DIABETES

COMPLICATIONS
Primary Complications of insulin deficiency
Decreased glucose uptake by cells
- Hyperglycaemia
- Glycosuria
- Osmotic diuresis
- Electrolyte depletion

Increased protein breakdown

- Increased plasma amino acids
- Nitrogen and ketone loss in urine

Increased lipolysis
- Increased plasma free fatty acid (Acidosis)
- Ketogenesis, ketonaemia, ketonuria
3
Acute (Short term)

Chronic (Long term)

 Acute Complications

Hypoglycemia
Diabetic ketoacidosis
Hyperosmolar hyperglycemic non-ketotic
syndrome
 Diabetes Mellitus
Acute Complication : Hypoglycemia
Hypoglycemia
Too much insulin (or oral agents) in relation to
glucose availability (unmodified insulin therapy)
Usually coincides with peak action of insulin/OA
2.2 2.5 mmol/L

Hypoglycemic specificity
Counter-regulatory hormone imbalance
Patients on -blockers
 Diabetes Mellitus
Acute Complication : Hypoglycemia
Brain requires constant glucose supply thus
hypoglycemia affects mental function

Brain glucose deprivation (CNS symptoms)

Confusion, irritability
Nervous system stimulation
Anxiety, tachycardia, tremors
Hunger, weakness, visual disturbances
If untreated Loss of conciousness, seizures, coma,
death
 Diabetes Mellitus
Acute Complication : Hypoglycemia
Treatment for hypoglycemia
Ingest simple CHO (fruit juice, soft drink), or
commercial gel or tablet
Avoid sweets with fat (slows sugar absorption)
Check glucose level < 3.9 mmol/L
Then eat usual meal snack or meal and recheck

Treatment for hypoglycemia if not alert enough

to swallow
Glucose IV
Glucagon 1m IM or SC (glycogen glucose)
Then complex CHO diet when alert
 Diabetes Mellitus
Acute Complication : Diabetic Keto Acidosis

Blood Glucose > 20 30 mmol/L

Usually in Type 1 diabetes; can occur in Type 2
Causes:
Infection
Stressors (physiological, psychological)
Stopping insulin
Undiagnosed diabetes
ALTERED CARBOHYDRATE METABOLISM

Insulin

Glucose Utilization
+
Glycogenolysis

Hyperglycemia

Glucosuria
(osmotic diuresis)

Polyuria**
(and electrolyte imbalance)

Polydipsia**

** Hallmark symptoms of diabetes 10

ALTERED PROTEIN METABOLISM

Insulin

Protein Catabolism

Gluconeogenesis
(amino acids glucose)

Hyperglycemia

Weight Loss and Fatigue
11
ALTERED FAT METABOLISM

Insulin

Lipolysis

Free fatty acids + ketones

Acidosis + Weight Loss

12
Degree of insulin deficiency Lipolysis

Free acids + Acetyl co-enzyme A

Aceto acetic acid

Beta-hydroxy butyric acid + Acetone

Hyper ketonaemia

Osmotic pressure in blood plasma

Withdrawal of water from cells
(Moderate Ketoacidosis)

Contraction of size of cells and extra cellular space

Haemo-concentration

Blood volume

Fall in Blood Pressure (B.P.) 13
 Average loss of fluid in moderate diabetic keto-acidosis
- 6 litre water
- 500 mmol Na
- 400 mmol Cl
- 350+ mmol K

Fall in B.P. cause major complication in Kidney

functions
1. Renal ischaemia (Less blood supply in kidneys)
2. Oliguria (Low output of urine)
 Diabetes Mellitus
Acute Complication: DKA

Pathophysiology
Continuation of effects of insulin deficiency
Severe metabolic acidosis
Severe dehydration shock
Severe electrolyte imbalance ( Na, K, Cl, Mg, PO4)
Clinical Manifestations
Dehydration ( Heart Rate; Blood Pressure)
Kussmauls breathing
Smell of acetone in breath
Abdominal pain, cardiac dysrhythmias
 Diabetes Mellitus
Acute Complication: DKA
Treatment
Replace fluid and electrolytes
K replacement (10-300 mmol up to 24 h)
0.9% NaCl, 1.4% NaHCO3, 5-10% dextrose
Glucose, bicarbonates every 1-2 h
Insulin (First IV bolus injection, then infusion)
10-20 units initial, 4-6 units hourly
Maximum - Doubled dose
Blood glucose level monitored and dose reduced 1-4 units
Antibiotics if infections occur
 Diabetes Mellitus
Acute Complication: HHNS
Hyperosmolar hyperglycemic non-ketotic syndrome
BG > 44.5 mmol/L
Occurs in Type II diabetics (often elderly)
Causes: Similar to DKA
Pathophysiology
Similar to DKA, except there is enough insulin to prevent
ketosis (fat breakdown), but not enough to prevent
hyperglycemia
Extreme hyperglycemia causes intracellular dehydration due
to movement of water from cells

Type 1 Moderate hyperglyceamia Severe Ketoacidosis

Type 2 Extreme hyperglyceamia & dehydration No acidosis
Hyper osmolar diabetic coma (syndrome)
 Diabetes Mellitus
Acute Complication: HHNS
Clincial manifestation:
dehydration, weakness, polyuria, polydipsia,
seizures, coma

