to treatasy to treat

Adapted from Antischkow N.Adapted from Antischkow N. Beitr Path Anat Allg PathBeitr Path Anat Allg Path 1913;56:3791913;56:379404.404.


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Risk )ac"ors /or .ar#io(asclar Disease

Associa"ion 1i"$ "ype 2 Dia%e"es

Speci/ic Non Speci/icMicroal%minria

!lyca"e# LDL

!lyca"e# HDL

Hyper"ri-lyceri#emia

Small #ense LDL

.ar#iac a"onomic neropa"$y

En#o"$elial #ys/nc"ion

Al"ere# /i%rinolysis an#

"$rom%osis

Hyper"ension

Lipi#s

Decrease# HDL

O%esi"y

Renal /ailre

Feli( P/ Fros01a% LA2 E%3o#ri%olo(! a%3 Me$aolis1 &''456'6


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. A"asi /ak"or risikoA"asi /ak"or risiko

. Ken#alikan ka#ar -lkosa #ara$Ken#alikan ka#ar -lkosa #ara$. Pence-a$an #en-an aspirin3Pence-a$an #en-an aspirin3#an s"a"in#an s"a"in

. In/ark miokar# ak"In/ark miokar# ak" I..UI..U

Terapi P0K pa#a pasienTerapi P0K pa#a pasien

#ia%e"es#ia%e"es


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Penyaki" Ar"eri Peri/er


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Penyaki" Ar"eri Peri/erPenyaki" Ar"eri Peri/er

. Dasar 4 a"erosklerosisDasar 4 a"erosklerosis

. Ber$%n-an #en-an sia3 lamaBer$%n-an #en-an sia3 lama

#ia%e"es#ia%e"es. Pre(alensi sli" #i"en"kan ok -e5alaPre(alensi sli" #i"en"kan ok -e5ala

asimp"oma"ik #an neropa"i yan-asimp"oma"ik #an neropa"i yan-

6men-a%rkan76men-a%rkan7. Pasien #a"an- %ero%a" okPasien #a"an- %ero%a" ok

-an--ren 8 lcer iskemik-an--ren 8 lcer iskemik


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Dia-nosis PADDia-nosis PAD

!e5ala Klinis + )on"aine klasi/ikasi klinik,

Gra3e I 7 "ol3 se%sa$io%/ %u1%ess

Gra3e II 7 "lau3i#a$io% I%$er1i$$e%$

Gra3e III 7 %!eri saa$ is$ira0a$Gra3e I8 7 ulkus/ %ekrosis *s,o%$a%eus (a%(((re%+

Pemeriksaan )isis 4,ulsasi ar$eri 3orsalis ,e3is/

$iialis ,os$erior/ ,o,li$ea

Pemeriksaan "am%a$an7 USG Do,,ler/ A%kle

Bra#0ial I%3e9


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Terapi PAP pa#a DMTerapi PAP pa#a DM

. Far1akolo(is 7 vaso3ila$or/ a%$i a((re(asiFar1akolo(is 7 vaso3ila$or/ a%$i a((re(asi

,la$ele$ *as,iri%:#lo,i3ro(el+ ,e%$o9!-ili%e/,la$ele$ *as,iri%:#lo,i3ro(el+ ,e%$o9!-ili%e/

#ilos$a;ol2#ilos$a;ol2

. Revaskularisasi 7 s$e%$/ a%(io,las$!Revaskularisasi 7 s$e%$/ a%(io,las$!


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Komplikasi Mikroan-iopa"iKomplikasi Mikroan-iopa"iDia%e"ikDia%e"ik


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OXIDATIVESTRESSS

O2 NO

Hyperglicemia

Polyol pathwayGlco!e o"i#atio$

pathway

Protei$ glyco!ylatio$

pathway

AGE!

NO %e$chi$g

&D& o"i#atio$

A$tio"i#a$t

#e'e$ce

NADPH

E$#othelial #y!'$ctio$

NO(#epe$#e$t

)a!o#ilatatio$

*oaglatio$ acti)atio$

Hemorheologic alteratio$

Reti$opathy Va!clopathy Neropathy Nephropathy

Pa"o-enesis komplikasi mikroan-iopa"i #ia%e"ik


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NE)ROPATI DIABETIK


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Ne-ro,a$i 3iae$ikNe-ro,a$i 3iae$ik

!ides c"rrent "nti! #00$

%ia&etic nephropath'("rric"!"m )od"!e ***+7&

!ide # of 37

Risk factors

, -oor .!'caemic contro!

