Diabetes Complications

• Long-term complications:

  • Consistently raised blood glucose affects:
  • Large blood vessels
  • Small blood vessels
  • Nerves
• Atherosclerosis:

  • Diabetes is linked to an accelerated rate of atherosclerosis
  • Modifiable risk factors
  • Non modifiable risk factors
  • Establish CV Risk
  • Optimize medication
  • 80% of all diabetic deaths are due to
  • atherosclerosis
• Peripheral Artery Disease (PAD):

  • PAD risk is increased in individuals with diabetes:
  • age (> 40 years 20%*, > 50 years 29%*) duration of diabetes
  • presence of peripheral neuropathy
  • *probably an underestimate due to asymptomatic nature PAD
• Diabetic Symmetrical Peripheral Neuropathy (DSPN)

  • Accounts for 75% of all neuropathies
  • Cause unknown but prevailing theory suggests oxidative and inflammatory stress in the context of metabolic dysfunction damages nerve cells
  • 10 - 30% of individuals with impaired glucose tolerance (IGT) have been shown to have small fibre peripheral neuropathy
  • It is the most important cause of foot ulceration and contributes to falls and fractures
• Diabetic Autonomic Neuropathies:

  • Autonomic neuropathies affect the autonomic neurones:
  • parasympathetic
  • sympathetic
  • or both
  • The major clinical manifestations are:
  • Hypoglycaemic unawareness
  • Resting tachycardia
  • Orthostatic hypotension
  • Gastroparesis
  • Constipation
  • Diarrhoea
  • Neurogenic bladder
  • Sudomotor dysfunction
• Cardiac Autonomic Neuropathy (CAN):

  • Cardiac Autonomic Neuropathy is the most important of the autonomic neuropathies in cardiac prevention & rehab
  • In Type 2 DM the prevalence of CAN increases with diabetes duration CAN has shown to be present in 60% of people with a diagnosis of Type 2 DM ≥ 15 + years
  • It is also present in people with IGT, insulin resistance and metabolic syndrome
• Cardiac Autonomic Neuropathy (CAN):

  • Early stages:
  • Individuals may be completely asymptomatic with the only
  • sign being decreased HRV with deep breathing
  • More advanced stages:
  • resting tachycardia (> 100bpm)
  • exercise intolerance
  • may also be accompanied by orthostatic hypotension
• Cardiac Autonomic Neuropathy (CAN)

  • CAN is difficult to treat and the focus is on alleviating symptoms and preventing further deconditioning
  • CAN is an independent risk factor for:
  • CV mortality
  • arrhythmia
  • silent ischaemia
• Diabetic Retinopathy (DR)

  • There are two types of diabetic retinopathy:
  • Non-proliferative diabetic neuropathy (NPDR)
  • Proliferative diabetic neuropathy (PDR)
• Diabetic Kidney Disease (DKD):

  • Other terms used for DKD:
  • Chronic kidney disease (CKD), kidney disease of diabetes, diabetic nephropathy
  • Diabetes is the leading cause of:
  • Chronic kidney disease (CKD)
  • End-stage renal failure (ESRF)
• Diabetic Kidney Disease (DKD)

  • Approx 40% of individuals with diabetes develop DKD
  • The kidney is affected in 3 ways (individuals often have a combination)
  • Diabetic neuropathy - damage to the glomeruli (microscopic filters of the kidney)
  • Renovascular disease – narrowing of the artery to one or both of the kidneys
  • Urinary tract infections
• Musculoskeletal (MSK) Issues:

  • Increase in reported MSK pain frequency and intensity
  • Osteoarthritis
  • Rheumatoid Arthritis
  • Gout
  • Fibromyalgia
  • Dupytrens contracture
  • ‘Frozen shoulder’ (adhesive capsulitis)
  • Osteoporosis
  • (Diabetes and Musculoskeletal disorders – a review, J Diab Metab Disorder Control 2020)
• Influences on blood glucose levels:

