Treatment of Diabetes in Type II Diabetes Mellitus

Treatment of Diabetes in Type II Diabetes Mellitus

Treatment of diabetes starts with educating patient about this disease. He is also educated about symptoms related to low and high sugar levels so that he can recognise these. He is encouraged to carry a diabetes card with his medication, and the name of his doctor written on it. He is also encouraged to carry with him sugar candies etc near him to treat hypoglycemia. Home blood glucose monitoring can be taught to nearly all patients.

The various risk factors are noted and the complications if any are studied. The goal of treatment is to reduce the sugar to near normal levels to ward off complications of diabetes and reduce risk to life, vital organs while permitting a good quality of life.

Non-pharmacologic measures

To reduce risk of heart disease and stroke, weight should be reduced to normal levels. If a person is overweight (BMI ie Wt in kgs/ ht in meters squared) and BMI is between 25 to 29.9 wt can be reduced gradually to with in limits. If a person is obese BMI >30 then more urgent weight reduction is required.

A weight reduction of about 10 kgs will make a substantial difference in diabetic control


If overweight or obese calories are cut down. About 15% calories should come from proteins and < 30 % from fats. The rest of calories may be from complex carbohydrates. Simple sugars are not advisable. Sugar substitutes can be taken.

If weight does not reduce after 6 months of trial, weight reduction tablets (Orlistat) etc may be considered. In severe obesity cases bariatric surgery may be the only alternative if all else fails.


About 150 mins of exercise in a week is recommended. Aerobic exercises are preferred though in younger patients who do not have heart disease or advanced diabetic retinopathy weight lifting twice a week is encouraged.

The exercise should be done on most days of the week and be sufficiently vigorous to be of cardiac benefit.


Smoking is a huge risk factor for heart disease. Since diabetes itself is a high-risk state for angina and myocardial infarction continued smoking increased the risk manifold. Smoking should be stopped totally to reduce this risk.

Drugs are required in nearly all cases for sugar control. More about drugs later.



Dialysers are small plastic cylinders. These have an inlet for blood entry and outlet for blood exit.

It also has an entry opening for dialysate and exit for the fluid.

Its main body has hundreds of small tubes all connected to a common plate at the top and bottom portion of the dialyser. Blood enters at the entry point and flows through these tubes. These tubes are again joined at the exit and then blood goes out through a common tube back to the patient.

These tubes are nowadays made of synthetic material of different types. Some common types are polysulfone, polymethamethyl acrylate, poly acrylonitrile and polyamide. Earlier cellular or semisynthetic membranes were also in use (hemophane, cuprophane, cellulose etc. ) These membranes are now gradually being replaced by synthetic membranes. Synthetic membranes are comparatively inert and produce fewer reactions. These are easy to clean and sterilise.

The large no of tubes (called capillariesin medical parlance) increase the surface area to about .5 to 1.8 sq meters. Thus larger amount of blood can interchange impurities across the membranes.

Dialysate fluid flows outside the capillaries and the exchange of water, ions and waste material occurs through the membrane. Membranes have small micropores to facilitate this exchange.

Dialysis reuse : its benefits and harms.

Dialysers are reused in many centers across the world. This has the advantage of reducing dialysis costs. The protein loss (due to protein stuck on membranes) is less when dialysers are reused.

Some patients react when their blood comes in contact with dialysis membrane. This is called a first use effect. In reuse cases this is not seen.

The dialysers are checked prior to reuse to see that capillaries are intact. A large no of capillaries are functional (measured by total volume of capillaries.), and harmful chemicals used in cleaning dialysers are cleared.

Dialyser reuse is done semi-automatically by machines which also check for its safety before reuse is permitted. Manual washing and checking only by visual estimates is not useful and hence discarded by good centers. After cleaning of blood products dialysers are sterilised and kept separately for each patient in a clean container.


