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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
http://www.eyesearch.com/cloudy.vision.jpghttp://www.eyesearch.com/cloudy.vision.jpghttp://www.eyesearch.com/cloudy.vision.jpghttp://www.eyesearch.com/cloudy.vision.jpg7/17/2019 Blocks a 7 LecVVVHture Diabetes Complications
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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