Non communicable diseases, are leading cause of death world wide

1. Session 4.4: Chronic
Complications of Diabetes
Mellitus
Module 4: Management of
Patient with Diabetes
Mellitus

2. Learning Objectives
• At the end of this session participants are
expected to be able to:
• Describe long term effects and risk factors
for chronic complications of diabetes
mellitus
• Recognize clinical presentation and
management of chronic complications of
diabetes mellitus
• Prevent chronic complications of diabetes
mellitus

3. Activity: Buzzing
 What are the long-term effect and risk factors
for chronic complications of diabetes mellitus?

4. Long Term Effect of Diabetes Mellitus

5. Risk Factors for Chronic
Complications of Diabetes

6. Activity: Small Group Discussion
• What is the clinical presentation of
patients with chronic complications of
diabetes mellitus?

7. Clinical Presentation of Patients with
Chronic Complications of Diabetes

8. Complications
 Left untreated, chronic hyperglycaemia
damages the small and large blood vessels,
leading to complications such as
 vision defects, kidney failure, numb feet,
heart attack, stroke, peripheral vascular
disease, pain in the back of the legs and
feet problems

9. Small Vessels (Micro-Vascular)
 There are three micro vascular complications:
• Diabetic retinopathy (diabetes eye disease)
may present with deterioration in vision
(severe or blindness in 12% after 15years)
• Nephropathy (kidney complications) may
present with cloudy urine, weakness,
lethargy or blood in urine
• Neuropathy (nerve complications) may
present as tingling, numbness or loss of
sensation in the feet

10. Small Vessels (Micro-Vascular) (2)
 Microvascular complications
 Set in early and are more common in
people of African origin because of delay in
the diagnosis
 They are a major cause of illness
(morbidity)

11. Diabetic Neuropathy
Diabetes neuropathy is:
 Damage to nerves and affects up to 50-60%
of people with diabetes
 Considered a microvascular complication of
diabetes
 Can be focal or diffuse
 Involves peripheral sensory, motor or
autonomic pathways

12. Diabetic Neuropathy (2)
Most common include:
 Distal symmetrical sensorimotor diabetic
polyneuropathy (DPN)
 Present as tingling, pain, numbness, or
weakness in the feet and hands
 Facilitate development of ulcers due to
external trauma and/or abnormal distribution of
the internal bone pressure
 Autonomic neuropathy involving gastrointestinal,
genitourinary, and cardiovascular systems
 Contribute to hypoglycaemic unawareness

13. Diabetic Neuropathy (3)
 Lower limb amputation in people with
diabetes is 10 to 20 times more common
compared to those without diabetes
 The risk is higher in low- and middle-income
countries

14. Retinopathy
 Diabetes retinopathy is the leading cause of
blindness in middle-aged population
 Annual dilated ophthalmologic evaluations
are recommended to monitor retinopathy
 Newly diagnosed T1DM patients should have
an initial dilated eye examination within 3 to 5
years after onset of their disease
 Person with T2DM should have a
comprehensive eye examination at the time
of diagnosis and yearly thereafter

15. Retinopathy (2)
 Laser photocoagulation therapy has been the
mainstay treatment for preservation of vision
in diabetic retinopathy, but it does not restore
lost vision
 Close ophthalmologic follow-up is
recommended to determine the timing and
extent of laser or other therapies

16. Nephropathy
Diabetes nephropathy:
 Accounts for nearly 50% of end-stage renal
disease
 Is a leading cause of diabetes-related
morbidity and mortality
 Its earliest sign is microalbuminuria, defined
as albumin to creatinine ratio in a spot urine
sample of 30 to 300mcg/mg

17. Nephropathy (2)
 Macroalbuminuria
 Defined as a albumin: creatinine ratio
≥300mcg/mg
 Carries a worse prognosis with regard to
progression of kidney disease and need for
renal replacement therapy
 Testing for albuminuria:
 For T1DM: Within 5 years of diagnosis,
then annually
 For T2DM: at the time of diagnosis, then
annually

18. Nephropathy (3)
 Serum creatinine:
 Measure annually for both T1DM and
T2DM
 Calculate eGFR and refer to Nephrologist
all patients with eGFR < 60ml/min
regardless of aetiology

