, 2015

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Theoretical top~csto be studied populated by the

department
1. Glucose estimation:
s. Normal blood glucose level
Jt Regulation of blood glucose level
~ Abnormalities of blood glucose (Hypoglycemia & Glucosuria)
jt Insulin & Diabetes Mellitus

2. Total plasma proteins estimation:

!Z General protein metabolism
Practical Exam
-7 Stations:
1. Pipetti ng of the reagent
2. Pipetting of the standard & test
3. Theoretical question (case)
4. Theoretical question (True or False) --
5. Theoretical question (MCQ 9r essay question)
6. Reading of the absorbance of the test & standard &
7. Calculation of the concentration of the test through the equation

Reading of test
C:mcer'U'z::tlc;l of test = X concentration 0'( standard
R~acJing of standard

T
Concentration of test = X cone, of 5
s

••
+ Comment on the result (Normal, increased or decreased)

~ Concentration of the standard for glucose is 100 mg/dl

.st Concentration of the standard for total plasma protein is 6..,gjdl
-----------------------------------------------------------------------------------------------------------------~

1
 ctical 2nd year 2015

1. Glucose estimation

1-
Test (T) Standard (S)
Glucose reagent 1 ml 1 ml
Test solution 10 u
Standard solution 10 u

Regulation of blood glucose

Fasting blood glucose (8-12 h) : 70 - 100 mg /dl
2 h post prandial:
--
70 - 140 mg /dl
A. Regulation by tissues & organs:
1. GIT: prevents sudden t in blood glucose through
• Slow rate of evacuation
• Maximum rate of absorption is 1 g /kg / h
o Secretion of gastric inhibitory peptide ~ 1 insulin (anttcipatorv effect)
2. Liver: Main glucose homoeostat
• During hyperglycemia: liver J blood glucose by :
-i Uptakeof glucose =70xidation (major & minor)
-'I Utilization of glucose ,..~>Storage (glvcogenesis & lipogenesis)
During hypoglycemia (fasting) : Liver i blood glucose by :
~1 glycogenolysis & gluconeogenesis
3. Kidney:
e During hyperglycemia: i Glycogenesis & excretion of glucose (if exceeds 180 mg/dl)
e During fasting: t gluconeogenesis
4. Skeletal Ms & adipose tissues:
e During hyperglycemia: i Uptake by Glut 4 (insulin dependent) & T storage
e During hypoglycemia: t Uptake & i catabolism of Ms (S( lipolysis in adipose tissue
B. Hormonal regulation:
1. Insulin: The only hypoglycemic hormone by;
-i Uptake of glucose !IT Oxidation (major & minor)
i Utilization of glucose /~Storage
5 (glycogenesis & lipogenesis)
- 1glycogenolysis & gluconeogenesis

2
 tical 2nd year i' 2015

. Anti-insulins : i Blood glucose

• Glucagon: i Glycogenolysis & gluconeogenesis & t glycolysis I glycogenesis
• Adrenaline: j Glycogenolysis I gluconeogenesis I lipolysis & ~ glycolysis} glycogenesis
• Glucocorticoids & GH : j Gluconeogenesis} lipolysis & 1 uptake} glycolysis
• Thyroxine: j Absorption, glycolysis} glycogenolysis gluconeogenesis & 1 storage
I

Hypoglycemia
Def. : J Blood glucose less than 4S mg /dl
Causes:
A. Fasting hypoglycemia:
1. t Insulin: Insulinoma or insulin overdose
2. 1Anti-insulins : Hypofunction of pituitary hypothyroidism or Addison disease
I

3. Liver disease: 1 Glycogen & t gluconeogenesis

4. Renal failure : ~ gluconeogenesis
5. Genetic diseases: Von Gierk's disease, fructose 1)6 bis-Pase deficiency or abnormal carnitine shuttle
B. Post-prandial hypoglycemia:
1. Alimentary hypoglycemis : In gastrectomy ~ rapid absorption of glucose
2.Reactive hvpoglvcernia : i glucose after CHO meal
3. Genetic diseases: Hereditary fructose intolerance & galactosemia
Glucosuria
Def. Presence of detectable amounts of glucose in urine
Causes:
A. Hyperglycemic glucosuria:
1. Diabetes mellitus: The commonest cause
2. Adrenaline glucosuria: Due to stress} pheochromocytoma & injection of adrenaline
3. Alimentary glucosuria; After gastrectomy or gastro-jejunostomy
C, Normoglycemic glucosuria:
1. Congenital renal glucosuria (diabetes innocens) : Isola Led defect in the kidneys
2. Renal fdilure
3. Pregnancy
4. Experimental glucosuria by phlorizin
Insulin
Chemistry:
jl 51 aa. Arranged in 2 chains A (21aa) & B (30 aa) connected by 2 disulfide bonds