Hemo – Dialyser


Complications of Diabetes Mellitus

Complications of Diabetes Mellitus

Complications of diabetes are due to high sugars and damage to the small and big blood vessels mainly.

High sugars can cause frequent skin and deeper tissue infections. Infections are common, more severe, often require prolonged treatment and may turn serious if not treated fast and appropriately.

In case of very high sugars (DKA or Hyperosmolar states) a person may become unconscious and this may be life threatening. Severe dehydration, salt and water imbalance, accumulation of acids, decreased kidney function may supervene. Treament in hospital is required for patients.

Long term complications are due to blood vessel and nerve tissue damage.

In feet painless wounds (trophic ulcers) may occur and not heal for months. If infected secondarily even amputations may result.

Damage to retina is called retinopathy. In most countries now, diabetes is the major cause of blindness. Regular check up by eye doctors and laser treatment of newly formed blood vessels may prevent blindness at a later stage.

Damage to nerves may cause numbness usually more in hands and feet. Involvement of nerves supplying muscles can cause weakness in moving limbs. Involvement of nerves supplying bladder and large intestines may result in disturbance in acts of passing urine and defecation. Constipation , diarrhea and retention of urine may occur.

Long term diabetes can damage kidney in multiple ways. The details can be seen later in the kidney care part.

Involvement of coronary arteries results in high risk of heart attacks and angina. Similarly strokes causing paralysis etc occur with a much higher frequency in diabetics.

Dialysis Machines

Dialysis machines


Machines used to perform hemodialysis are of different varieties. The following fuctions are carried out by these machine

Proportionate mixing of dialysate concentrate and treated water to form dialysate. The composition of dialysate is similar to blood without cells, proteins, lipids and some other complex salts. The dialysate consists mainly of water and various main salts and ions eg sodium, potassium, chloride , bicarbonate, calcium etc.

The dialysate is freed of dissolved gases, and is heated to body temperature. Very low temperature may cause hypothremia and high temperature of dialysated may cause fever.

These machines has a self cleaning mechanism with hot water and various chemicals to take care of various pathogens.

It pulls blood at speeds set by the dialysis personnel and also supplies dialysate at required rate. It can also create negative pressure so that extra fluid can be removed from the body.

During dialysis a person may require various medicines to be administered. This is facilitated by the machine.

Additionally, machines have safety measures. It can detect air in blood so that air does not enter patients’ blood vessels. The machines go into auto shut mode if air is detected in returning blood.

If blood gets hemolysed (hemoglobin leaks out of RBCs) a serious situation for a patient may develop. Machines can detect leaked hemoglobin and sound an alarm.

Most newer machines have built in blood pressure monitoring system. If blood pressure becomes lower or higher than set range, an alarm is sounded and corrective measures can be taken.

Machines also monitor the flow of blood from the patient. If the pressure in the tubing is recorded higher or lower than set limits, alarms sound for the call to dialysis nurse or technician.

Modern machines can also measure dialysis dose. (more about this later in dialysis adequacy)

Next topic in dialysis series is dialysers.

Diabetes mellitus

Diabetes Mellitus

Diabetes is a condition where a person either does not produce required amounts of insulin or is unable to utilise insulin appropriately. It is a common (about 10% of the population), complex disease. It can cause complications if not treated and controlled well.

Types of Diabetes:

There are 2 common types of diabetes Type I and Type II. There are other rare varieties due to pancreatic diseases, hormonal disorders, in pregnancy, after drugs and even rarer genetic disorders.

Type I is the cause in about 10 % of cases, onset is in childhood or young age and insulin is required for treatment.

Type II is the common variety, onset is usually around 50 Yrs of age, often associated with overweight and the risk is high if one parent is diabetic (30 %) and if both parents are diabetic (50 %). During initial stages, diet modification and oral drugs may control sugars but later insulin may be required.


