2.16
Typ-II-Diabetes II: Pathophysiologie
Pathophysiologie
Typ-2-Diabetes mellitus (T2DM) ist eine chronische Stoffwechselerkrankung, die durch Insulinresistenz und eine fortschreitende β-Zell-…
Typ-2-Diabetes mellitus ist eine chronische, progressive Stoffwechselstörung, die durch Insulinresistenz und eine fortschreitende Betazelldysfunktion der Bauchspeicheldrüse gekennzeichnet ist und zu einer beeinträchtigten Glukoseregulation führt.
Insulinresistenz entwickelt sich zunächst im Skelett, in der Leber und im Fettgewebe.
Die Skelettmuskulatur, der primäre Ort der postprandialen Glukoseaufnahme, reagiert weniger auf Insulin und reduziert die Glukosefreisetzung.
Unterdessen führt hepatische Insulinresistenz zu einer anhaltenden Glukoseproduktion auch nach den Mahlzeiten.
Beeinträchtigte Insulinsignalübertragung und dysregulierte Alphazellen erhöhen die Glukagonspiegel und erhöhen so die Leberglukoseproduktion weiter.
Als Reaktion darauf kompensieren Betazellen zunächst durch eine erhöhte Insulinsekretion; eine längere Exposition gegenüber Hyperglykämie und metabolischem Stress beeinträchtigt jedoch zunehmend die Funktion der Betazellen.
Im Fettgewebe erhöht die Insulinresistenz die Lipolyse und erhöht die zirkulierenden freien Fettsäuren, die die Insulinresistenz durch lipotoxische Effekte verschlimmern.
Diese miteinander verbundenen Stoffwechselstörungen tragen zusammen zu chronischer Hyperglykämie.
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Q1: What causes insulin resistance in type 2 diabetes?
Insulin resistance develops initially in skeletal muscle, liver, and adipose tissue. Skeletal muscle becomes less responsive to insulin, reducing glucose clearance despite normal or high insulin levels. The liver fails to suppress gluconeogenesis, causing excess glucose production. In adipose tissue, insulin resistance increases lipolysis, elevating free fatty acids that worsen insulin resistance through lipotoxic effects.
Q2: How does hepatic glucose output increase in type 2 diabetes?
Hepatic insulin resistance prevents the liver from suppressing glucose production after meals. Additionally, impaired insulin signaling and dysregulated alpha cells elevate glucagon levels, further increasing hepatic glucose output. This dual mechanism sustains chronic hyperglycemia by maintaining elevated fasting and postprandial glucose levels despite the body's attempt to regulate blood sugar.
Q3: What happens to pancreatic beta cells over time in type 2 diabetes?
Beta cells initially compensate for insulin resistance by increasing insulin secretion. However, prolonged exposure to hyperglycemia and metabolic stress progressively impairs beta-cell function. Glucotoxicity, lipotoxicity, oxidative stress, and inflammation reduce beta-cell mass through apoptosis, leading to inadequate insulin secretion and worsening glucose control.
Q4: How do free fatty acids contribute to type 2 diabetes progression?
Elevated free fatty acids from increased adipose tissue lipolysis worsen hepatic insulin resistance and directly damage beta cells through lipotoxic effects. Reduced lipoprotein lipase activity contributes to diabetic dyslipidemia, characterized by high triglycerides, low HDL, and small dense LDL particles, further perpetuating metabolic dysfunction.
Q5: What role does skeletal muscle play in glucose regulation in type 2 diabetes?
Skeletal muscle is the primary site of postprandial glucose uptake. In type 2 diabetes, muscle insulin resistance reduces glucose clearance despite normal or elevated insulin levels. Additionally, muscle insulin resistance alters protein metabolism, increasing amino acid release that fuels gluconeogenesis, further elevating blood glucose.
Q6: How can type 2 diabetes lead to serious acute complications?
Stress hormones including cortisol and catecholamines worsen hyperglycemia and may trigger hyperosmolar hyperglycemic state or, rarely, diabetic ketoacidosis. Chronic hyperglycemia causes protein glycation, oxidative stress, and inflammation, leading to macrovascular complications such as coronary artery disease and stroke, as well as microvascular complications.
Q7: What are the long-term microvascular complications of type 2 diabetes?
Chronic hyperglycemia causes microvascular complications including diabetic neuropathy, diabetic nephropathy, and diabetic retinopathy. These result from protein glycation, oxidative stress, and inflammation affecting small blood vessels and nerves. Understanding these complications is essential for recognizing clinical manifestations and diagnosis in affected patients.