Ueda 2016 7-diabetic complications - adel el sayed

1. www.uedaegypt.org

2. Diabetes Complications
Agenda
1.Micro-Vascular Complications
A.Retinopathy
B.Nephropathy
C.Neuropathy
2.Macro-Vascular Complications
A.Peripheral Vascular Disease
B.Cardiovascular Diseases and Risk Management
3.Diabetic Foot

3. Nephropathy
 Diabetic nephropathy occurs in one in four women
and one in five men with type 2 diabetes and is the
single leading cause of end-stage renal disease.
 There is strong evidence that treatment in the early
stages of CKD reduces progression of kidney
damage, morbidity and mortality.
 Therefore people with type 2 diabetes should be
screened and retested regularly to detect early
indications of kidney damage and to monitor the
effects of treatment.

4. Intensive diabetes management with the goal of
achieving near normoglycaemia delays the onset
of microalbuminuria and the progression of
microalbuminuria to macroalbuminuria in patients
with type 2 diabetes.
SBP appears to be the best indicator of the risk of
CKD in type 2 diabetes. General advice is
approaching a target of 130/80 mmHg.
Nephropathy

5. Recommendations
KD1 Kidney function should be assessed at diagnosis and
annually by:
• Urine test for albuminuria.
• Measurement of serum creatinine and calculation
of eGFR.
KD2 Urinary albumin / creatinine ratio (ACR)
measurement in an early morning first void spot
specimen is the preferred method for assessment of
albuminuria/ proteinuria Where a first void
specimen is not possible or practical, a random spot
urine specimen is acceptable.

6. KD3 If ACR is raised (microalbuminuria ACR > 2.5 mg/
mmol in men, > 3.5 mg/mmol in women), repeat ACR
twice over the following 4 months.
Microalbuminuria is confirmed if ACR is elevated in
two out of three tests, in the absence of infection or
overt proteinuria.
If both repeat tests are not raised, check again
annually.
An ACR > 30 mg/mmol indicates macroalbuminuria.
Recommendations

7. KD4 Chronic kidney disease is diagnosed on the basis
of a raised urine albumin/protein or a reduced
eGFR (< 60 ml/min/1.73 m2) calculated from the
MDRD formula and using a standardized creatinine
assay.
Recommendations

8. KD5 Individuals with chronic kidney disease should be
managed as follows:
 Use ACE-inhibitors or ARBs in individuals with
micro - or macroalbuminuria, titrated to maximum
tolerated dose.
 Intensify management of blood pressure (target ≤
130/80 mmHg) using blood pressure lowering
medications and dietary modification.
Recommendations

9. KD5 “cont”
 Monitor ACR, eGFR and serum potassium.
 Advise limiting protein intake to 1 g/kg daily if
proteinuric.
 Intensify other renal and cardiovascular
protection measures .
Recommendations

10. KD6 Agree referral criteria for specialist renal care
between local diabetes specialists and nephrologists.
Referral criteria might include
eGFR<30ml/min/1.73m2, progressive deterioration
of kidney function, persistent proteinuria,
biochemical or fluid retention problems.
Recommendations

11. Criteria For Referral To
SpecialistRenal Care
 eGFR <30 mL/min/1.73m2
 Persistent significant albuminuria (UACR ≥30 mg/mmol)
 A decline >5 mL/min/1.73m2 over a 6-month period which is
confirmed on at least three separate readings.
 Glomerular haematuria with macroalbuminuria
 CKD and hypertension that is hard to get to target despite at
least three antihypertensive agents.