Synthesis:
" By ~ cells of islets of langerhans of pancreas
.ll Synthesized in the form preproinsulin (109 aa) by removal of signal peptide (23 aa) converted to
proinsulin (86 ad) A & B connected by C peptide (35 ad) w' is secreted in equimolar amounts e' insulin
" Circulating C peptide contains 31 aa and used to measure the endogenous insulin secretion
jl Stored in ~ cells in combination e\ zinc

3
 tical 2nd year ) 201 5

Secretion: in response to l' intracellular calcium

! l' : Glucose,aa. especially arginine & GIT hormones (oral glucose r insulin more than IV glucose)
! J :Anti-insulins
Catabolism: By GSH insulin transhvdrogsnase & insulin protease
Mechanism of action:
! Through insulin receptors w' is formed of 4 subunits (2et & 2~)
~ Insulin binds e' a subunit leading to conformational change in the ~ subunit leading activation of
tyrosine kinase leads to autophosphorylation of tyrosine activating IRS w' performs the action of insulin
~ 4 IRS are recognized having the same structure but different tissue distribution
Actions of insulin:
1. CHO metabolism:
~t uptake of glucose (activates Glut 4 & induces glcokinase of the liver)
,..t utilization of glucose : ~ oxidation & "" storage (glycogenesis &Iipogenesis)
.t -l-glucose formation (glycogenesis & gluconeogenesis)
2. lipid metabolism:
.l l' lipogenesis & -l- lipolysis
.l ~ ketogenesis & l' ketolysis
~ l'Cholesterol synthesis
~ l' activity of LPL -7 clearance of chylomicrons
3. Ptn metabolism:
~l' anabolism &~ Ptn catabolism
Insulin resistance:
Def. : A state at w' a given cone. Of insulin produce less than expected biological effect
Causes; Obesity: ~ No. of receptors - Post receptor failure to activate tyrosine kinase
Congenital: Mutation of insulin receptors, glucose transporters or signaling ptn - antibodies
Hereditary: -l- exercise - Diet 2' high CHO K F,!\ - Aging·· Mc:dications
Tissues affected: Muscle (~ glycogen) - Liver (~ glycogen & l'glu~ose formation) - adipose tissue
(1'Lipolysis)
Diabetes Mellitus
Def.: Disease characterized by hyperglycemia, glucosuria, polyuria, polydepsia, plyphagia & loss of wt.
Classifications: Type 10M, type 110M, gestational OM & other specific types
Gestational OM :
Oef. : Glucose intolerance w' is 1st recognized during pregnancy
Cause: Placental steroid hormones
Prognosis: Blood glucose returns normal after 2-4 weeks of labor but 10% may continue e' DM
Specific types of OM :
l1' anti
insulin hormones ~ Surgical excision of pancreas
" Hemochromatosis .It Drug induced diabetes I.e. thiazide & salbutamol

4
 2015

el & type" OM: IACK OL T

Type 1(100M) Type 2 (NIDDM)
incidence 1Q..fQ... 9_Q.%
-
Age Under 20 Above ,iQ. yea rs
~ause •.Autoimmune
- Viral
__ III

destruction
~~,"~ II

of S-~~ils -
- Defect in insulin secretion
- Insulin resistance
/' '(-~.",,,,"," - .

