Updated: 7/24/2020

Complications of Diabetes

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  • A 58-year-old male presents to his primary care physician for a routine checkup. He states that he has noticed some swelling of his ankles bilaterally but otherwise feels well. The patient has a 15-year history of diabetes mellitus. He takes metformin. His father died of a myocardial infarction at age 61. Routine labs are drawn. Urine dipstick is negative for protein. A spot urine microalbumin/creatinine ratio is elevated. (Diabetic nephropathy)
Introduction
  • Introduction
    • demographics
      • diabetes is 1 of the top 10 leading causes of death in the US
      • majority of deaths in people with diabetes is due to cardiovascular disease
  • Treatment
    • strict glycemic control prevents microvascular disease
    • lifestyle modifications (i.e., weight loss and exercise) and management of hypertension and dyslipidemia to prevent macrovascular complications 
Complications of Diabetes
Short-Term

Category

Complication

Pathogenesis

Hyperglycemia

  • Diabetic ketoacidosis (DKA) 
  • Hyperosmolar hyperglycemia state (HHS) 
  • Poor glycemic control

Hypoglycemia

  •  Life-threatening hypoglycemia 
  • Secondary to therapy
Long-Term

Category

Complication

Pathogenesis

Macrovascular

  •  Coronary artery disease (CAD) 
  •  Peripheral arterial disease (PAD) 
  •  Stroke 
  • Accelerated atherosclerosis due to chronic inflammation and injury to arterial walls

Microvascular

  • Diabetic retinopathy 
    • nonproliferative
    • proliferative
    • macular edema
  • Diabetic nephropathy 
  • Diabetic neuropathy 
    • peripheral neuropathy
    • central neuropathy
      • cranial nerve III palsy 
  • Autonomic dysfunction
    • gastroparesis
    • impotence 
    • neurogenic bladder/overflow incontinence 
  • Diabetic foot
  • Chronic hyperglycemia causes glycation of proteins and lipids resulting in impaired cell membrane function, osmotic damage, and tissue injury


Immune dysfunction

  • Urinary tract infections (UTIs) 
  • Rhinocerebral mucomycosis 
  • Pseudomonas malignant external otitis 
  • Hyperglycemic environment enhances virulence
  • Lower secretions of inflammatory cytokines
  • Decreased leukocyte adherence and chemotaxis
  • Impaired neutrophil phagocytosis

Other

  • Necrobiosis lipoidica
  • Non-alcoholic fatty liver disease (NAFLD) 

          