12. Neuropathy
UEDA Diabetes Mini-Course
Aswan Feb. 2016

13. Neuropathy

14. Peripheral neuropathy - sensory motor
 Most common form of neuropathy
 Affects approximately 50% after 15 years
 Affects long nerves (feet and legs) first
 Glove and stocking distribution
 Bilateral
 Equal symptoms in both limbs

15. Diabetic Peripheral Neuropathy -
Risk Factors
 Poor glycaemic control
 Long duration
 Age
 Height
 Excessive alcohol intake

16. Neuropathy
 Pain and paraesthesia are common peripheral neuropathic
symptoms, and if the autonomic nervous system is involved,
gastrointestinal, bladder and sexual problems arise.
 Diabetic neuropathic complications increase the patient burden
of self-care and overall management.
 The clinical focus is on prevention via good glycaemic control,
and early recognition facilitated by good history and routine
sensory testing.
 Before any treatment is instigated, exclusion of non-diabetic
causes of neuropathy is suggested. This includes assessment for
vitamin B12 de ciency, hypothyroidism, renal disease and
review of neurotoxic drugs.

17. Autonomic neuropathy may result in:
 Orthostatic hypotension with >20 mmHg drop
 Impaired and unpredictable gastric emptying (gastroparesis), which can
cause a person’s blood glucose levels to be erratic and dif cult to control.
Pro-kinetic agents such as metoclopramide, domperidone or erythromycin
may improve symptoms
 Diarrhoea
 Delayed/incomplete bladder emptying
 Erectile dysfunction and retrograde ejaculation in males
 Reduced vaginal lubrication with arousal in women
 Loss of cardiac pain, ‘silent’ ischaemia or infarction
 Sudden, unexpected cardiorespiratory arrest especially under anaesthetic or
treatment with respiratory depressant medications
 Dificulty recognising hypoglycaemia
 Unexplained ankle oedema.
Autonomic Neuropathy

18. Diabetic Peripheral Neuropathy
Recommendations
 All patients should be screened for distal symmetric
polyneuropathy starting at diagnosis of type 2 diabetes and
at least annually thereafter, using simple clinical tests
 Antidepressants, including tricyclics, duloxetine and
venlafaxine should be considered for the treatment of
patients with painful diabetic peripheral neuropathy
 Anticonvulsants, including pregabalin and gabapentin
should be considered for the treatment of patients with
painful diabetic peripheral neuropathy

19. NU1
 Diagnose sensorimotor nerve damage by history
and examination (monofilament with or without
temperature, non-traumatic pin-prick, vibration
[tuning fork], ankle reflexes), and/or simple
quantitative testing (e.g. biothesiometer vibration
perception).
 Use serum B12, thyroid function tests, creatinine/
urea and medication history to exclude other
causes.
Recommendations

20. NU2
 Diagnose symptomatic (painful) diabetic neuropathyby excluding
other possible causes of the symptoms.
 Manage by stabilizing blood glucose control, and treatment with
tricyclic antidepressants if simple analgesia is not successful.
 If a one month trial of tricyclic therapy is not successful, further
treatment options include pregabalin/gabapentin and duloxetine,
then tramadol and oxycodone. Further management normally
requires referral to a pain control team.
 Be aware of the psychological impact of continuing symptoms,
particularly if sleep is disturbed.
Recommendations

21. NU3
 Diagnose erectile dysfunction by history (including
medication history), exclusion of endocrine conditions
(measure prolactin and testosterone), and a trial of a
phosphodiesterase type-5 (PDE5) inhibitor (where not
contraindicated by nitrate therapy).
 Consider other approaches such as intra-urethral or
intracavernosal drugs and sexual and relationship
counselling, where PDE5 inhibitors fail or cannot be
used.
Recommendations

22. Retinopathy
UEDA Diabetes Mini-Course
Aswan Feb. 2016

23. Retinopathy
 Diabetic retinopathy (DR) occurs as a result of
microvascular disease of the retina and causes visual
impairment and blindness.
 DR is categorised as:
 Non-proliferative DR
 Proliferative DR.
 Tight control of blood glucose and BP reduces the risk of
onset and progression of diabetic eye disease in type 2
diabetes.
 With good screening and care, visual impairment due to
diabetes can be avoided for the vast majority of patients.

