blocks a 7 lecvvvhture diabetes complications

7/17/2019 Blocks a 7 LecVVVHture Diabetes Complications

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Diabetes Complications

DG van Zyl


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The Ticking Clock


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Different Diabetes Complications

Macro vascular

Micro vascular

Neuropathy

Infections


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Mechanisms

Hyperglycemia Tissue damage

*Repeated acute changes

in cellular metabolism

**Cumulative long term

changes in stable

macromolecules

Genetic susceptibility

Independent accelerating factors


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Macro vascular Complications


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Macro-vascular Complications

Ischemic heart disease

Cerebrovascular disease

eripheral vascular disease

Diabetic patients have a ! to " times higher risk for

development of these complications than thegeneral population


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Macro-vascular Complications

The ma#or cardiovascular risk factors in the

non-diabetic population $smoking%

hypertension and hyperlipidemia& alsooperate in diabetes% but the risks are

enhanced in the presence of diabetes'

(verall life e)pectancy in diabetic patients is* to +, years shorter than non-diabetic

people'


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Macro-vascular Disease

(nce clinical macro-vascular disease

develops in diabetic patients they have a

poorer prognosis for survival thannormoglycemic patients ith

macrovascular disease

The protective effect females have for thedevelopment of vascular disease are lost

in diabetic females


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C.D Morbidity and Mortality in

Type ! DM

/ramingham Data0 !,year follo-up0.ge12-*10 !-3 fold increase in

clinically evidentatheroscleroticdisease in diabetics

omendiabetics4malediabetics in terms ofC.D mortality

Multiple 5isk /actorIntervention Trial$M5/IT& 2,,, men ith type !

DM /olloed for +! years Men ith type ! DM

had absolute risk ofC.D-related death 3times higher than non-diabetic cohort


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5isk /actor Clustering in

Diabetes

Type ! Diabetes at Diagnosis0 2,6 have hypertension

3,6 have dyslipidemia 78D90

rospective study

Nely detected type ! DM0 332 ith C.D% : year follo-up

.ssociated ith elevated ;D;-C% lo levels of


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Cardiovascular Death 5ates0

M5/IT data

Stamler J. et al !iabetes Care" #$" %&%'%%%


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5isk of MI in Diabetes

Haffner S( et al )J(" &&+" ,,+',&%


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lasma Glucose as Independent

5isk /actor

-ndersson ! et al. !iabetes Care #/" #0&%'#0%&


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Glycemic Control to 5educe C.D

DCCT trial: +11+ patients% type + diabetes

5andomi=ed to intensive

glycemic control vs'

conventional therapy

Monitored prospectively for "'2

years

5esults0

;ess retinopathy by 2,6 Macrovascular complications0

1+6 reduction $not statistically

significant&

-small number of events in

young patient cohort

UKPDS: 3:"* patients ith

nely diagnosed type !

DM

Intensive vs'

Conventional therapy

+, year follo-up

Microvascular

endpoints improved Trend only toards

reduced incidence of MI

$ p4,',2!&


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>ffect of


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?hy orry about


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athophysiology of hypertension

Type + DM

9econdary tonephropathy

.ctivation of the5..9

Type ! DM


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Goals of Treatment of


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>ffect of Cholesterol

Serum c$olesterol vs Mortality

,

+,

!,

3,

1,

2,",

*,

1 2 " *

s%C$olesterol (mmol&')

Te

!earMortality(per

"###)

Non-diabetic

Diabetic


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Dyslipidaemia in DM

Most common abnormality is s


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Micro vascular Complications


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>ye Complications

Cataracts

Non en=ymatic glycation of lens protein and

subseuent cross linking

9orbitol accumulation could also lead to osmoticselling of the lens but evidence of involvement

in cataract formation is less strong


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>ye Complications

5etinopathy $stages&

@ackground

re-proliferative

roliferative

.dvanced diabetic eye disease

Maculopathy

Glaucoma


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Diabetic 5etinopathy $D5&

D5 is the leading cause of blindness in theorking population of the ?estern orld

The prevalence increase ith the durationof the disease $fe ithin 2 years% :, J+,,6 ill have some form of D5 after !,years&

Maculopathy is most common in type !patients and can cause severe visual loss
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@ackground 5etinopathy

Micro aneurisms

9cattered e)udates


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@ackground retinopathy


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re-roliferative 5etinopathy

5apid increase inamount of microaneurisms

Multiple hemorrhages Cotton ool spots

$H2&

Fenous beading%looping andduplication

Proliferative retinopathy


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roliferative 5etinopathy

Ne vessels $on disc%

elsehere&

/ibrous proliferation$on disc% elsehere&


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roliferative retinopathy


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Fitreous @leeding


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5ubeosis Iridis


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.dvanced Diabetic >ye Disease

5etinal detachment

ith or ithout retinal

tears 5ubeosis iridis

Neovascular

glaucoma


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Maculopathy

Macular edema $focal

or diffuse&

Ischaemicmaculopathy


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Maculopathy


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Diabetic Nephropathy $DN&

Diabetes has become the most commoncause of end stage renal failure in the 79

and >urope.bout !, J 3,6 of patients ith diabetes

develop evidence of nephropathy

The prevalence of DN is higher in @lack.mericans than in ?hites $/igures for9outh .frica is not available&


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9tages of Diabetic Nephropathy