Treatment
Re-hydrate
Insulin IV
Monitor closely
 Diabetes Mellitus
Chronic Complications (Long-Term)
Artherosceloris & Angiopathy
Macrovascular
Microvascular
Retinopathy
Nephropathy
Neuropathy
Skin problems
Infections
 Angiopathy
Angiopathy blood vessel disease
Related to altered lipid metabolism of diabetes
Macrovascular
Disease of large and mid-sized vessels
Pulmonary Vascular Disease (Lungs)
Cerebro Vascular Disease (Brain)
Cardio Vascular Disease (Heart)
Microvascular
Due to thickening of small vessel membranes
 Atherosclerosis
Blood vessel (artery) wall thickens as a result of the
accumulation of calcium and fatty materials. It reduces
the elasticity of the blood vessel and therefore allows less
blood to travel through
Atherosclerosis & Diabetic Microangiopathy

Ocular microangiopathy (Vision problems)

Nephron micro angiopathy (Kidney cells)
Angina pectoris (Heart attack)
Cardiac failure (Heart failure)
 Intermittent Claudication (Limping)

Gangrene
Intermittent Claudication - walk with
difficulty, typically because of a
damaged or stiff leg or foot.
Gangrene - Death of body tissues i.e.
necrosis
Diabetic Neuropathy
Diabetic Neuropathy
Symptomless but severe disability
Duration of diabetes and degree of metabolic control
Axon degeneration (Shrinkage Fragmentation)
Thickening of cell basal lamina
Demyelination
Abnormality of intra-neural capillaries
Motor, sensory and autonomic nerves
Poly neuropathy
Microvascular Neuropathy

Sensory Neuropathy
Loss of sensation, abnormal sensation, pain of
hands and/or feet
Can progress to partial or complete loss of
sensitivity to touch and temperature high
risk of injury without pain

Autonomic neuropathy
Hypoglycemic unawareness
Silent myocardial infraction (MI) Heart attack
Neurogenic bladder Urine retention
Cardiovascular - Pain and dysfunction

Gastro intestinal - Chronic bowel dysfunction, diarrhoea

Genito urinary - Bladder dysfunction

Foot - Chronic ulcer of feet

Diabetic foot
 Diabetes Mellitus
Chronic Complications
Diabetic Foot
Microvascular disease supply of oxygen,
WBCs, nutrients
Neuropathic & ischemic condition
Difficult in walking
Sensory neuropathy injury
Prevention of ulceration / injury
Management

Pain management Tricyclic antidepressants

(Amitriptyline, Imipramine)

Hospitalized - Bed rest

I.V. antibiotics

Surgical debridement of wound area

Drainage of pus

Diuretics
 Diabetic Nephropathy
30 yrs diabetes 25% renal failure death
Microvascular condition - Damage to vessels supplying
glomeruli (kidney cells)
Stage 1:

Glomerular hyper-perfusion (high blood flow)

Renal hypertrophy (more urine output)

Microalbuminuria (Albumin excretion > 30 g/min)

--- Reversible damage

Proteinuria (> 150 mg/L) --- Irreversible renal damage

Blood creatinine > 200 mol/L --- Severe renal failure

Stage 2:

Thickening of Glomerular capillary

basement membrane

Accumulation of proteins

Deposition of fibrinogen and fibrin

(clotting proteins) on capillary

Narrowing of capillary pores

Hyalinisation (Glass like appearance)

Uriemia
Management

Low protein diet (40-60 g/day)

Antihypertensive agents

Diuretics

Renal (Kidney) Dialysis

EYE
Diabetic Retinopathy
Retina Light sensitive cells in the eye
Microangiopathy in eye - Retinal damage
Early stages - Symptomless
Blindness in adults > 65 yrs age
Regular opthalmoscopy
Retinal photo coagulation therapy (Laser surgery)

Classification: (Based on diagnosis of vision)

- Background retinopathy
- Pre-malignant retinopathy
- Malignant retinopathy
Features:

- Microaneurysms (Circular dark red spots or dots)

- Retinal haemorrhage (Blot round or flame shape)
- Hard exudates (Leakage of plasma)
- Soft exudate (cotton wool spots Hypertension)
- Venous change (Dilation, beading, loops)
- Neovascularisation (New vascular formation)
- Pre-retinal haemorrhage (Bleeding in retina)
- Vitreous haemorrhage (Bleeding of vitroeus humor)
- Fibrous proliferation (New fibers formation)
Neovascularisation
1. Mature vessels
(Optic disc & retina)
2. Fine tufts
3. Fragile, leaky and rupture
4. Haemorrhage
5. Retinitis
6. White cloudy haze
7. Dense white sheet covering the retina (No bleeding)
8. Retinal detachment
9. Development of new abnormal vessels on anterior
surface of iris (More severe)
10. Rubeosis iridis
11. Obstruct the outflow of aqueous fluid (Glaucoma)
12. Increase in the intra ocular pressure
Cataract
Clouding of lens of eye (opacity)
Visual impairment
Poorly controlled diabetes in young patients
Prevention or Diagnosis

Yearly eye check up for the following cases

- Early onset of diabetes

- Long duration diabetes
- Hypertension
- Pregnancy
- Use of oral contraceptive pills
- Heavy smoking
- Alcohol abuse
- Neuropathy
- Persistant proteinuria
Treatment
1. Retinal Photocoagulation
- Xenon arc (white light)
- Laser (Monochromatic blue / green light)

Destroy areas of retinal ischaemia causing

neovascularisation
Seal leaking exudates
Remove the new vessels directly
2. Vitrectomy (Removal of Vitreous humor)
3. Cataract surgery
 Diabetes Mellitus
Chronic Complications
Infection
Immune deficiencies
Delayed detection of other diseases due to
sensory neuropathy
Decreased circulation delays or prevents
immune response
 Occurrence with Diabetes Death Rate

Atherosclerosis 70 %
Renal failure 10 %
Cancer 10 %
Infections 6%
Diabetic Ketoacidosis 1%
Others 3%