COMPLICATION OF DIABETES BY DR ANEEZA JALIL

1. Complications of Diabetes
Mellitus
Dr Aneza Jalil

2. Complications

3. Significance
• People with diabetes have an increased risk of developing a number
of serious health problems. Consistently high blood glucose levels can
lead to serious diseases affecting the heart and blood
vessels, eyes, kidneys, nerves and teeth. In addition, people with
diabetes also have a higher risk of developing infections.

4. Burden of Disease
• In almost all high-income countries, diabetes is a leading cause
of cardiovascular disease, blindness, kidney failure, and lower limb
amputation.

5. Key focus
• Maintaining blood glucose levels, blood pressure, and cholesterol at
or close to normal can help delay or prevent diabetes complications.
Therefore people with diabetes need regular monitoring.

6. Macro vascular
• Stroke, myocardial infarction, peripheral arterial disease, claudication
and ischemia.

7. Micro vascular
• Nephropathy, retinopathy, autonomic and peripheral neuropathy,
diabetic foot disease like ulceration and Arthropathy.

8. Pathogenesis
• Pathological changes of atherosclerosis appear much earlier and are
more severe and extensive
• Diabetes amplifies the effect of other risk factors like smoking,
hypertension and dyslipidemia
• The risk of complications is positively correlated with the duration
and degree of sustained hyperglycemia

9. Histopathology
• Thickening of capillary basement membrane, increased vascular
permeability
• Local response of endothelium to generalized vascular injury.
• When combined with hypertension and hyperinsulinemia the process
of lipoproteins deposition exaggerates

10. Complications

11. Cardiovascular disease
affects the heart and blood vessels and may cause fatal complications
such as coronary artery disease (leading to heart attack) and stroke.
Cardiovascular disease is the most common cause of death in people
with diabetes. High blood pressure, high cholesterol, high blood
glucose and other risk factors contribute to increasing the risk of
cardiovascular complications.

12. Kidney disease (diabetic nephropathy)
caused by damage to small blood vessels in the kidneys leading to the
kidneys becoming less efficient or to fail altogether. Kidney disease is
much more common in people with diabetes than in those without
diabetes. Maintaining near normal levels of blood glucose and blood
pressure can greatly reduce the risk of kidney disease.
Risk factors are poor glycemic control, long duration of Diabetes,
presence of other microvascular complications, pre existing
hypertension, ethnicity, family history of diabetic nephropathy and
family history of hypertension

13. Pathogenesis of nephropathy
• Activation of renin angiotensin system leads to intra renal and systemic
effects as well as direct toxic effects of hyperglycemia. This leads to renal
inflammation and fibrosis
• Microalbuminuria in urine coincides with glomerular basement membrane
thickening, deposition of matrix material in mesangium, nodular sclerosis,
glomerulosclerosis, glomeruli progressively lost and renal functions
deteriorates.
• Diagnosis and screening is by Microalbuminuria.
• Managed by aggressive control of glycemic level, hypertension and
cardiovascular risk factors. Ace inhibitors or angiotensin receptor blockers.
• Addition of a diuretic and/or salt restriction improves effects
• Renal transplant

14. Nerve disease (diabetic neuropathy)
diabetes can cause damage to the nerves throughout the body when blood
glucose and blood pressure are too high. This can lead to problems with
digestion, erectile dysfunction, and many other functions. Among the most
commonly affected areas are the extremities, in particular the feet. Nerve
damage in these areas is called peripheral neuropathy, and can lead to pain,
tingling, and loss of feeling. Loss of feeling is particularly important because
it can allow injuries to go unnoticed, leading to serious infections and
possible amputations. People with diabetes carry a risk of amputation that
may be more than 25 times greater than that of people without diabetes.
However, with comprehensive management, a large proportion of
amputations related to diabetes can be prevented. Even when amputation
takes place, the remaining leg and the person’s life can be saved by good
follow-up care from a multidisciplinary foot team. People with diabetes
should regularly examine their feet.

