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Updated: Jul 24 2020

Complications of Diabetes

  • Snapshot
    • 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
      • 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
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