Classically symptoms in diabetes are polyuria (more urine), polydypsia (more thirst ) and polyphagia ( more eating). In children very high sugars may develop suddenly and patient may become unconscious at the onset (DKA etc). Infections both recurrent and difficult to treat may occur. However in a large no the disease remains without many symptoms and found out accidentally or when complecations arise.

Signs are seen only in advanced and long standing diseases. These are few and may include eye, heart, nerve changes, dehydration and very rapid breathing due to acid accumulation in the body.

Diagnosis of diabetes:

Diabetes is diagnosed by blood glucose testing or glycated hemoglobin levels.

Normal Plasma glucose level after 8 hrs of fasting is < 100 mg/dl. Normal 2 hrs after breakfast (called PP) or after 75 gms of glucose orally is <140 mg.   Diabetes is diagnosed if either fasting plasma glucose is >126 or PP or oral GTT (after 75 gms of glucose is >200 mg/dl.

If fasting value is 100 -125 it is called impaired fasting glucose and if PP or Oral GTT is between 140 and 199 mg/dl it is called impaired glucose tolerance( IGT).

In a person with symptoms of diabetes a random value of plasma sugar >200 mg /dl or fasing plasma sugar >126 mg/dl qualifies for diagnosis of diabetes.

Lab tests for diabetes  

For common types of diabetes the following tests may be required at the time of initial diagnosis.

Complete blood counts, Blood sugar, kidney and liver function tests, urine routine and urine for microalbumin, lipid profile, Chest X Ray, ECG. Ultrasonography of abdomen, fundus examination, foot examination and blood pressure is noted.

In Type I cases or where genetic, pancreatic or hormonal disorders are suspected, tests for these are carried out as appropriate.

This is a chronic disease and lifelong follow up and treatment are required.



Coming next ~

Complications of diabetes

Treatment of diabetes.

Dialysis Water

Dialysis water

During hemo-dialysis about 500 ml (range 50-800 ml) of dialysate flows through the dialyer (The plastic casing that contains dialysis membrane and which partitions blood on one side and dialysate on the other).

Water treatment is an essential requisite for safe dialysis.

In a 4 to 5 hrs session about 120 to 150 liters of water thus comes into contact with blood.

A very small impurity in this water thus can get magnified and produce serious consequences in the renal failure patient.

If dialysis water is unfit, it results in recurrent fever, poor health and nutrition of patient, electrolyte abnormalities etc. High aluminium levels can produce brain disorder called dementia and aluminium related bone disease. High chlorine levels can cause severe reactions.

Water treatment is done for ensuring safe dialysis water.

If ground or municipal supply provides hard water it is softened by machine.

Particulate matter is removed by filters consisting of pebbles, sand and other materials first so that large particles are removed, small particles than are removed by microfilters which can remove 5-micron size particles.

Chlorine is removed by adsorption on to carbon particles. It should be present in water before it is treated but removed during water treatment.

Excessive salts are measured as TDS (total dissolved solids) expressed as parts per million or ppm in short.Both cations and anions measured and TDS is equal to about 100 X total ions expressed as milliequivalents. It is usually 0.5 to 1 times the conductivity value.

Bacteria and their products produce harmful substances. These need to be removed and water prevented from letting them grow again by regular maintenance of the pipes and drainage system.

To produce water of sufficiently good quality, various criteria have been laid by different countries. AAMI dialysis criteria is one such criteria. In these acceptable levels of various chemicals and other impurities are mentioned.

Good quality dialysis water reduces morbidity, mortality, and complications in dialysis. It results in better overall health and quality of life for the patient.

Treatment of Hypertension

Treatment of Hypertension

Why should hypertension be treated ?

The following are the benefits of treating hypertension:-

  • 50 % reduction in risk of heart failure
  • 30-40% reduction of risk of strokes of brain
  • 20-30 % reduction in risk of heart attacks.

The benefit occurs in all age groups including elderly. If a cause has been found (as happens in very few cases) treatment of underlying cause is useful e.g. treating kidney disease, removing adrenal tumours, stopping steroids, analgesics, contraceptive pills, certain anti depressants etc.