15. Types of neuropathy
• Symmetrical sensory polyneuropathy glove and stocking type mostly
distal
• Asymmetrical motor neuropathy mostly proximal
• Autonomic like cardiovascular, gastrointestinal, genitourinary, sudo
motor, vasomotor, pupillary

16. Sensory and motor neuropathy
• Change in gait, loss of arches, weakness and atrophy of muscles and
thus structural changes in feet clawing of toes and exposure of
metatarsal heads
• Amyotrophy is weakness and wasting of proximal muscles
• Tendon reflexes are absent and sometimes extensor plantar response

17. Autonomic neuropathy
• Dizziness and fainting when standing, caused by a sudden drop in blood pressure.
• Urinary problems, such as difficulty starting urination, incontinence, difficulty sensing a full bladder and
inability to completely empty the bladder, which can lead to urinary tract infections.
• Sexual difficulties, including problems achieving or maintaining an erection (erectile dysfunction) or
ejaculation problems in men. In women, problems include vaginal dryness, low libido and difficulty reaching
orgasm.
• Difficulty digesting food, such as feeling full after a few bites of food, loss of appetite, diarrhea, constipation,
abdominal bloating, nausea, vomiting, difficulty swallowing and heartburn, all due to changes in digestive
function.
• Inability to recognize low blood sugar (hypoglycemia), because the warning signals, such as getting shaky,
aren't there.
• Sweating abnormalities, such as sweating too much or too little, which affect the ability to regulate body
temperature.
• Sluggish pupil reaction, making it difficult to adjust from light to dark and seeing well when driving at night.
• Exercise intolerance, which can occur if your heart rate stays the same instead of adjusting to your activity
level.

18. Diagnosis of neuropathy
• Heart rate response test
• Blood pressure response to standing
• MIBG scan of heart
• Diagnosis of gastroparesis by technetium scan after solid meal
delayed emptying

19. Diabetic foot
• Diabetic foot and lower limb complications are severe and chronic.
They affect 40 to 60 million people with diabetes globally. Chronic
ulcers and amputations result in a significant reduction in the
quality of life and increase the risk of early death.
• Less than one-third of physicians recognise the signs of diabetes-
related peripheral neuropathy. The resulting missed diagnoses
contribute greatly to the high rates of disease and mortality.

20. Diabetic foot
• High blood glucose can cause damage to the nerves throughout the body.
Neuropathy is a frequently encountered complication of diabetes. Nerve
damage can be quite significant and allow injuries to go unnoticed, leading
to ulceration, serious infections and in some case amputations.
• Diabetic foot is one of the most common, costly and severe complications
of diabetes. Amputation in people with diabetes is 10 to 20 times more
common than in people without diabetes and it is estimated that every 30
seconds a lower limb or part of a lower limb is lost somewhere in the world
as a consequence of diabetes.1
• Diabetic foot can result in an important economic, social, and public health
burden; especially in low-income communities, if there is neither an
appropriate educational programme, nor adequate and suitable footwear.

21. Eye disease (diabetic retinopathy)
most people with diabetes will develop some form of eye disease
(retinopathy) causing reduced vision or blindness. Consistently high
levels of blood glucose, together with high blood pressure and high
cholesterol, are the main causes of retinopathy. It can be managed
through regular eye checks and keeping glucose and lipid levels at or
close to normal.

22. Pregnancy complications
Women with any type of diabetes during pregnancy risk a number of
complications if they do not carefully monitor and manage their
condition. To prevent possible organ damage to the fetus, women with
type 1 diabetes or type 2 diabetes should achieve target glucose levels
before conception. All women with diabetes during pregnancy, type 1,
type 2 or gestational should strive for target blood glucose levels
throughout to minimize complications. High blood glucose during
pregnancy can lead to the fetus putting on excess weight. This can lead
to problems in delivery, trauma to the child and mother, and a sudden
drop in blood glucose for the child after birth. Children who are
exposed for a long time to high blood glucose in the womb are at
higher risk of developing diabetes in the future.

23. Oral Complications
People with diabetes have an increased risk of inflammation of the
gums (periodontitis) if blood glucose is not properly managed.
Periodontitis is a major cause of tooth loss and is associated with an
increased risk of cardiovascular disease (CVD). Regular oral check-ups
should be established to ensure early diagnosis, particularly among
people with previously undiagnosed diabetes and prompt management
of any oral complications in people with diabetes. Annual visits are
recommended for symptoms of gum disease such as bleeding when
brushing teeth or swollen gums.

24. Prevention
• Improved glycemic control
• DCCT for type 1 study and UKPDS for Type 2 DM proved it.
• Less frequent complications and slower progression of disease
• Managing hypertension and dyslipidemia further slows down the
progression