Diabetes Mellitus:- Part 6 – Diabetes Mellitus Complications and Prevention

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

The complication of Diabetes Mellitus:

1. There may be hypoglycemia.
2. In 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 may lose consciousness.
3. Type II may develop hyperosmolar coma.
4. Peripheral neuropathy.
5. Diabetic retinopathy and cataract formation, it 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 patients with 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.

Diagnosis	Fasting glucose level	Random glucose level	2-hour glucose level (in OGTT)	HbA1c
Prediabetics	100 to 125 mg/dL	140 to 199 mg/dL	40 to 199 mg/dL	5.7 to 6.4%
Diabetes mellitus	> 126 mg/dL	>200 mg/dL	>200 mg/dL	>6.5%

The Complication Of Diabetes Mellitus:

Acute complications are:

1. Hypoglycemia:
2. In the case of excess insulin injection, and excess intake of alcohol especially with an empty stomach can lead to hypoglycemia.
3. The increased risk for hypoglycemia includes autonomic neuropathy, gastroparesis, and end-stage chronic kidney disease.
4. Hypoglycemia occurs in impaired glucagon response, sympathoadrenal responses, and cortical deficiency.
5. Hyperglycemia:
6. In patients with hyperglycemia of Type I diabetes mellitus left uncontrolled, they may develop life-threatening complications like diabetic Ketoacidosis.
   1. Without treatment, the patient may become acidotic and dehydrated and may lose consciousness.
7. Type II may develop hyperosmolar coma.

Chronic complications are:

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 there is loss function appears ina stocking-glove pattern and is due to an axonal neuropathic process.
   2. Foot both motor and sensory nerve conduction is 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 functions, like 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. Occular complications:
   1. Premature cataracts occur in diabetics.
   2. There is retinopathy of two types, one is called nonproliferative and the other is called proliferative retinopathy.
   3. Glaucoma occurs in 6% of the diabetics.
4. The involvement of small and large size blood vessels.
   1. Cardiovascular microangiopathy may explain the etiology of congestive cardiomyopathy in diabetics 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. In type 1 diabetes mellitus, they have also increased the risk of coronary artery disease. It is lower than the type 2 DM.
   4. AMI is the leading cause of death in patients with 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 the type 1diabetes 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 diseases (diabetic nephropathy), and may lead to end-stage renal disease.
   4. Initially, there is proteinuria, followed by the decline in renal functions where there is an increase in the blood urea and creatinine.
      1. This renal disease can be assessed by the microalbuminuria.
      2. Also, advise the albumin/creatinine ratio.
         1. Albumin/creatinine ratio <30 is normal.
         2. The ratio of 30 to 300 mcg/mg suggests abnormal microalbuminuria.
         3. A chronic renal disease suspected when there is persistent albumin excreted more than 30 mcg/mg creatinine.
         4. When the treatment is inadequate then patients develop nephrotic syndrome with hypoalbuminemia, edema, an increase in the LDL-cholesterol, and increasing azotemia.
         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,  there is progressive stiffness of the hand 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 hyperuricemia and the tophaceous gout are more common in the type2 diabetics.

Work up of diabetic patients to prevent the complications:

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.

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