Ketosis Common Rare

Onset Rapid Slow
level of insulin Absent or V&Ei low Usually present
Ireatment Insulin Injection Oral hypoglycemic drugs
Metabolic changes In DM
Similar to those occurring during starvation
1. CHOmetabolism:
~ -l- uptake of glucose
-'- -l- utilization of glucose : -l- oxidation &~ storage (glycogenesis &Iipogenesis)
-'-1' glucose formation (glycogenesis & gluconeogenesis)
This leads to hyperglycemia glucosuria I I polyuria & polydepsia
2. Changes in lipid metabolism:
-'- -!- lipogenesis & + lipolvsls
-'-
t ketogenesis & ~ ketolysis -7 ketosis
;it Hypertriacylglycerolemia & hypercholesterclem!a
3. Changes in Ptn metabolism:
.l t Ptn catabolism & -L anabolism (,y healing of wounds & t infection)
4. Water & electrolyte imbalance :
.!t Glucosuria & polyuria ~ Dehydration
~ Acidosis ~ loss of buffer cations: Na , K & j\JH4 ,

5. Complications of Diabetes: in uncontrolled diabetics + genetic susceptibility

A. Vascular complications:
• Macrovascular complications: due to atherosclerosis -7 CHD & stroke ~ mortality
• Microvascular complications: Retinopathy, nephropathy & neuropathy
Mechanism (cause) of vascular complications:
1. Activation of aldose reductase-s I' sorbitol w' poorly passes through membranes-7osmotic damage
2; Glycation of Ptns : glycated Ptns produce complex aggregates -7 microvascular complications
3. Reactive oxygen species (ROS)
B. Diabetic cataract: Due to activation of aldose reductase so :
~l' sorbitol w' poorly passes through cell membranes
-'--l- NADPH+H t
~ -l- GSH

5
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Diagnosis of OM
.Fasting & 2 " post-prandial
j
blood glucose I

Norma! Diabetic IGT

Fasting (mg/dl) -t 100 l' 126 100-126
2h PP (mg/dl) -t 140 l' 200 140 - 200
Z. Oral Glucose Tolerance Test (OGTT) :
,.After fasting for 8 - 12 h blood sample is withdrawn
I Pt. is given 75 g glucose in 250 ml water
'- Blood & urine samples are taken at intervals of 30 min
'- Blood samples are tested for glucose & urine samples
are tested for glucose & acetone
Normal curve:
Blood: fasting glucose below 100, rises after oral glucose then decrease below 140
Urine: A" urine samples are free of glucose & acetone
Diabetic curve:
Blood: fasting glucose more than 126 I rises more after oral glucose then 2h PP more than 200
Urine: urine samples contain glucose & may be acetone
IGT: Blood glucose is higher than normal but less than DM
Flat curve: due to malabsorption - delayed evacuation - hypopituitarism
Lagging curve.' due to gastrectomy - hyperthyroidism
Renal glucosuria: glucose in urine while blood glucose doesn't exceed 180 mg/dl
Gestational DM :
Normal blood glucose in pregnancy: fasting: around 75 mg /dl - 2h PP rarely exceeds 120 mgjdl
To diagnose gestational OM 2 or more values must exceed the following values:
I Fasting 11 h I 2h ~~3-h-~
I Glucose level
I (mgjdl) I 95 1130 1155 1140 __ !
3. Measurement of glycatec Hb (rlbAlc) ;
.!. Used in diagnosis & follow up of diabetes

.It Glucose binds to f\1-terminal valine

~ Not affected by the immediate change in blood glucose
Jt Give idea about blood glucose for the last 60 days (6-8 weeks)
Jt Normal: 4 - 6.5 % , DM : l' 6.5 % , Un controlled DM : l' 8 %
4. Measurement of plasma fructosamine :
~ Suitable when there's a problem in measurement of HbAlc i.e. hemolytic anemias, recent treatment
or pregnancy
.It Gives an idea about the blood glucose over a shorter period 2 - 3 weeks I"

6
 /
ical 2nd year 2015

Diabetic coma
D ketoacidosis Hyperosmolar coma Hypoglycemic
coma
Type of OM
I
I III Any
Cause Poor treatment Poor treatment Over
treatment
Cause of coma Ketoacidosis Hvpercsmolaritv Hypoglycemia
Respiration Hyp erve nti lation Normal Normal
Skin Dry Dry Sweaty
Pulse Rapid weak Rapid weak Rapid strong
Plasma glucose High High Low
Urine glucose Present ,
Present Absent
Urine ketone Present Absent Absent
Treatment IV insulin + glucose
-~-
+ .bicarbonate + K
-
IV insulin IV glucose

• Diabetic ketoacidosis is common in type I & can occur in type II & is associated e' k~s & dehydration
»
• Diabetic ketoacidosis can be precipitated by stress and infection