, /'per!ipidaemia

, /'pertension

, enetic predisposition

, !omer"!ar h'per+fi!tration d"rin.ear!' period

, 1thnicit'

, 2on. disease d"ration

, mokin.


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Ne-ro,a$i 3iae$ikNe-ro,a$i 3iae$ik



!ide 3 of 37

Diabetic nephropathy

, A&o"t #0 to 30 of peop!ewith dia&etes

, *n t'pe # dia&etes4 a sma!!erfraction of these pro.ress to(5%

, -eop!e with t'pe # dia&etes o6er ha!f of those with dia&etesstartin. on dia!'sis


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Penan#a kersakan -in5alPenan#a kersakan -in5al

Serum &reum

Serum 'reatinin

'lirens 'reatinin

!ystatin-!


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DETEKSI DINIDETEKSI DINI

Pe%!aki$ Gi%


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Penyaki" !in5al Dia%e"es +ADAPenyaki" !in5al Dia%e"es +ADA299:,299:,

Parame"er Urine AER Urine AER Al%min

+;-8min, +m-82< $, rine8crea"

m-8-r

Normal =29 =>9 =>9

Mikroal%minria 29&'?? >9&2?? >9&2??

Makroal%minria @ 299 @>99 @>99

Diae$es #are &''=5&6 Su,,l7S>?S>&


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Ne/ropa"i Dia%e"ikNe/ropa"i Dia%e"ik

Mikroalu1i%uria 7Mikroalu1i%uria 7

? Ko1,likasi %e-ro,a$i 3iae$ik $a0a, 3i%iKo1,likasi %e-ro,a$i 3iae$ik $a0a, 3i%i

? Pe$a%3a ke


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Normal rinary

al%min

secre"ion

Pro"einria

En# S"a-e

Renal Disease

+ESRD,

Dea"$

Microal%minria

50%

(5-10 years)

20%

(20 year)

- 40%


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!am%aran klinis!am%aran klinis

ne/ropa"i #ia%e"ikne/ropa"i #ia%e"ik

.KD +!!K,.KD +!!K,

. Mual/ 1u%$a0Mual/ 1u%$a0

. A%oreksiaA%oreksia

. Fa$i(ueFa$i(ue

La%ora"orimLa%ora"orim

ne/ropa"i #ia%e"ikne/ropa"i #ia%e"ik

.KD +!!K,.KD +!!K,

. Kuli$ keri%(/ (a$alKuli$ keri%(/ (a$al

. E3e1aE3e1a

. Sesak *3is,%ea+Sesak *3is,%ea+

##ureum kreatininureum kreatinin


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TERAPI NE)ROPATI DIABETIKTERAPI NE)ROPATI DIABETIK

. Kon"rol -lkosa #ara$Kon"rol -lkosa #ara$

. Kon"rol $iper"ensiKon"rol $iper"ensi

. S"op rokokS"op rokok

. Die" ren#a$ pro"einDie" ren#a$ pro"ein

. )armakolo-i 4 Penyeka" A.E3 ARB)armakolo-i 4 Penyeka" A.E3 ARB

MIKROALBUMINURIANORMOALBUMINURIA

%ia&etic nephropath'


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!ide 1# of 37

Interventions: glycaemic control

, %ia&etes (ontro! and (omp!icationsria! 8%((9

occ"rrence of microa!&"min"ria

&' 40 occ"rrence of macroa!&"min"ria

&' 50

, :nited in.dom -rospecti6e %ia&etest"d' 8:-%9

o6era!! micro6asc"!arcomp!ication rate &' #5


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$lood-gluose$lood-gluose targetstargets&or people&or people

'ith Diabetes'ith Diabetes

Para1e$erPara1e$er Nor1alNor1al

*1(:3l+*1(:3l+

GoalGoal

*1(:3l+*1(:3l+

Lakuka% Ti%3aka%Lakuka% Ti%3aka%

GDPGDP @ 4''@ 4'' 9&'29 @' or 4>' 1(:3l@' or 4>' 1(:3l

&)PP&)PP @ 4>'@ 4>' ='


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Kon"rol -lkosa #ara$ pa#a NDKon"rol -lkosa #ara$ pa#a ND

