2.16
Diabetes tipo II II: Fisiopatología
Fisiopatología
La diabetes mellitus tipo 2 (DT2) es un trastorno metabólico crónico caracterizado por resistencia a la insulina y una disfunción progre…
La diabetes mellitus tipo 2 es un trastorno metabólico progresivo crónico caracterizado por resistencia a la insulina y disfunción progresiva de las células beta pancreáticas, que conduce a una alteración de la regulación de la glucosa.
La resistencia a la insulina se desarrolla inicialmente en el músculo esquelético, el hígado y el tejido adiposo.
El músculo esquelético, el principal lugar de captación de glucosa tras el prandial, se vuelve menos sensible a la insulina, reduciendo la eliminación de glucosa.
Mientras tanto, la resistencia hepática a la insulina provoca una producción continua de glucosa incluso después de las comidas.
La señalización de insulina alterada y las células alfa desreguladas elevan los niveles de glucagón, incrementando aún más la producción de glucosa hepática.
En respuesta, las células beta compensan inicialmente aumentando la secreción de insulina; sin embargo, la exposición prolongada a la hiperglucemia y al estrés metabólico afecta progresivamente la función de las células beta.
En el tejido adiposo, la resistencia a la insulina aumenta la lipólisis, elevando los ácidos grasos libres circulantes, que empeoran la resistencia a la insulina a través de efectos lipotóxicos.
Estas alteraciones metabólicas interconectadas sostienen colectivamente la hiperglucemia crónica.
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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.