19. Large vessels (Macro-vascular)
Complications
 Cardiovascular disease is the leading
cause of mortality in patients with diabetes
 Diabetes confers an increased risk of:
 Acute coronary syndrome
 Myocardial infarction
 Heart failure
 Atrial fibrillation, stroke, peripheral vascular
disease and sudden death are 2 to 5 times
the risk in nondiabetic comparator groups

20. Large vessels (Macro-vascular)
Complications (2)
 Heart attack, angina (the most common
complication of diabetes) can present as chest
pains, shortness of breath and sweating
 Stroke presents as weakness or paralysis of
limbs, face
 Peripheral vascular disease, presents as
pain in the back of the leg on walking
 Poor blood flow in the feet, leading to
infections and ulcers
 Poor blood flow in the penis may lead to
impotence

21. Hypertension
 Hypertension is present in:
 > 75% of persons with T2DM
 > 50% of persons with T1DM
 BP reduction:
 Reduces the frequency of myocardial
infarction, cerebrovascular disease, and
diabetes-related deaths
 Slows the progression of nephropathy,
retinopathy, and vision loss
 Blood pressure should be checked at every
visit in patients with diabetes

22. Hypertension (2)
Lifestyle therapy and medical treatment for
hypertension in people with diabetes
• Considered if BP ≥ 130/80mmhg
• Includes weight loss, low salt, low fat and low
carbohydrate diet, and moderation of alcohol
intake
• Stop smoking cigarette
• Increased physical activity

23. Hypertension (3)
 Use Angiotensin-converting enzyme
Inhibitors (ACEIs) or Angiotensin receptor
blockers (ARBs) as initial therapy because:
 Proven benefit in lowering cardiovascular
mortality
 Decreased progression of both retinopathy
and nephropathy in individual with diabetes
 Second and third-line treatment with diuretics
 B-blockers or calcium channel blockers
should be tailored to the individual patient

24. Impaired Immune System
 Prolonged high blood glucose (chronic
hyperglycaemia) leads to a weakening of
immune system
 As a result, patients get recurrent bacterial
and fungal infections of penis, vagina, skin,
eye, urinary tract, respiratory tract (coughs,
colds)
 They are also more prone to getting
tuberculosis (TB)

25. Hyperlipidaemia
 Diabetic patients should have a fasting lipid
profile (total cholesterol, low-density
lipoprotein LDL, HDL-cholesterol and
Triglycerides)
 Check yearly
 Treat with statin therapy to achieve normal
targets

26. Activity: Buzzing
 How do you prevent chronic
complications of diabetes mellitus?

27. Prevention of Chronic
Complications of Diabetes Mellitus
 Slow, chronic hyperglycaemia is the source of
most diabetic illness and death
 Cardiovascular and microvascular
complications may be prevented or delayed
when glycaemic levels are controlled
 Microvascular complications could be
significantly reduced up to 70% when
glycaemic goals are within near-normal levels
(NIDDK, 2008)

28. Prevention of Chronic Complications
of Diabetes Mellitus (2)
Primary Prevention
 Includes activities aimed at preventing
diabetes from occurring in susceptible
populations
Secondary Prevention
 Early diagnosis and effective control of
diabetes in order to delay the progress of
the disease
Tertiary Prevention
 Prevent complications and disabilities due
to diabetes

29. Prevention of Chronic Complications
of Diabetes Mellitus (6)

30. Key Points
 Long term effects of hyperglycaemia
include kidney diseases, heart diseases,
eye diseases, and nerve diseases
 Risk factors for chronic complications of
diabetes other than hyperglycaemia
include genetic susceptibility and
environmental factors such as nutrition,
obesity and physical inactivity

31. Key Points (2)
 Left untreated, chronic hyperglycaemia
damages the small and large blood vessels,
leading to complications such as:
 vision defects, kidney failure, numb feet,
heart attack, stroke, peripheral vascular
disease, pain in the back of the legs and
feet problems
 Prevention includes primary, secondary and
tertiary

32. Session Evaluation
 What are the chronic complications of
diabetes mellitus?
 How can you prevent these
complications?