-
• Diabetic ketoacidosis is treated by K to prevent hypokalemia as insulin produces intracellular shift of K
• Hyperosmolar coma is common in type II diabetes old age exposed to stress
Treatment of DM ;
1. Diet control : -l- weight in obese persons e' type II DM
2. Exercise : ~ Hyperglycemia & improves glucose tolerance
3. Oral antidiabetic drugs: in type" OM NOT in type!
a. l' insulin secretion: Sulfonylurea: Binds ATP sensitive K channels
b. l' insulin sensitivity: Metformin: .l.hcpatic glucolJ2ogenesis; /~insllljn sensitivity
c. ,1- acscrprior 'JI' [;-)0 ;l, ',<:a~: Acarbose 2, orlistat
d. Glucagon like peptide receptor agonist: ~'insuljn - ~ glucagon - -l- gastric emptying -1'~cell mass
4. Insulin.' SC or inhalation (under trials)
Case study
Type j diabetes mellitus
Characters: Child, i level of blood glucose, Polyuria -loss of weight - coma
Questions:
1. What is your diagnosis?
2. What are the causes of this condition?
_-
Auto-immune destruction of ~ cell- _w _
viral infection

3. What are the complications of this condition?

Hypercholesterolemia - atherosclerosis - cataract - retinopathy - nephropathy-
4. Comment on the repeating coma -
Diabetic ketoacidosis due to :

7
 tical 2nd year ]201 5
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t lipolysis ---7 i FFA ---7 i TCA cycle -> i acetyl CoA ---7 i ATP
Ilnsulin &
t Anti-insulin ~ 1Glycolysis ---7 .J., pyruvate ---7 t oxaloacetate
"i Acetyl C:oA in mitochondria may be either utilized iFl--E1J
f~X.Q.,.~sis(cytosol) or oxidation in TeA
cycle (mitochondria) or in ketogenesis (mitochondria)
'II As there is no oxaloacetate & i ATP level-» acetyl CoA is utilized in K8J>~he$i$
? As there is low insulin, level -7 1 ketolysis
..i Ketogenesis &.,Iketolysis ~ ketosis
5. What are the lines of treatment of this kind rf! coma ?
2. IV glucose & insulin in OM
3. Bicarbonate to correct acidosis
'5
4. K in case of hypokalemia
5. IV fluids in cases of dehydration a
6. Compare between different types of coma in this condition?
See before
7. What is the normal level of blood glucose?
Fasting: less than 100 rng /dl & 2h post-prandial: less than 140 mg/dl
--". .
Type II diabetes mellitus
Characters; Adult (more than 40 years old), Obese, i level of blood glucose, Polyuria r loss of weight
Questions:
1. What is your diagnosis ?
2, What are the causes of thls condition?
Insulin resistance - defect in insulin secretion
3. What are the complications of this condition? .
Hypercholesterolemia - atherosclerosis - cataract - retinopathy - nephropathv - neuropcith\j L-- ...