In the majority of cases, no cause is found. In these, we suggest non-pharmacologic ways as well as medicines to lower blood pressure.

Non-pharmacological methods may reduce blood pressure by 5- 10 mm on their own. These include

Reduction of weight if overweight

Reduction of salt in diet (avoid pickles, salted foods, preserved foods). Do not take salt substitutes if there is associated kidney disease.

Dash diet ( dietary approaches to stop hypertension diet ). Increase vegetables, whole grain cereals, low fat, low sugar and sweets, more fruits, fish and chicken if you are a non vegetarian

Increase physical activity, both physical aerobic activity and relaxation exercises may help

Stop or cut down on alcohol and smoking

Learn about Hypertension.

Pharmacological methods may reduce blood pressure

2 or more drugs are required if BP is >20/10 above the normal range. More medicines and higher doses are needed if blood pressure is due to kidney disease. These drugs may cause side effects and hence prescriptions are tailor made to suit particular requirements of the patient.

The drugs include

Diuretics : – which increase salt and water excretion in the body. These work only if salt is cut down in the diet.

ACE- inhibitors and ARB’s : -These are a class of medicines which protects against ill effects of high BP on kidneys, heart and brain. However, treatment is complicated and always should be under the guidance of a competent physician. These drugs are known to cause fetal malformations. Inform your doctor if you are pregnant or are planning to have a child,

Calcium Channel Blockers :- Very useful and often used class of drugs. Some times these may cause feet to swell otherwise these are well tolerated.

Betablockers:- These reduce heart rate and blood pressure. This is useful in reducing stress on the heart. However, these may cause serious worsening in asthma and may aggravate prostate symptoms, and may cause impotence.

Centrally acting and alfa blockers:- These are also useful in controlling BP. Some of these may cause or worsen depression.

Dialysis Access

Dialysis Access

Blood flows on one side of membrane while dialysate flows on the other side. To ensure effective dialysis a high blood flow is required for taking blood from the body to the dialysis machine. The blood flow required is about 5ml/kg body weight /min. Usually 250 ml to as much as 500-600 ml if tolerated.

The way to achieve this is through creation of dialysis access. This may be temporary or permanent.

A temporary access is made in those patients who will require dialysis for a few days to few weeks as in acute kidney injury ( also called earlier as ARF or acute renal failure), while awaiting creation of a permanent access.

Temporary access is obtained by inserting a tube in neck veins (Int Jugular Vein) usually on right but sometimes on left side. It is uncommon nowadays to use subclavian (behind collar bone ) or upper thigh veins. The advantage of this is that it is ready to use immediately however it often gets infected and may cause clot formation in the vein in which it is placed. It should be used for less than 2 weeks and never handled by patient. Sudden dislodgement may cause bleeding. In case long term dialysis is required and AV fistula( read further on to know about AVF) is not yet ready a permanent dialysis catheter which is useful for a few months is a far better though costly choice.

The method of choice is creation of arterio-venous fistula (AVF). It is usually made in the wrist but if blood vessels are small or thrombosed it is at times made in arm near elbow. This requires surgery usuaally under local aneasthesia. The failure rates are higher if done by inexperienced surgeons (1 in 2 to 1 in 4 AVFs may fail.)

It takes 2 to 3 months to mature and hence should be made much before the need of dialysis arises. It should be checked to see that it is working. If there is stoppage of flow early treatment may make it work again but if delayed another AVF creation is required.

If injured rapid bleeding may occur. So protect these from injuries. Do not allow these to be used for drugs and samples other than in dialysis room by dialysis personnel.

A good AVF is a life line for patients. Get it made early & keep it functional !!



The heart pumps blood so that it can reach various parts of the body and supply these parts with oxygen and nutrients. The pressure generated by the heart forces the blood to go from the heart to various organs and return from there to be sent again. There is about 5 liters of blood in average adult and heart pumps about 70 ml in each heart beat. The force generated by heart results in pressure which can be measured.