. Pe1eria% i%suli% ker


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Kon"rol Hiper"ensi pa#a NDKon"rol Hiper"ensi pa#a ND

. Turu%ka% TD i%$e%si-Turu%ka% TD i%$e%si-. Tar(e$ TD @ 4' : ' 11 H(/Tar(e$ TD @ 4' : ' 11 H(/

. "KD"KD TD @ 4& : 11H(TD @ 4& : 11H(. Die$ re%3a0 ,ro$ei% 3a% (ara1Die$ re%3a0 ,ro$ei% 3a% (ara1. Hi%3ari Alko0olHi%3ari Alko0ol


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O%a" An"i Hiper"ensiO%a" An"i Hiper"ensi

. Pili0a% ,er$a1a 7Pili0a% ,er$a1a 7 A.E in$i%i"orA.E in$i%i"or *#a,$o,ril/*#a,$o,ril/lisi%o,ril/ ra1i,ril+ a$aulisi%o,ril/ ra1i,ril+ a$au ARBARB * valsar$a%/* valsar$a%/

$el1isar$a%/ iresar$a%+$el1isar$a%/ iresar$a%+

Me%uru%ka% la


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An"i $iper"ensiAn"i $iper"ensi

Diu$u0ka% &? 1a#a1 oa$ a%$iDiu$u0ka% &? 1a#a1 oa$ a%$i

0i,er$e%si 70i,er$e%si 7

"a,$o,ril a$au %o,er$e%"a,$o,ril a$au %o,er$e%8alsar$a% a$au iresar$a%8alsar$a% a$au iresar$a%

"a a%$a(o%is *%orvask/ a1lo3i,i%+"a a%$a(o%is *%orvask/ a1lo3i,i%+re%i% a%$a(o%is * Rasile;+re%i% a%$a(o%is * Rasile;+


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N"risi pa#a ne/ropa"i #ia%e"ikN"risi pa#a ne/ropa"i #ia%e"ik

. Ba$asi ,e1eria% #aira% *Ba$asi ,e1eria% #aira% * ''''

##:0ari+##:0ari+. Ba$asi ,ro$ei% *3ie$ re%3a0Ba$asi ,ro$ei% *3ie$ re%3a0

,ro$ei%+,ro$ei%+ seki$ar '/=?'/ (r:k(seki$ar '/=?'/ (r:k(

BB:0ariBB:0ari

. AJasi kaliu1 3a% alu1i% 3ara0AJasi kaliu1 3a% alu1i% 3ara0


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Es"imasi !)REs"imasi !)R. GFR @ =' 1l:1i%GFR @ =' 1l:1i% ko%serva$i-ko%serva$i-

. GFR @ ' 1l:1i%GFR @ ' 1l:1i% ,re3ialisis,re3ialisis

. GFR @ 4 1l:1i%GFR @ 4 1l:1i% 3ialisis/3ialisis/

$ra%s,la%$asi$ra%s,la%$asi


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Neropa"i Dia%e"ikNeropa"i Dia%e"ik


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. Diala1iDiala1i 'C ,e%3eri$a 3iae$es'C ,e%3eri$a 3iae$esse$ela0 4 $a0u%se$ela0 4 $a0u%

. Glove and stockingGlove and stocking %euro,a$i%euro,a$i

. Bila$eralBila$eral

. Ge


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Others ClassificationOthers Classification

Neuropati SensorikNeuropati Sensorik

Neuropati OtonomNeuropati Otonom

Neuropati MotorikNeuropati Motorik

Fenomena Reversibel CepatFenomena Reversibel Cepat

Manifestasi yang telah MenetapManifestasi yang telah Menetap

T0o1as PK2 I%$er%a$io%al Te9$ook o- Diae$es Melli$us/ &''>

Jenis Serabut Sara&

(espons terhadap )erapi


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Fak$or risikoFak$or risiko

. Ko%$rol (like1i urukKo%$rol (like1i uruk

. La1a 1e%(i3a, Diae$esLa1a 1e%(i3a, Diae$es

. U1urU1ur

. Pe1i%u1 alko0olPe1i%u1 alko0ol


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Neropa"i Dia%e"ikNeropa"i Dia%e"ikSymp"oms4Symp"oms4

. ur%i%(ur%i%(

. ,i%s a%3 %ee3les,i%s a%3 %ee3les

. ,ai%,ai%

No s!1,$o1sNo s!1,$o1s


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.alls.alls


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Neropa"i o"onomNeropa"i o"onom