24. ES1 Ensure that examination of the eyes of people
with type 2 diabetes is performed around the
time of diagnosis and then routinely every 1-2
years as part of a formal recall process:
 Measure and document visual acuity, corrected
with glasses.
 Assess retinopathy:
 Using retinal photography through dilated
pupils, performed by an appropriately trained
health-care professional, or
 By examination by an ophthalmic specialist.
Recommendations

25. ES4 The following frequency of screening is
suggested:
 1-2 years if no retinopathy.
 12 months if minimal unchanged retinopathy.
 3 to 6 months if worsening since last examination.
 More often during pregnancy.
Recommendations

26. ES6 Advise that good control of blood glucose, blood
pressure and blood lipids can help to reduce the
risk of eye damage developing or worsening.
ES7 Advise that diabetic retinopathy is not a
contraindication for use of aspirin if this is
indicated for prevention of CVD.
ES8 Advise that tests of intra-ocular pressure should be
made periodically.
Recommendations

27. Diabetic Foot Disease

28. Peripheral Vascular Disease
UEDA Diabetes Mini-Course
Aswan Feb. 2016

29. Peripheral Vascular Disease
Cause: decreased perfusion due to
macrovascular disease
Sites: more distal Tibial and peroneal
arteries (segment between the knee and
the ankle but aortic-illiac to knee less
frequently)

30. Peripheral vascular disease in
diabetes
15-40 times more likely to have
lower limb amputation
People over 70 years have a 70-fold
increased risk of amputation

31. Characteristics Of Atherosclerosis
In Diabetes
 More common
 Affects young age group
 No sex difference
 Smokers
 Faster in progress

32. Peripheral Vascular Disease

33. Signs of Vascular Disease

34. Peripheral vascular disease and
diabetes
There are four stages
Occlusive disease without symptoms
Intermittent claudication
Ischaemic rest pain (nighttime)
Ulceration/gangrene

35. Vascular Assessment

36. Peripheral vascular disease non
invasive evaluation (1 of 2)
Methods
Doppler pressure studies (ABI)
Duplex arterial imaging
Rationale
Identify and confirm presence of disease
Predict healing of ulcers or determine
need for early surgical intervention

37.  Doppler ultrasound
 Measures pressure at brachial, pedal and toe
arteries
 Ankle Brachial Index (ABI)
 <0.9 abnormal
 0.9 to 1.0 normal
 >1.3 non-compressible
 Duplex arterial imaging - allows narrowing or
obstruction of blood vessels to be localised
Peripheral vascular disease non
invasive evaluation (2 of 2)

38. AmputationCauses of Diabetic

39. Peripheral Vascular Disease
Treatment
Quit smoking
Walk through pain
Surgical intervention
85% of amputations are preventable!
An amputation occurs every 30 seconds
due to diabetes

40. Cardiovascular Risk
UEDA Diabetes Mini-Course
Aswan Feb. 2016

41. Cardiovascular Risk
 CVD is the leading cause of death in people
with diabetes, making assessment of
cardiovascular risk a vital part of diabetes
care.
 Assessment of combined multiple risk
factors (absolute CVD risk) is more accurate
than the use of individual risk factors.

42. Cardiovascular Risk
 As with glycaemic targets, treatment targets in CVD
need to be made on an individual basis, balancing
the benefits and risks of interventions.
 The risks associated with the effort required to reach
a particular target, as opposed to achieving a near-
target value, may outweigh any small absolute
benefit.
 Any reduction in risk factor values will be associated
with some benefit.

43. Diabetics with High CVD Risk
Diabetes and age >60 years
Diabetes with microalbuminuria (>20 mcg/min or
urinary albuminto-creatinine ratio (UACR) >2.5
mg/mmol for men, >3.5 mg/mmol for women)
Moderate or severe CKD (CKD) (persistent
proteinuria or eGFR <45 mL/min/1.73 m2)
A previous diagnosis of familial
hypercholesterolaemia
SBP ≥180 mmHg or DBP ≥110 mmHg
Serum total cholesterol >7.5 mmol/L

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47. Lifestyle Interventions To Reduce
Cardiovascular Risk
 Lifestyle changes in nutrition, physical activity and
smoking status fundamentally underpin a
comprehensive approach to cardiovascular risk
minimization.
 One study, the Look AHEAD study, showed improved
HbA1c and quality of life benefit but no reduction in
risk of cardiovascular morbidity or mortality in
people with type 2 diabetes.
 Lifestyle changes show excellent cost-effectiveness in
lowering the burden of disease and remain, the basis
for management of all cardiovascular risk levels

