Diabetes Complications Rezvan Salehidoost, M.D., Endocrinologist
Different Diabetes Complications Macro vascular Micro vascular Infections
Macro vascular Complications
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
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.
Cardiovascular Death Rates: MRFIT data Stamler J., et al Diabetes Care: 16: 434-444
Risk of MI in Diabetes Haffner, SM et al NEJM: 339: 229-234
Plasma Glucose as Independent Risk Factor Andersson, DK et al. Diabetes Care 18: 1534-1543
Ten Year Mortality (per 1000) Effect of Hypertension Mortality vs systolic blood pressure 70 60 50 40 30 Non-diabetic Diabetic 20 10 0 110 120 130 140 150 160 Systolic Blood pressure (mmhg)
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;317:703-713
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
Ten Year Mortality (per 1000) Effect of Cholesterol Serum cholesterol vs Mortality 70 60 50 40 30 20 10 0 4 5 6 7 s-cholesterol (mmol/l) Non-diabetic Diabetic
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)
Micro vascular Complications
Eye Complications Cataracts Retinopathy Glaucoma
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, 80 100% will have some form of DR after 20 years) Maculopathy is most common in type 2 patients and can cause severe visual loss
Nonpeoliferative Retinopathy Micro aneurisms Scattered exudates Hemorrhages(flame shaped, Dot and Blot) Cotton wool spots (<5) Venous dilatations Background retinopathy
Proliferative Retinopathy New vessels (on disc, elsewhere) Fibrous proliferation (on disc, elsewhere) Hemorrhages (preretinal, vitreous) Panretinal photo-coagulation
Proliferative retinopathy
Vitreous Bleeding
Rubeosis Iridis
Maculopathy
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)
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
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
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
Diabetic Neuropathy Sensorimotor neuropathy (acute/chronic) Autonomic neuropathy Mononeuropathy Spontaneous Entrapment External pressure palsies Proximal motor neuropathy
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
Complications of Sensorimotor neuropathy Ulceration (painless) Charcot arthropathy
Autonomic Neuropathy Symptomatic Postural hypotension Gastroparesis Diabetic diarrhea Neuropathic bladder Erectile dysfunction
Mononeuropathies Cranial nerve palsies (most common are n. IV,VI,VII) Truncal neuropathy (rare)
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
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
Rhino-Cerebral Mucormycosis
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
Using of the Monofilament