This document discusses chronic complications of diabetes mellitus. It describes long-term effects like vision defects, kidney failure, and nerve damage. Risk factors include hyperglycemia as well as genetic and lifestyle factors. Complications are microvascular, affecting small blood vessels, and macrovascular, involving large vessels. Prevention requires controlling blood sugar through lifestyle changes and medication to delay complications like eye, kidney, and heart disease.

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?