Hypertension is said to occur when the recorded blood pressure is higher than expected for the particular age. Children have lower BP, it gradually rises to adult levels and continues to increase with age in most cases. BP is measured by sphygmomanometer which was earlier mercury based but are now aneroid or electronic. BP is measured as Systolic ( higher value of the two ) and diastolic (lower reading) and written as systolic/diastolic BP in mm of Hg. e.g. 120/80 mm Hg.

Blood pressure at birth is about 70 to 85 /30 to 45 , at 5 yrs 90-110/50-66 , at 10 yr 100-120/60-80. In adults blood pressure is diagnosed when it is usually more than 140/90 mm Hg.

Causes of high blood pressure.

In most cases, there is no apparent cause. Suspicion usually falls on genetic disease, high salt intake, higher weight etc. in younger patient sometimes a cause is detected. It is often due to kidney disease, hormonal disorders, blood vessel diseases or diseases disturbing immunity. It can at times be caused by drugs like steroids and analgesics.

Symptoms of high Blood pressure

Most patients have no symptoms due to high blood pressure. It is only the measurement of blood pressure which reveals the diagnosis. Some patients with high blood pressure may have headaches, dizziness, throbbing or at times shortness of breath. If blood pressure rises suddenly to very high levels it may cause emergencies. These may include vision loss, renal failure, alteration in consciousness ( drowsiness or unconsciousness), or heart failure (manifested as breathlessness worse on lying down or activity)

Clinically it is diagnosed by BP measurement, usually on more than one occasion while a person is sitting with back supported. 2 or 3 readings may be taken and the lower readings are usually more accurate. If in doubt multiple readings can be taken while the person is continuing his activities (ABPM or ambulatory BP monitoring). Eyes are checked as blood vessels can be seen in the retina, ECG and X Ray Chest may show heart enlargement.

Laboratory tests:-

Lab tests are done to find the cause of high blood pressure if any, its effects on various organ systems and complications. The usual tests done are Blood counts, urine routine examination, Blood Urea, S Creatinine, S electrolytes, Blood Sugar, Lipid profile in blood, ECG, X Ray of chest and Ultrasonography of abdomen. In special cases hormones may be measured or Doppler Ultrasound studies are done to check blood flow and vessels in different areas.

Complications of high blood pressure:-

Complications arise if the blood pressure is very high or it has been present for  a long time. Not all persons with high BP get complications. Some of the complications are :

  • Strokes (paralytic attacks due to bleeding in the brain or reduced blood supply to part of the brain)
  • Increased likelyhood of heart attacks.
  • Heart failure (not stoppage of heart beat or cardiac arrest ) but inability of heart to meet bodily demands. This is diagnosed by swelling of feet, breathlessness at night after sleeping for 2-3 hours, fatigue etc.
  • Chronic renal disease resulting in renal failure if allowed to go unchecked for long periods.
  • Decreased blood supply to other organs due to thickening of blood vessel walls and narrowing of their internal lumen (athersosclerosis of aorta, limb vessels, vessels supplying brain, kidneys, heart, eyes etc.)

Coming up soon :

Treatment of high blood pressure





Swine flu and other influenzas






When the kidneys fail to maintain the body in a healthy state, the condition is called chronic renal failure. In advanced stages of chronic renal failiure, symptoms arise. These are called uremic symptoms and may consist of one or more of the following:-

Weakness, decreased appetite, nausea, vomiting, hiccups, breathlessness, swelling of the body, decreased amount of urine etc. Later on a person may develop fits or increasing drowsiness, unconsciousness, extreme weakness, muscle paralysis etc. Initially these symptoms are mild but later on they do not allow a person to live a normal life and still later they will kill a person unless treated.

