Diabetes Care

For patients suffering from type II /adult onset diabetes :

In type II diabetes, diagnosis is often late (after the disease has already been present for some time). In early days T2DM (short for the adult type of diabetes) are often without symptoms. Hence the delay in diagnosis. This means complications will be seen early after diagnosis.

Foot Care :

Foot disease in diabetes may lead to difficulty in walking, pain and may lead to infections. If neglected amputation may be required.

Inspect feet with a mirror before going to sleep every night.

Use well fitting shoewear.

Do not walk bare feet even in the house.

Socks should be clean and correct size.

In case of deformities of feet, special shoes can be worn.

Eye Care :

It is nowadays the commonest cause of blindness throughout the world.

Check for refractory error at the time of diagnosis and once sugars are controlled.  In T2DM every year examination for changes in retina are required. If there are already changes, check up is required more often.

Retina is checked after dilating pupil with an ophthalmoscope.

Kidneys :

It is one of the common causes of kidney failure leading to requirement of dialysis and renal transplant. Early treatment may reverse diabetic kidney disease or slow its progression.

In early cases urine is checked for passage of extra amounts of albumin. This can be quantified to see response to therapy. This test is called urine for microalbuminuria, and urine albumin /creatinine ratio. If the disease is already present, USG, S Cr and testing for voiding function (Uroflowmetry) etc may be useful.

In those without evidence of kidney disease these tests are carried out every year. Frequency otherwise may depend on the stage of involvement. More severe involvement necessitates more frequent reviews.

Nerves :

Nerve involvement is checked by touch, pain, vibration sense.

During winters, hot water should be checked with either a thermometer or elbows. If fingers are used for checking temperature, very hot water may lead to burns.

Precautions should be taken to avoid falls.

Sugar Levels :

HbA1C level may be done every 3 months to monitor overall sugar control in blood. In most cases a level of < 7 is desirable.

If hypoglycaemia is frequent , a level of < 8 may be  all that can be achieved safely. In cases of some microvascular complications, a level < 6.5 may help but is difficult to achieve. Home sugar monitoring is done from capillary blood. The levels are different from venous blood levels tested in laboratories. Only sides of fingers should be used and not the areas used for holding functions of the hand. In T2DM once weekly sugars may be enough. In T1DM almost daily or before each meal sugars are required. Levels for control should not be done within 2 hours of meals. Check if there is uncertainty about diagnosis of hypoglycaemia. Do not wait for giving sugars, if testing takes time or symptoms are severe (loss of consciousness, confused talk, fits etc.) Treatment presumptively may prevent permanent damage to the brain. However sugar is not the treatment in diabetics for every small symptom. Record times of sugar checking and dates in a notebook for planning of drugs. Lipids and Statins : If there are more cardiovascular risk factors, age > 50 yrs in man, smoking, lower levels of LDL cholesterol are desirable. Daily 75 or 150 mg  of aspirin or statins may decrease risk of heart attacks. Bleeding complications however increase with aspirin.

Regular exercise, monitoring weight, smoking cessation all are essential parts of diabetic care.

Polycystic Kidney Disease

Polycystic Kidney Disease

Introduction and Genetics:

This is one of the commonest genetic disorders affecting kidneys. The disease runs in families. The reported incidence is 1 in 400 to 1in 1000. Both man and woman are affected. If one parent is affected the children of the patient have 50% chance of inheriting the disease.

One-quarter of patients may not provide a history of the disease in parents or siblings because of death prior to diagnosis, an undiagnosed disease in the other members or insufficient investigation of the other family members.

The disease can be found by genetic testing in the fetus. However as the disease has normal mentation and causes problems in adult life, genetic testing in a fetus are rarely carried out.

The disease is usually of two types. 85% suffer from an abnormality of Chromosome 16 and rest from Chromosome no 4. Type PKD 1 (ch 16 variety) is the more severe form. It causes renal failure at about 55 Yrs of age while Type PKD II at 70 Yrs of age.

Those patients with hypertension, males, with larger kidney size develop renal failure early.

There are hundred to thousands of cysts distributed in both kidneys in all areas. Liver and pancreas, and sometimes lungs may also have cysts. A fewhave intracranial aneurysms( dilatation of blood vessels). Cardiac valvular defects are also common. Affected kidneys may have a stone formation or these can be infected.

Patients may have initial symptoms of abdominal pain due to large kidneys, high blood pressure or urinary tract infections. USG done for unrelated symptoms sometimes reveals the diagnosis.

In affected families, the  no of cysts at various age groups helps in ascertaining the probability of disease. It has to be distinguished in initial cases (probands) where family history is not available, from other cystic diseases of the kidneys.

Treatment includes control of high blood pressure, statins, lower protein intake and general measures. Patients may waste salt in their urine and may suffer from low sodium levels. ACE inhibitors and ARBs are often used for the control of BP while care is taken to look for their side effects and safety.

A vasopressin inhibitor has been used increasingly for slowing/ Stopping the disease progression in ADPKD patients. It is more useful if started early before the s cr is very high.

Death is more often due to cardiac or strokes rather than kidney failure.

Dialysis

Dialysis

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.

Hemodialysis

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.