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.

Drugs after Renal Transplant: II

Drugs after Renal Transplant: II

There are a number of other drugs used in transplant recipients after they are discharged from the hospital.

In the initial period these include:

Antibiotics to prevent urinary tract infections. These may need to be continued for 6 months. These (Trimethoprim + Sulfas) may prevent pneumocystis infection of the lungs as well.

A common infection in transplant recipients is due to cytomegalovirus. This can be prevented by a drug called Valgancyclovir. It is usually given for 90 – 100 days. It is a costly drug and the total treatment may cost about 25000 to 45000 ₹ depending on the dose and duration of CMV prophylaxis.

Anti Hypertensive drugs, sugar lowering drugs may be required in cases of Hypertensives and diabetics.

Immunosuppression after Kidney Transplant

Immunosuppression after Kidney Transplant

The drugs are always taken on the advice of a physician experienced in dealing with transplants. Patients should never change doses on their own. Stopping of drugs may result in acute rejection and damage to or loss of the kidney. Usually three drugs are given. These are required to be taken lifelong.

The medicines may be Tacrolimus/ cyclosporine.

Older patients of functioning transplants may be on cyclosporine. These drugs are similar and called Calcineurin inhibitors. These drugs have a no of interactions with other drugs. Simultaneous intake of other drugs may increase or decrease the levels of these drugs.

Some common side efftects of CNI inhibitors are tremors, high BP, increase in urea and creatinine( due to kidney dysfunction) , swelling of the feet and high blood sugars. These also increase chances of infections.

Cyclosporine can also increase body hair, facial hair, or hair from the ears. This is called hirsutism and may be very unpleasant side effect in ladies. The dosage of these drugs are based on their blood levels which need to be checked periodically.

Azathioprine or mycophenolate.

These drugs are the other commonly used immunosuppressives. They may decrease blood cell formation (WBCs or RBCs or platelets or all three togather. They can also increase infections in the transplant recipient. Mycophenolate may cause abdominal cramps, diarrhoea or constipation.

These are expensive drugs and the blood levels are not easily available.

The interactions are fewer with other drugs.

Steroids

This is an important component of the immunosuppressive regime.

These drugs are started at very high levels in the 1st few days and rapidly reduced.

Though very effective in its action, these drugs are full of side effects. These drugs may cause weight gain, high sugars, high BP, dyslipidemias, behavioral disorders, hirsutism, rounding of the face, muscle weakness and sleeplessness. They can also cause bone weakness and increase chances of infections as do the other transplant medicines.

The drugs are always taken under medical supervision and sudden changes or stoppage of the drug may be catastrophic.

 Renal Transplant : Survival after kidney transplant.

Renal Transplant : Survival after kidney transplant.

Renal transplant is the treatment of choice for patients of End Stage Renal Disease. Compared to Hemodialysis and peritoneal dialysis, the patients live longer and overall have a better quality of life. After the 1st 2 weeks of transplant, the death rate in transplant patients is lower than patients on dialysis.

In the USA, survival recipients of living donor kidneys at 5 yrs is now 91 % while in the case of cadaver kidneys, it is 84 %. If not so well functioning kidneys (called extended donor kidneys ) are transplanted survival at 5 yrs is 70%. This does not mean that all kidneys are working, but the patients are living.

Survival is better in children and less in those over 40, men compared to women, smokers, those suffering from diabetes and heart diseases.

The death when it occurs is usually due to heart diseases or due to infections. The no of cancers also increases after transplant and this is another major cause.

Compared to normal population , renal transplant still is a serious risk for mortality. For example in US in the 1st year after transplant death risk in patients is 14 times compared to age and sex matched population.