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Complication
of
Diabetes Mellitus
Diabetic Complication
Acute : Chronic :
Microangiopathy Macroangiopathy
Hypoglycemia
DKA consists of the biochemical triad of
ketonaemia (ketosis),
hyperglycaemia, and
acidaemia.
PRECIPITATING FACTOR(S)
The ADA Workgroup on Hypoglycemia defined
hypoglycemia in diabetes as “all episodes of abnormally
low plasma glucose concentration that expose the
individual to potential harm ”.
HYPOGLYCEMIA
HYPOGLYCEMIA
+
+
ACTH
+
Response to hypoglycemia
90 –
80 – Counter-regulation
70 – Autonomic symptoms
60 –
Neuroglycopenic symptoms
50 –
40 –
Coma
30 –
20 –
10 – Permanent damage
0 – Death
Signs Symptoms
Neuro-glycopenic Neurogenic
Signs Symptoms
Neuro-glycopenic Neurogenic
Cardiovascular
disease
Diabetic
Myocardiac infarct
Nephropathy Most common cause
of death in diabetics
Accounts for ~40% of all new
cases of Diabetic
end-stage renal disease
(ESRD).
Neuropathy
Most common cause of
lower limb amputation
Microvascular complications
Macrovascular complications
Monocyte
Vessel lumen
Circulating LDL
Endothelium
Adhesion
molecules
(VCAM-1, ICAM-1) Circulating LDL
Inflammatory mediators
(CRP, CD40/CD40L, Ox-LDL Intima
TNF-α, IL-1, IL-6)
Foam
cell
Macrophage
CD40L=CD40 ligand; TNF-α=tumor necrosis factor-alpha; IL=interleukin; VCAM=vascular cell adhesion molecule;
ICAM=intercellular adhesion molecule.
Cockerill GW et al. Arterioscler Thromb Vasc Biol. 1995;15:1987-1994; Andre P et al. Circulation. 2002;106:896-899; Libby
P. Circulation. 2001;104:365-372; Libby P et al. Circulation. 2002;105:1135-1143; Ross R. N Engl J Med. 1999;340:115-126.
Risk factors for macroangiopathy diabetics
Dyslipidemia
exagerate/accelerate
Diabetes
Hypertension Risk Macro
Factors angiopathy
Hyperinsulinemia
UKPDS: Reducing HbA1c Associated with
Reduction in Risk of Fatal / Non-Fatal MI
Risk of fatal and non-fatal MI by HbA1c level
10
p<0.0001 n=3,642
# of events=496
Hazard ratio
Heart attacks
1% Microvascular complications
*p<0.0001
UKPDS 35, BMJ 2000; 321: 405-12
Early Diagnosis of Chronic
Complication
Retinopathy
• It’s recommended to perform a routine-
retinal check up each year
• Methods:
– direct opthalmoscope
– indirect opthalmoscope with slit-lam bio-
microscope
– retinal photography
• Early referral
Nephropathy
Because of variabilityin urinary albumin excretion, two of three specimens collected within a 3-to-6 month
period should be abnormal before considering a patient to have crossed one of these diagnostic threshold.
Exercise within 24 h, infection, fever, congestive heart failure, marked hyperglycemia, marked
hypertension, pyuria, and hematuria may elevate urinary albumin excretion over baseline values.
NEUROPATI
DIABETIK
• Diffuse Neuropathy
1. Distal symmetrical sensorimotor polyneuropathy
2. Autonomic Neuropathy
Sudomotor neuropathy
Cardiovascular autonomic neuropathy
Gastrointestinal neuropathy
Genitourinary neuropathy
3. Symmetric proximal lower limb motor neuropathy
• Focal Neuropathy
1. Cranial neuropathy
2. Radiculopathy/ plexopathy
3. Entrapment neuropathy
Thomas, 1997
• Sensoric Neuropathy
• Autonomic Neuropathy
• Motoric Neuropathy
Peripheral
Neuropathy Arterial
Disease
Foot
Trauma
Deformity
Pathophysiology of diabetic foot
Diabetes Mellitus
Structural
Impaired Response
Deformity Ischemia
Cheiroarthropathy to Infection