48. Antihypertensive Medication To Manage
Cardiovascular Risk
Lowering BP reduces cardiovascular events and
all-cause mortality in people with type 2 diabetes
in the same manner as for the general
population.
BP-lowering therapy in people with diabetes
should preferentially include an angiotensin
converting enzyme inhibitor (ACEI) or angiotensin
receptor blocker (ARB)
If monotherapy does not sufficiently reduce BP
add one of the following:
Calcium channel blocker (78) NVDPA, 2012 B
Low-dose thiazide or thiazide-like diuretic

49. Antihypertensive Medication To Manage
Cardiovascular Risk
 While no difference is noted between different
classes of BP-lowering therapy for CVD outcomes,
there is clear evidence that in people with type 2
diabetes, antihypertensive therapy with an ARB or
ACEI decreases the rate of progression of
albuminuria, promotes regression to
normoalbuminuria and may reduce the risk of
decline in renal function.
 Combination of an ARB and an ACEI are not
recommended.

50. The Target Level For Optimum BP
The target levels for BP therapy have been based
on little direct evidence.
Metaanalyses demonstrate that more intensive
BP control (SBP ≤130 mmHg) compared to usual
(<140/90 mmHg) was associated with further
reduction in stroke only, but there was a 40%
increase in serious adverse events.
Until such deliberations are complete, the general
international BP target for people with diabetes
remains ≤130/80 mmHg.

51. Lipid Medication To Manage
Cardiovascular Risk
 Use statins as first-line therapy
 GPs should consider treatable secondary causes of
raised blood lipids before commencing drug therapy.
 The data clearly demonstrate that statin therapy
results in a significant decrease in CAD morbidity and
mortality in type 2 diabetes for those at high
cardiovascular risk. This benefit is in contrast to the
contentious effects of improved glycaemic control in
CVD.

52. Lipid Medication To Manage
Cardiovascular Risk
 Apart from statins, the evidence for other lipid-
lowering therapy in decreasing the risk of CAD is
weak or inconsistent.
 Nicotinic acid, bile-acid resins, ezetimibe and fibrates
(fenofibrate, gemfibrozil) have been suggested as
alternatives for people who cannot tolerate a statin.
 The use of nicotinic acid, in particular, as well as
gemfibrozil and cholestyramine is limited by a high
rate of adverse effects.

53. Antithrombotic Therapy
 Prescription of antithrombotic therapy (e.g. aspirin,
clopidogrel) is not usually recommended in primary
prevention.
 GPs may need to make individual judgements
regarding this because of other guidelines
recommendations (e.g. transient ischaemic attack
[TIA]).
 Guidelines for secondary prevention routinely
advocate intensive antithrombotic therapy.

54. Diabetic Foot
UEDA Diabetes Mini-Course
Aswan Feb. 2016

55. Some statistics
People with diabetes are 25 times more likely
to lose a foot than people without diabetes
More than 1 million people lose a leg every
year due to diabetes (every 30 seconds)
70% of all leg amputations happen to people
with diabetes
5 years after a lower limb amputation up to
70% of people may have died
(International Diabetes Federation, 2005)

56. Prevention
49-85% of amputations can be prevented
through a care strategy that combines
Prevention
Multi-disciplinary treatment of ulcers
Appropriate organization
Close monitoring
Education of people with diabetes and
health professionals
(International Diabetes Federation, 2005)

57. Painless Nature of Diabetic Foot Disease

58. Sensory Nerve Damage

59. Motor Nerve Damage

60. Autonomic Nerve Damage

61. Foot Assessment

62. Screening Tests for Peripheral
Neuropathy

63. Risk Categorization System

64. Lastly we hope that course will achieve
its goals and help you all in getting the
best of the forthcoming conference
UEDA Board
UEDA Diabetes Mini-Course
Aswan Feb. 2016