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A"onomic ner(eA"onomic ner(e

#ama-e#ama-e


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Dia%e"ic perip$eral neropa"$yDia%e"ic perip$eral neropa"$y

screenin- "es"sscreenin- "es"s

Tes" sensa"ionTes" sensa"ion

. Bio"$esiome"erBio"$esiome"er

. Tnin- /orkTnin- /ork

. '9 -r mono/ilamen"'9 -r mono/ilamen"

Ankle re/leesAnkle re/lees


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Assessmen" o/ $i-$ riskAssessmen" o/ $i-$ risk

c$arac"eris"icsc$arac"eris"ics

E)NS i# li / "$ " " " /


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E)NS -i#elines /or "$e "rea"men" o/E)NS -i#elines /or "$e "rea"men" o/

pain/l polyneropa"$ypain/l polyneropa"$y

Dru(s Ji$0 es$alis0e3 e--i#a#! i%#lu3e T"As/ SNRIs/Dru(s Ji$0 es$alis0e3 e--i#a#! i%#lu3e T"As/ SNRIs/

(aa,e%$i%/ ,re(aali%/ s$ro%( o,ioi3s a%3 $ra1a3ol(aa,e%$i%/ ,re(aali%/ s$ro%( o,ioi3s a%3 $ra1a3ol

EFNS7 Euro,ea% Fe3era$io% o- Neurolo(i#al So#ie$ies

Firs$ li%e $0era,!Firs$ li%e $0era,!Pre(aali% *L!ri#aPre(aali% *L!ri#a++: (aa,e%$i% *Neuro%$i%: (aa,e%$i% *Neuro%$i%++T"As:SNRIs or *evi3e%#e level A+T"As:SNRIs or *evi3e%#e level A+

Se#o%3 li%e $0era,!Se#o%3 li%e $0era,! O,ioi3s a%3 la1o$ri(i%e *evi3e%#e level B+O,ioi3s a%3 la1o$ri(i%e *evi3e%#e level B+

La#k o- orLa#k o- orJeak e--i#a#!Jeak e--i#a#!

SSRIs/ #a,sai#i%/ 1e9ile$i%e/ o9#ara;e,i%e a%3SSRIs/ #a,sai#i%/ 1e9ile$i%e/ o9#ara;e,i%e a%3$o,ira1a$e *evi3e%#e level A+$o,ira1a$e *evi3e%#e level A+

LoJ s$re%($0 evi3e%#eLoJ s$re%($0 evi3e%#eor sa-e$! #o%#er%sor sa-e$! #o%#er%s

"ara1a;e,i%e a%3 val,roa$e"ara1a;e,i%e a%3 val,roa$e

Recommen#a"ions4


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Re"inopa"i Dia%e"ikRe"inopa"i Dia%e"ik


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Penyaki" Ma"a Dia%e"ikPenyaki" Ma"a Dia%e"ik

Re$i%o,a$i 3iae$ikRe$i%o,a$i 3iae$ik

Ka$arak 3iae$ikKa$arak 3iae$ik Iri$is rekure%Iri$is rekure%


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Skrinin- ma"a pa#a DMSkrinin- ma"a pa#a DM

. DM $i,e 4DM $i,e 4 ,eriksa o-$al1osko,i :,eriksa o-$al1osko,i :

-u%3usko,i-u%3usko,i se$ela0 $a0u%se$ela0 $a0u%

$er3ia(%osis/ sela%


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8isus8isus

Fu%3usko,i 3irekFu%3usko,i 3irek

Fu%3usko,i i%3irekFu%3usko,i i%3irek

Fo$o Re$i%aFo$o Re$i%a

Teka%a% i%$ra okuler Glauko1a Teka%a% i%$ra okuler Glauko1a

Skrinin- RDSkrinin- RD

) k" Ri ik)ak"or Risiko


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)ak"or Risiko)ak"or Risiko


. Ko%$rol (lukosa 3ara0 urukKo%$rol (lukosa 3ara0 uruk

. Hi,er$e%siHi,er$e%si

. Disli,i3e1iaDisli,i3e1ia

. Ne-ro,a$i 3iae$ikNe-ro,a$i 3iae$ik

. La1a%!a 1e%(i3a, DMLa1a%!a 1e%(i3a, DM


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Klasi/ikasi RDKlasi/ikasi RD