The process of taking over of failed kidney functions by treatment is called Renal Replacement Therapy (RRT). This mainly comprises of Dialysis and Renal Transplant.

Dialysis is the process through which the accumulated waste products are removed. It also removes extra water salt, potassium, acid, phosphorus and molecules of middle size.  Thus it attempts to return the body to a healthy state.

Dialysis is mainly of two types:- Hemodialysis and Peritoneal dialysis.


In this a membrane called dialysis membrane is used as a filter. It is folded many times over to increase its area to about .5 sq meters to 2 sq meters (for children and adults of various sizes). This membrane allows only small molecules to move from one side to the other.

Blood flows on one side of the membrane and dial sate fluid flows on the other. The dialysate fluid is produced in the dialysis machine by diluting commercial concentrates. The composition of the dialysate is similar to Blood without cells, proteins, fats and other larger molecules.

Smaller molecules present in high concentration in blood and dialysate move across because of difference in concentration (called electrochemical gradient) from a higher concentration to lower concentration. Pressure can be applied across the membrane to create pressure to push water and salt across as well.

Functions of the Kidney

Functions of the Kidney

The main function of the kidney is the maintenance of the interior composition of the body. Due to continued digestion and utilisation of food in the body, construction and destruction of the various body tissues, waste products are generated daily.

  • Excretion of waste products

If allowed to collect in the body, the function of the body is affected. These waste products are thrown out from the body by liver and intestines, lungs, skin and kidneys.

Kidneys excrete urea, creatinine and similar products in a concentrated form in urine. The amount of excretion closely balances the amount of production of these materials.

  •  Water and salt balance

Kidneys maintain salt and water balance in the body. When healthy, a person may drink upto 10 liters of water or as low as ½ litre in a day. The kidneys increase and decrease urine appropriately to maintaine the total body water.

About 1 litre of blood flows through kidney. Of this about 180 litres of water, some salts and small particle are filtered daily in the kidney. Of this 180 litres, only 1 to 2 litre is finally excreted as urine. The rest is absorbed back to the blood from urinary tubules. Thus kidneys can dilute or concentrate urine.

The body water in humans depends to a large extent on salt content of the body. In case of reduced intake of salt , kidneys limit salt wastage in urine and similarly if intake is high , kidneys try to excrete extra salt.

Kidneys also excrete phosphate, ammonia products, urates and various drugs ingested by humans.

  • Acid balance

Urine is acidic in nature as it has to carry the daily acids produced from metabolism and activities of daily living, exercise etc. by excreting acid the pH of the body tissue and blood is maintained in a narrow range.

  • Haemoglobin production

Kidneys produce a hormone called erythropoietin or EPO in short. EPO stimulates bonemarrow to produces RBCs and hemoglobin. Lack of EPO production in the kidneys leads to anemia or decreased  hemoglobin.

  • Bone Health

Vitamin D produced from the ultraviolet radiation from sun or ingested in food is inactive. The liver and kidneys transform this inactive form to active form. Lack of activation leads to various bone abnormalities, fractures, bone pains and muscle weakness.

Structure of the Kidney

Structure of the Kidney

There are 2 kidneys in human body. Each weighs about  125 gms. These are located one on each side of the spine in abdomen. These are covered and protected in their upper part by ribs. These are bean shaped and beans are said to be kidney shaped.

Each kidney has about 1 million filtering units. These are called renal corpuscles and can be seen by microscope . The ball like portion where formation of urine begins by filtering from blood is called glomerulus. The filtered fluid gets modified while passing through tube like structures.

Kidneys are very rich in blood supply. It gets more blood per 100 gms of tissue than any other organ except heart.  About one fifth of the total blood pumped by heart goes to the kidneys.

After the urine is formed in the kidneys, it comes to the urinary bladder by two tubes called ureters. The urine can be stored in bladder till voided at will. Various valve like structures prevent urine from flowing backwards and leakage through the urethra , the final part connecting bladder to the outside.