 
Diabetic Nephropathy
  • Diabetic nephropathy
    • pathogenesis
      • glycosylation of basement membrane
      • increased permeability and thickened glomerular basement membrane
  • Presentation
    • hypertension
    • foamy urine
    • signs of renal failure
  • Studies
    • urinalysis
      • proteinuria
        • microalbuminuria
          • earliest sign
        • progresses to nephrotic syndrome 
    • renal biopsy
      • not necessary for diagnosis
      • glomerular basement membrane thickening
      • Kimmelstiel-Wilson nodules 
        • pathognomonic
  • Treatment
    • angiotensin-converting enzyme inhibitor (ACEi) or angiotensin-receptor blocker (ARB)
      • regardless of blood pressure
Diabetic Peripheral Neuropathy
  • Peripheral neuropathy
    • pathogenesis
      • glycosylation of axon proteins
  • Presentation
    • progressive, symmetric “stocking-glove” loss of sensation, burning, or pain in distal lower extremities
    • can progress to motor weakness and areflexia
  • Studies
    • monofilament test
    • pinprick test
  • Treatment
    • pain management
      • pregabalin or gabapentin
      • serotonin norepinephrine receptor inhibitors (SNRIs) (i.e., duloxetine or venlafaxine)
  • Complications
    • diabetic foot
Diabetic Foot
  • Diabetic foot
    • pathogenesis
      • combination of vascular (poor circulation) and nerve (loss of sensation) damage
  • Presentation
    • painless ulcer 
      • most commonly on plantar metatarsal heads 
    • neuropathic arthropathy (Charcot foot) 
      • acute
        • nontender, erythematous, swollen, and warm joint
      • chronic
        • joint or foot deformity
          • most commonly collapse of tarsometatarsal joint and valgus angulation
  • Imaging
    • radiograph
    • magnetic resonance imaging (MRI)
      • if osteomyelitis is suspected
  • Studies
    • to rule out infection/osteomyelitis
      • white blood cell count
      • erythrocyte sedimentation rate
      • C-reactive protein
  • Treatment
    • conservative
      • immobilization and rest
      • accommodative footwear
      • wound care and dressing changes
    • antibiotics
      • indicated for infection
    • surgery
      • indicated for
        • infection requiring debridement or osteomyelitis
        • revascularization if underlying peripheral artery disease
        • severe deformities
  • Complications
    • secondary infection
      • cellulitis
      • osteomyelitis
      • spontaneous fractures
Diabetic Gastroparesis
  • Diabetic gastroparesis
    • pathogenesis
      • nerve damage leading to delayed gastric emptying
  • Presentation
    • nausea
    • vomiting
    • early satiety
    • bloating
    • constipation
    • weight loss
  • Imaging
    • scintigraphy
      • delayed gastric emptying
    • endoscopy
      • rule out obstructive lesion
    • computed tomography (CT)
      • rule out obstructive lesion
  • Treatment
    • prokinetics agents
      • first-line
        • metoclopramide
      • alternatives
        • domperidone
        • erythromycin
        • cisapride
  • Complications
    • risk of postprandial hypoglycemia
Necrobiosis Lipoidica
  • Necrobiosis lipoidica
    • demographics
      • majority associated with diabetes mellitus
      • can also be associated with thyroid disease
      • females > males
    • pathogenesis
      • collagen degeneration and lipid accumulation in skin
  • Presentation
    • pretibial skin lesions 
      • sharply demarcated, reddish-brown, or yellowish plaques with irregular margins and central sclerosis/atrophy
  • Studies
    • skin biopsy
      • palisaded and interstitial granulomas in dermis and subcutaneous tissue
      • necrobiosis of collagen
      • infiltration of lymphocytes and plasma cells
    • if no known history of diabetes mellitus or thyroid disorders, patient should be evaluated for these
  • Treatment
    • first-line
      • high-potency topical steroid
    • alternatives
      • intralesional corticosteroid
      • topical tacrolimus

 

Complications of Diabetes

Short-term

Category

Complication

Pathogenesis

Hyperglycemia

·         Diabetic ketoacidosis (DKA)

·         Hyperosmolar hyperglycemia state (HHS)

·         Poor glycemic control

Hypoglycemia

·         Life-threatening hypoglycemia

·         Usually secondary to therapy

Long-term

Category

Complication

Pathogenesis

Macrovascular

·         Coronary artery disease (CAD)

·         Peripheral vascular disease (PVD)

·         Stroke

·         Accelerated atherosclerosis due to chronic inflammation and injury to arterial walls

Microvascular

·         Diabetic retinopathy

o   Nonproliferative

o   Proliferative

o   Macular edema

·         Diabetic nephropathy

·         Diabetic neuropathy

o   Peripheral neuropathy

o   Central neuropathy

§  Cranial nerve III palsy

o   Autonomic dysfunction

§  Gastroparesis

§  Impotence

§  Neurogenic bladder

·         Diabetic foot

·         Chronic hyperglycemia causes glycation of proteins and lipids resulting in impaired cell membrane function, osmotic damage, and tissue injury

Immune dysfunction

·         Urinary tract infections (UTIs)

·         Rhinocerebral mucormycosis

·         Pseudomonas malignant external otitis

 

·         Hyperglycemic environment enhances virulence

·         Lower secretions of inflammatory cytokines

·         Decreased leukocyte adherence and chemotaxis

·         Impaired neutrophil phagocytosis

Other

·         Necrobiosis lipoidica

·         Non-alcoholic fatty liver disease (NAFLD)

·          

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(M2.EC.15.11) A 45-year-old male with a 15-year history of diabetes mellitus presents to his primary care provider for a routine checkup. His doctor is concerned about his renal function and would like to order a test to detect renal impairment. Which of the following is the most sensitive test for detecting renal impairment in diabetic patients?

QID: 104336
1

Cystatin C levels

0%

(0/59)

2

Urine microalbumin to creatinine ratio

95%

(56/59)

3

Hemoglobin A1C

0%

(0/59)

4

Urine protein dipstick

2%

(1/59)

5

Urinalysis

2%

(1/59)

M 6 D

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