  • Exercise/physical activity
  • Nutritional intake – what and when
  • Blood glucose lowering medication
  • Other medications – e.g., β blockers, ace inhibitors, thiazides, statins, steroids
  • Stress
  • Other illnesses/medical conditions
  • Infection
  • Pain
• Hypoglycaemia = ‘Hypo’

  • Diabetes UK recommends a practical policy of 4 mmol/L the lowest acceptable blood glucose level in people with diabetes
• Hypoglycaemia impact on the cardiovascular (CV) system:

  • Endothelial dysfunction
  • Inflammation
  • Blood coagulation abnormalities
  • Sympathoadrenal response cause
  • Increased adrenaline
  • Increased contractility
  • Increased oxygen consumption
  • Increased cardiac workload
• Hypoglycaemia - signs and symptoms:

  • autonomic
  • sweating
  • palpitations
  • shaking
  • hunger
  • neuroglycopenic
  • confusion
  • drowsiness
  • odd behaviour
  • speech difficulty
  • incoordination
  • general malaise
  • headache
  • nausea
• Hyperglycaemia:

  • World Health Organisation (WHO) define hyperglycaemia as:
  • Fasting plasma glucose ≥ 7.0 mmol/L
  • 2 hour post load plasma glucose ≥ 11.1 mmol/L
  • HbA1c ≥ 48 mmol/mol
  • Categories of hyperglycaemia:
  • Transient
  • Diabetic Ketoacidosis (DKA)
  • Hyperosmolar Hyperglycaemic State
• Causes of Hyperglycaemia

  • Stress
  • Eating too much carbohydrate
  • Overtreating a hypo
  • Recent illness/surgery
  • Sickness/diarrhoea
  • Infection
  • Missed medication/injection
  • Other medications – steroids,
  • Poor storage of medication – hot weather
  • Lipohypertrophy
• Symptoms of hyperglycaemia:

  • Increased Thirst (Polydipsia) – Feeling unusually thirsty despite drinking fluids.
  • Frequent Urination (Polyuria) – Needing to urinate more often, especially at night.
  • Dry Mouth – A persistent feeling of dryness in the mouth.
  • Fatigue – Feeling unusually tired or weak.
  • Blurred Vision – Difficulty focusing or seeing clearly.
  • Hunger (Polyphagia) – Feeling hungry even after eating
• Symptoms of hyperglycaemia cont:

  • Headaches – Due to dehydration and fluctuating blood sugar levels.
  • Fruity Breath Odour – A sign of ketones in the blood (Diabetic Ketoacidosis - DKA)
  • Nausea and Vomiting – Resulting from metabolic imbalances.
  • Shortness of Breath – Due to acidosis and dehydration
  • Confusion or Difficulty Concentrating – Can lead to diabetic coma if severe.
  • Slow Healing Wounds & Infections – High blood sugar impairs immune function.
  • Tingling or Numbness – Especially in the hands and feet (nerve damage)
• Diabetic Ketoacidosis (DKA):

  • DKA is a complex disordered metabolic state characterised by:
  • hyperglycaemia
  • acidosis
  • ketonaemia
  • it is a medial emergency
• DKA – blood testing for ketones:

  • Blood ketone testing strips:
  • < than 0.6 mmol/L is a normal reading
  • 0.6 to 1.5 mmol/L: a slightly increased risk of DKA - test again in a couple of hours
  • 1.6 to 2.9 mmol/L: an increased risk of DKA - the diabetes team or GP or 111 should be contacted as soon as possible
  • 3 mmol/L or over means very high risk of DKA – medical assistance required IMMEDIATELY
• Hyperosmolar Hyperglycaemic State (HHS):

  • No precise definition of HHS but common features are:
  • It comes on over many days
  • An individual presents as severely dehydrated and very unwell
  • Other existing co morbidities are common
  • Metabolic and dehydration disturbances are more extreme than in DKA
  • Mainly seen in the elderly but younger individuals presenting
  • more often as the initial presentation of Type 2 DM