4. Cornpare bstwesn types o'r this condition ,S~:; oefor,: I·

5. iNhat are the lines of treatment in this case
OraJ hypoglycemic drugs then insulin
- ~~~... ~ sc ..••.

5. 'What is the ncrrnal leve) 0'[ blood gtucoss ?

Fasting; Less than 100 mg /dl & 2h post-prandial: les$ than 140 mg/dl
7. Explain why cataract may occur in. this case
,
\
j

Due to activation of aldo$~ rgQl 1,.ilSe so : \

.l l' sorbitol w' poorly passes through cell membranes I
~ .J,. NADPH+H+ ~ .J,. GSH
Jt l' NDH+H+ -7 .J., Glycolysis

Mea questions
\
I

L. Ketoacidosis is both a normal physiologic response to prolonged caloric restriction (during fasting)
ind also an abnormal process associated with type 1 diabetes. which one of the following sets of
rvents best distinguishes the untreated metabolic process from the physiological one 'of fasting?
relative to the fasting state I in type 1 diabetes mellitus I there is

8
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~.An increased glucagon-insulin ratio, a higher liver cAMP level and an eQuivale1,hlood glucose level
b. An equivalent insulin level, a higher liver cAMP and a higher blood glucose le}'lel
c. A lower insulin level, a higher blood glucose and high blood FA level \
d. A lower insulin level, a higher blood glucose and equivalent blood FA level \
2. How does insulin promote the growth and di-ffereurtiation of hepatocvtes? i

a. It increases adenylate cyclase activity /'

b. It binds a nuclear receptors
c. It activates protein kinase C !
d. It activates tyrosine kinase '
3. Which of the following statements about insulin is I\JOTcorrect? Insulin a,ts to :
a. Increase the rate of synthesis of liver glucokinase j
!
b. Enhance the rate of transport of amino acids into muscles i
c. Increase the activity of intracellular tyrosine kinase I
d. Increase the rate of transport of glucose into brain cells !
4. All the following statements correctly describes insulin EXCEPT: .
a. It is a small protein composed of 2 chains connected by disulfide bridges
b. It is antagonistic to the action of glucagon
c. It is converted from proinsulin to insulin primarily following secretion from ~eta cells
d. It is inactive when in the proinsulin form!,
~
5. Relative or absolute lack 0-( insulin in humans would result in which one of the following reactions
I
in the liver?
A. Increased glycogen synthesis.
B. Decreased gluconeogenesis from lactate. \
I
c. Decreased glycogenolysis.
D. Increased formation of 3-hydroxybutyrate.
E. Decreased action of hormone-sensitive lipase . \
6. Which one of the following is most often found in untreated patients with Tvpe 1 and Type 2
diabetes?
A. Hyperglycemia.
B. Extremely low levels of insulin synthesis and secretion.
C. Synthesis of an insulin with an abnormal amino acid sequence.
D. A simple pattern of genetic inheritance.
E. Ketoacidosis.
,
7. An obese individual with Type 2 diabetes:
A. Usually shows a normal glucose tolerance test. \
B. Usually has a lower plasma level of insulin than a normal individual. \
c. Usually shows significant improvement in glucose tolerance if body weight is redu;ced to normal.
D. Usually benefits from receiving insulin about six hours after a meal.
E. Usually has lower plasma levels of glucagon than a normal individual

I
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 riCClI 2nd year Ii 201 5
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. An individual with insulin resistance:

~. Usually shows elevated fasting glucose levels,
B. Usually shows elevated fasting insulin levels.
C, Will eventually become diabetic.
O. 15 rarely obese.
E. Is treated by injection of insulin
9. Glutathione-insulin transhvdrogenase:
J
a. requires the presence of glutathione as a coenzyme
b. degrades insulin by reduction of the disulphide bonds
c. insulin degradation occurs in the liver
.f
d. all of the above I
I
I
lO.Which of the following statements about insulin is NOT correct?
f
a. increase the rate of synthesis of liver glucokinase !
b. enhance the rate of transport of amino acids into muscles
c. increase the activity of intracellular tyrosine kinase
d. increase the rate of transport of glucose into brain cells
11. Obesity, genetic profile, and aging all contribute to the development of Tvpe, II diabetes. O'r the
r

following, which is the most important additive factor for these three conditions I in the development
of Type 1\ diabetes? I,
(A) elevated hepatic ketogenesis
~
I
(8) elevated pancreatic glucagon secretion
(C) impaired renal clearance of glucose
(D) increased adipose tissue activity leading to hyperlipidemia i

(E) muscle resistance to insulin \

12. Patients with poorly controlled diabetes mellitus have elevated levels of blood glucose. Om'!
severe consequence of the hyperglYCEmia is ar lncraass in gluCOSE 8U8cnment to serum proteins,
Which of the following proteins, when glvcosylated, is an 0xcelient measure of the length of time
someone has suffered from an episode of hyperglycemia?
(A) albumin (8) cholesterol \
(C) fatty acids (0) hemoglobin (E) transferrin
13. In Type I diabetes, the increased production of ketone bodies is primarily a result O"{ which of the
following? \
A) a substantially increased rate of fatty acid oxidation by hepatocytes
8) an increase in the rate of the citric acid cycle
C) decreased cyclic adenosine monophosphate(cAMP) levels in adipocytes
D) elevated acetyl-CoA levels in skeletal muscle (E) increased gluconeogenesis
Answers:
2.0 3.0 4.C 5.0
7. C 8. B 9. D 10.0
.1. e 12.D 13. A

10