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9tages of DN

9tage I

glomerular filtration and kidney

hypertrophy

9tage II

u-albumin e)cretion 3,mgE!1h

9tage III

Microalbuminuria $3, J 3,, mgE!1h&


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9tages of DN $cont&

9tage IF

(vert nephropathy $H 3,,mgE!1h% positive

u dipstick&

9tage F

>95D characteri=ed by blood urea and

creatinine levels% hyperkalaemia and fluidoverload


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Diabetic Neuropathy

9ensorimotor neuropathy $acuteEchronic&

.utonomic neuropathy

Mononeuropathy

9pontaneous

>ntrapment

>)ternal pressure palsies

ro)imal motor neuropathy


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9ensorimotor Neuropathy

atients may be asymptomatic E complain

of numbness% paresthesias% allodynia or

pain /eet are mostly affected% hands are

seldom affected

In Diabetic patients sensory neuropathyusually predominates

C li ti f 9 i t


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Complications of 9ensorimotor

neuropathy

7lceration $painless&

Neuropathic edema

Charcot arthropathy Callosities


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.utonomic Neuropathy

Symptomatic

ostural hypotension

Gastroparesis

Diabetic diarrhea

Neuropathic bladder

>rectile dysfunction

Neuropathic edemaCharcot arthropathy

Gustatatory seating

Subclinical abnormalities

.bnormal pupillary refle)es

>sophageal dysfunction

.bnormal cardiovascular

refle)es

@lunted counter-regulatory

responses to

hypoglycemia

Increased peripheral blood

flo


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Mononeuropathies

Cranial nerve palsies

$most common are n'

IF%FI%FII&

Truncal neuropathy

$rare&


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>ntrapment Neuropathies

Carpal tunnel syndrome $median nerve& 7lnar compression syndrome

Meralgia paresthetica $lat cut nerve to thethigh&

;at opliteal nerve compression $drop

foot&All the above are more common in diabetic

patients


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ro)imal Motor Neuropathy

.myotrophy J most common pro)imal

neuropathy% affects the Kuadriceps

muscles ith eakness and atrophy$synonym0 Diabetic /emoral radiculo-

neuropathy&


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Diabetic .myotrophy


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Thoracoabdominal 5adiculopathy


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9udomotor Dysautonomia


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9ummary

Diabetic neuropathy is a common

complication% and result in significant

morbidity Diabetic neuropathy present in numerous

ays


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9ummary $cont&

Diabetic neuropathy have badconseuences

Diabetic neuropathy can be prevented inonly one ay

(nce diabetic neuropathy is present it canonly be managed symptomatically

>arly diagnosis and aggressivemanagement can prevent progression


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Infections

The association beteen diabetes and increased

susceptibility to infection in general is not

supported by strong evidence


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Infections $cont&

9everal aspects of immunity are altered in

patients ith diabetes

There is evidence that improving glycemiccontrol patients improves immune function


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9pecific Infections

Community acuiredpneumonia

.cute bacterialcystitis

.cute pyelonephritis >mphysematous

pyelonephritis erinephric abscess /ungal cystitis

Necroti=ing fasciitis

Invasive otitis e)terna

5hinocerebralmucormycosis

>mphysematous

cholecystitis


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5hino-Cerebral Mucormycosis


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9creening and Management

9trategy for Diabetes

Complications

9creening for Macrovascular


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9creening for Macrovascular

Complications

+' >)amine pulses and for cardiovascular

disease

!' ;ipogram3' >CG

1' @lood pressure

+-3 annually

1 every visit $uarterly&


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9creening for >ye disease

Annually

Fisual acuity $corrected ith pinhole or

lenses&Careful eye e)amination $noting the clarity

of the lens and any retinal changes

$(phthalmoscopy through dilated pupils&


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9creening for >ye disease

When to refer?

9evere non-proliferativeEproliferative retinopathy

Macular edema or e)udates in close pro)imity tothe macula

Cataract

7ne)plained reduction in visual acuity


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9creening for Nephropathy

Annually

Do one of the folloing0

u .lbumin0Creatinine ratio $spot sample&!1h u .lbumin e)cretion rate

>arly morning .lbumin concentration

$spot sample&

Dipstick for MicroalbuminuriaIf positive the test must be repeated tice in the ensuing 3 months' Microalbuminuria ith

incipient nephropathy is diagnosed if ! or more of the tests are ithin themicroalbumin range


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Microalbuminuria

Increased risk for overt nephropathy Increased cardiovascular mortality

Increased risk of 5etinopathy Increased all-cause mortality

Thus

Microalbuminuria is an indication for screening

for possible vascular disease and aggressiveintervention to reduce all cardiovascular riskfactors

9creening Tests for


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9creening Tests for

Microalbuminuria

Category24h u

collection(mg/24h)

Timedcollection(mg/min)

Spotcollection(mg/mgcreat)

Normal


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?ho to 9creen /or

Microalbuminuria

Type " Diabetes

@egin ith puberty

.fter 2 yearsduration of disease

9hould be done

annually there after

Type ( Diabetes

9tart screening at

the Diagnosis ofdiabetes

9hould be done

annually there after


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Management of Nephropathy

Improvement of glycemic control

Treatment of hypertension

Treatment ith angiotensin convertingen=yme inhibitors

5estriction of dietary intake of protein

(nce persistent elevation in u-.lbumin is

found refer to a Internist or Nephrologist


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9creening for Neuropathy

+!:


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7sing of the Monofilament


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Management of Neuropathy

@urning pain J T.Ds E Capsaicin

;ancinating pain J .nticonvulsants E T.D E

Capsaicin ainful cramps J Kuinidine sulphate

5estless legs - Clona=epam


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DoLs and Donts of foot care

Patiet s$ould check feet daily ?ash feet daily 8eep toenails short rotect feet .lays ear shoes ;ook inside shoes before

putting them on .lays ear socks @reak in ne shoes gradually


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Conclusion

This is #ust an outline of the ma#or diabeticcomplications% and doesnt aim to be

comprehensive.ll complications are preventable ith

good glycaemic control The progression of most complications

can be halted if detected early andappropriate therapy instituted

blocks a 7 lecvvvhture diabetes complications

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