No% ,roli-era$i- re$i%o,a$i 3iae$ikNo% ,roli-era$i- re$i%o,a$i 3iae$ik

1ikroa%euris1a1ikroa%euris1a

eksu3a$eksu3a$

,er3ara0a%,er3ara0a%

Proli-era$i- re$i%o,a$i 3iae$ikProli-era$i- re$i%o,a$i 3iae$ik

,e1e%$uka% ,e1ulu0 3ara0 aru,e1e%$uka% ,e1ulu0 3ara0 aru

,er3ara0a% ,re re$i%al,er3ara0a% ,re re$i%al

s#ar?$issues#ar?$issue

Ri%(a%/

Se3a%(/

Bera$

%ia&etic retinopath'


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%ia&etic retinopath'("rric"!"m )od"!e ***+7a %ia&etic retinopath'

!ide 11 of 39

Normal retina

)ac"!a

;ptic disc



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p '("rric"!"m )od"!e ***+7a %ia&etic retinopath'

!ide 1# of 39

Non-proliferative diabetic

retinopathy

/ard e


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!ide 15 of 39

Proliferative retinopathy

New esse!s

-re+retina!

haemorrhae



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("rric"!"m )od"!e *** 7a %ia&etic retinopath'!ide 16 of 39

Advanced proliferativeretinopathy

car tiss"e

Pen-o%a"anPen-o%a"an


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Pen-o%a"anPen-o%a"an


Terapi in"ensi/Terapi in"ensi/

Ko%$rol (lukosa 3ara0 aikKo%$rol (lukosa 3ara0 aik ,ro(resi-i$as RD &'?' C,ro(resi-i$as RD &'?' C

*UKPDS+*UKPDS+

Ko%$rol (lukosa 3ara0 o,$i1alKo%$rol (lukosa 3ara0 o,$i1al

> C> C



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!ide #3 of 39

reatment

, 2aser therap':

-an+retina! for pro!iferati6e

retinopath'=oca! or .rid for mac"!ar

oedema

Ko%$rol (ula 3ara0 aikKo%$rol (ula 3ara0 aik 1e%uru%ka%1e%uru%ka%


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Se"iap' H%A'. Penrnan

Risiko ke5a#ian

'

Kema"ian aki%a" #ia%e"es

Penyaki" 5an"n- koroner

Penyaki" -in5al #ia%e"es

Penyaki" pem%l$ #ara$

peri/er

UKPDS 35. BMJ 2000; 321: 05!12.

Ko%$rol (ula 3ara0 aikKo%$rol (ula 3ara0 aik 1e%uru%ka%1e%uru%ka%

risiko ko1,likasi 3iae$esrisiko ko1,likasi 3iae$es

&>F

&

,@'2'''4

&'


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KesimplanKesimplan

. Ko1,likasi kro%ikKo1,likasi kro%ik 1ikro 3a% 1akro21ikro 3a% 1akro2

. MikroMikro RD/ND/ Neuro,a$i 3iae$ikRD/ND/ Neuro,a$i 3iae$ik

. MakroMakro

P)K/ s$rok/ PAPP)K/ s$rok/ PAP. Skri%i%( ko1,likasi 3i,erluka% 3a% ilaSkri%i%( ko1,likasi 3i,erluka% 3a% ila3i$e1uka% 0rs 3i$era,i i%$e%si-3i$e1uka% 0rs 3i$era,i i%$e%si-


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Pence-a$anPence-a$anPri1erPri1er7 1e%#e(a0 a(ar $i3ak $i1ul DM7 1e%#e(a0 a(ar $i3ak $i1ul DM

Seku%3erSeku%3er 7 Me%#e(a0 a(ar ,asie% DM7 Me%#e(a0 a(ar ,asie% DM

$i3ak erko1,likasi$i3ak erko1,likasiTersierTersier7Me%#e(a0 a(ar $i3ak $er


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Pe%#e(a0a% ,ri1erPe%#e(a0a% ,ri1erNu$risiNu$risi

A$asi Ke(e1uka%A$asi Ke(e1uka%

Ke(ia$a% $0% / ,eriksa (lukosa $era$ur

TGT:GDPTTGT:GDPT I%$e%sive Li-e s$!le/ oa$&I%$e%sive Li-e s$!le/ oa$&


71/71

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