Diabetes Mellitus Complications

• Diabetic patients need follow-up and proper control to prevent diabetic complications.

What are the complications as the presenting signs/symptoms?

1. Infections by staphylococcal.
2. History of impotence.
3. History of polyneuropathy, which will present as tingling and numbness of feet.
4. Arterial disease results in acute myocardial infarction or gangrene of the foot.
5. There is retinopathy, which is detected on examination by the eye specialist.

What will be the presentation of the complications of Diabetes Mellitus?

1. There may be hypoglycemia.
2. Patients with hyperglycemia of Type I, left uncontrolled, may develop life-threatening complications like diabetic Ketoacidosis.
   1. Without treatment, the patient may become acidotic and dehydrated and lose consciousness.
3. Type II may develop hyperosmolar coma.
4. Peripheral neuropathy.
5. Diabetic retinopathy and cataract formation may lead to blindness.
6. Cardiovascular microangiopathy.
   1. Coronary atherosclerosis.
   2. Myocardial infarction is 3 to 5 times more common in diabetic patients.
   3. AMI is the leading cause of death in diabetes mellitus type 2.
7. Peripheral vascular diseases like ischemia of lower extremities, erectile dysfunction, and intestinal ischemia.
   1. Gangrene of the foot.
8. Diabetic kidney diseases, diabetic nephropathy.
   1. It may lead to renal failure.
9. Chronic pyogenic skin infection.
   1. Candidal infection of the skin.
10. Bone and joints show contracture.
11. In the end, maybe result in stroke, gangrene, and coronary artery diseases.
12. These patients may have gum and mouth diseases.

Diabetes mellitus complications

Diabetes Mellitus complications

How will you classify the diabetes mellitus complications?

What are the Acute complications?

Hypoglycemia:

1. In the case of excess insulin injection and excess intake of alcohol, especially with an empty stomach, it can lead to hypoglycemia.
2. Increased hypoglycemia risk includes autonomic neuropathy, gastroparesis, and end-stage chronic kidney disease.
3. Hypoglycemia occurs in impaired glucagon response, sympathoadrenal responses, and cortical deficiency.
4. Hypoglycemia can be classified as:
   1. Reactive, seen after eating.
   2. Fasting hypoglycemia is seen due to organic diseases like the liver, kidneys, pancreas, and deficiency of hormones.
   3. Combined, including reactive and fasting hypoglycemia.

Hyperglycemia:

1. Patients with uncontrolled hyperglycemia of Type I diabetes mellitus may develop life-threatening complications like diabetic Ketoacidosis.
   1. Without treatment, the patient may become acidotic and dehydrated and lose consciousness.
2. Type 2 diabetes mellitus may develop hyperosmolar coma.
3. Hyperglycemia may be seen in:
   1. Diabetic ketoacidosis.
   2. Lactic acudosis.
   3. Alcoholic ketoacidosis.
   4. Hyperosmolar coma.

What are the Chronic complications?

1. These lead to hypertension, end-stage chronic renal diseases, Blindness, autonomic and peripheral neuropathy, amputation of the lower limbs,  myocardial infarction, and cerebrovascular accidents.
2. Diabetic neuropathy:
   1. The most common is diabetic peripheral neuropathy, where the loss of function appears in a stocking-glove pattern and is due to an axonal neuropathic process.
   2. Foot motor and sensory nerve conduction are delayed in the peripheral nerves, and ankle jerk may be absent.
   3. Isolated peripheral neuropathy is the involvement of the distribution of one nerve. This is attributed to vascular ischemia or traumatic damage. Cranial and femoral nerves are more commonly involved.
   4. Autonomic neuropathy is seen in advanced and long-standing diabetes mellitus. This may involve visceral blood pressure, pulse, gastrointestinal activity, urinary bladder function, and erectile function.
   5. Peripheral neuropathy. There is the involvement of the cranial and peripheral nerves.
3. Ocular complications:
   1. Premature cataracts occur in diabetics.
   2. There is retinopathy of two types; one is called nonproliferation, and the other is called proliferative retinopathy.
   3. Glaucoma occurs in 6% of diabetics.
4. The involvement of small and large size blood vessels.
   1. Cardiovascular microangiopathy may explain the etiology of congestive cardiomyopathy in people with diabetes who don’t have evident coronary artery disease.
   2. Coronary atherosclerosis gives 3 to 5 times more myocardial infection in diabetics and is the leading cause of death in type 2 diabetes mellitus.
   3. Type 1 diabetes mellitus has also increased the risk of coronary artery disease. It is lower than type 2 DM.
   4. AMI is the leading cause of death in diabetes mellitus type 2.
   5. Peripheral vascular diseases like ischemia of lower extremities, erectile dysfunction, and intestinal ischemia.
   6. Gangrene of the foot.
5. Diabetic nephropathy:
   1. 30% to 40% of type 1 diabetes Mellitus develop nephropathy over 20 years of diabetes.
   2. In type 2 diabetes, nephropathy is less common. Only 15 to 20% develop renal disease.
   3. Diabetic kidney disease (diabetic nephropathy) may lead to end-stage renal disease.
   4. Initially, there is proteinuria, followed by a decline in renal functions, increasing the blood urea and creatinine.
      1. This renal disease can be assessed by microalbuminuria.
   5. Also, advise the albumin/creatinine ratio.
      1. The albumin/creatinine ratio <30 is normal.
      2. The ratio of 30 to 300 mcg/mg suggests abnormal microalbuminuria.
      3. Chronic renal disease is suspected when persistent albumin excreted more than 30 mcg/mg creatinine.
      4. Patients develop nephrotic syndrome with hypoalbuminemia, edema, increased LDL-cholesterol, and increased azotemia when inadequate treatment.
      5. Ultimately, there is end-stage renal disease.
6. Chronic pyogenic skin infection.
   1. Candidal infection of the skin. Also, there is vulvovaginitis in the female with uncontrolled diabetes mellitus.
   2. In type 2 poorly controlled diabetics, there are eruptive cutaneous xanthomas.
7. Bone and joints show contracture.
   1. In chronic and long-standing diabetics, the hand’s progressive stiffness is secondary to the contracture and tightening of the skin over the joints (diabetic cheiroarthropathy).
   2. There may be frozen shoulders, which is adhesive capsulitis.
   3. There may be carpel-tunnel syndrome and dupuytyren-contracture.
   4. There may be hyperuricemia, and tophaceous gout is more common in type 2 diabetics.

Acute and chronic complications of diabetes mellitus:

How will you prevent complications for diabetic patients?

1. Basic metabolic panel:
   1. Fasting glucose level.
   2. Postprandial glucose level
   3. Microalbuminuria.
   4. BUN (urea).
   5. Creatinine.
   6. Electrolytes.
      1. Anion gap = (Sodium + potassium) — (Chloride + bicarbonate)
   7. HbA1c.
2. Lipid profile:
   1. Cholesterol.
   2. Triglycerides.
   3. HDL.
   4. LDL.
3. Check the urine regularly of all diabetic patients for microalbuminuria. The presence of proteinuria is the first sign of nephropathy.
   1. This can be slowed by antihypertensive therapy in case of hypertension.
   2. A renal biopsy may be done to evaluate kidney histology.

Questions and answers: