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.

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.

Symptoms:

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.

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.

Hypertension

Hypertension

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

Diabetes

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