Diabetes Complications. Rezvan Salehidoost, M.D., Endocrinologist

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1 Diabetes Complications Rezvan Salehidoost, M.D., Endocrinologist

2 Different Diabetes Complications Macro vascular Micro vascular Infections

3 Macro vascular Complications

4 Macro-vascular Complications Ischemic heart disease Cerebrovascular disease Peripheral vascular disease Diabetic patients have a 2 to 6 times higher risk for development of these complications than the general population

5 Macro-vascular Complications The major cardiovascular risk factors in the nondiabetic population (smoking, hypertension and hyperlipidemia) also operate in diabetes, but the risks are enhanced in the presence of diabetes. Overall life expectancy in diabetic patients is 7 to 10 years shorter than non-diabetic people.

6 Cardiovascular Death Rates: MRFIT data Stamler J., et al Diabetes Care: 16:

7 Risk of MI in Diabetes Haffner, SM et al NEJM: 339:

8 Plasma Glucose as Independent Risk Factor Andersson, DK et al. Diabetes Care 18:

9 Ten Year Mortality (per 1000) Effect of Hypertension Mortality vs systolic blood pressure Non-diabetic Diabetic Systolic Blood pressure (mmhg)

10 Why worry about Hypertension in Diabetic patients Treating hypertension can reduce the risk of: Death 32% Microvascular disease 37% Stroke 44% Heart failure 56% UKPDS BMJ 1998;317:

11 Hypertension in Type 1 and 2 Diabetes Type 1 Type 2 Develop after several years of DM Ultimately affects ~30% of patients Mostly present at diagnosis Affects at least 60% of patients

12 Ten Year Mortality (per 1000) Effect of Cholesterol Serum cholesterol vs Mortality s-cholesterol (mmol/l) Non-diabetic Diabetic

13 Screening for Macrovascular Complications 1. Examine pulses and for cardiovascular disease 2. Lipogram 3. ECG 4. Blood pressure 1-3 annually 4 every visit (quarterly)

14 Micro vascular Complications

15 Eye Complications Cataracts Retinopathy Glaucoma

16 Diabetic Retinopathy (DR) DR is the leading cause of blindness in the working population of the Western world The prevalence increase with the duration of the disease (few within 5 years, % will have some form of DR after 20 years) Maculopathy is most common in type 2 patients and can cause severe visual loss

17 Nonpeoliferative Retinopathy Micro aneurisms Scattered exudates Hemorrhages(flame shaped, Dot and Blot) Cotton wool spots (<5) Venous dilatations Background retinopathy

18 Proliferative Retinopathy New vessels (on disc, elsewhere) Fibrous proliferation (on disc, elsewhere) Hemorrhages (preretinal, vitreous) Panretinal photo-coagulation

19 Proliferative retinopathy

20 Vitreous Bleeding

21 Rubeosis Iridis

22 Maculopathy

23 Screening for Eye disease Annually Visual acuity (corrected with pinhole or lenses) Careful eye examination (noting the clarity of the lens and any retinal changes (Ophthalmoscopy through dilated pupils)

24 Diabetic Nephropathy (DN) Diabetes has become the most common cause of end stage renal failure in the US and Europe About 20 30% of patients with diabetes develop evidence of nephropathy

25 Screening for Nephropathy Annually Do one of the following: u Albumin:Creatinine ratio (spot sample) 24h u Albumin excretion rate If positive the test must be repeated twice in the ensuing 3 months. Microalbuminuria with incipient nephropathy is diagnosed if 2 or more of the tests are within the microalbumin range

26 Who to Screen For Microalbuminuria Type 1 Diabetes Begin with puberty After 5 years duration of disease Should be done annually there after Type 2 Diabetes Start screening at the Diagnosis of diabetes Should be done annually there after

27 Diabetic Neuropathy Sensorimotor neuropathy (acute/chronic) Autonomic neuropathy Mononeuropathy Spontaneous Entrapment External pressure palsies Proximal motor neuropathy

28 Sensorimotor Neuropathy Patients may be asymptomatic / complain of numbness, paresthesias, allodynia or pain Feet are mostly affected, hands are seldom affected In Diabetic patients sensory neuropathy usually predominates

29 Complications of Sensorimotor neuropathy Ulceration (painless) Charcot arthropathy

30 Autonomic Neuropathy Symptomatic Postural hypotension Gastroparesis Diabetic diarrhea Neuropathic bladder Erectile dysfunction

31 Mononeuropathies Cranial nerve palsies (most common are n. IV,VI,VII) Truncal neuropathy (rare)

32 Infections The association between diabetes and increased susceptibility to infection in general is not supported by strong evidence However, many specific infections are more common in diabetic patients and some occur almost exclusively in them

33 Specific Infections Community acquired pneumonia Acute bacterial cystitis Acute pyelonephritis Emphysematous pyelonephritis Perinephric abscess Fungal cystitis Necrotizing fasciitis Invasive otitis externa Rhinocerebral mucormycosis Emphysematous cholecystitis

34 Rhino-Cerebral Mucormycosis

35 Screening for Neuropathy 128 Hz tuning fork for testing of vibration perception 10g Semmers monofilament The main reason is to identify patients at risk for development of diabetic foot

36 Using of the Monofilament

130/80 vs. 140/90 If nephropathy is present the target should be 120/ /10/07

130/80 vs. 140/90 If nephropathy is present the target should be 120/ /10/07 DG van Zyl Macro vascular Micro vascular Neuropathy Infections Genetic susceptibility *Repeated acute changes in cellular metabolism Hyperglycemia Tissue damage **Cumulative long term changes in stable