Complications of Diabetes Mellitus

Complications of Diabetes Mellitus

Complications of diabetes are due to high sugars and damage to the small and big blood vessels mainly.

High sugars can cause frequent skin and deeper tissue infections. Infections are common, more severe, often require prolonged treatment and may turn serious if not treated fast and appropriately.

In case of very high sugars (DKA or Hyperosmolar states) a person may become unconscious and this may be life threatening. Severe dehydration, salt and water imbalance, accumulation of acids, decreased kidney function may supervene. Treament in hospital is required for patients.

Long term complications are due to blood vessel and nerve tissue damage.

In feet painless wounds (trophic ulcers) may occur and not heal for months. If infected secondarily even amputations may result.

Damage to retina is called retinopathy. In most countries now, diabetes is the major cause of blindness. Regular check up by eye doctors and laser treatment of newly formed blood vessels may prevent blindness at a later stage.

Damage to nerves may cause numbness usually more in hands and feet. Involvement of nerves supplying muscles can cause weakness in moving limbs. Involvement of nerves supplying bladder and large intestines may result in disturbance in acts of passing urine and defecation. Constipation , diarrhea and retention of urine may occur.

Long term diabetes can damage kidney in multiple ways. The details can be seen later in the kidney care part.

Involvement of coronary arteries results in high risk of heart attacks and angina. Similarly strokes causing paralysis etc occur with a much higher frequency in diabetics.

Dialysis Machines

Dialysis machines

 

Machines used to perform hemodialysis are of different varieties. The following fuctions are carried out by these machine

Proportionate mixing of dialysate concentrate and treated water to form dialysate. The composition of dialysate is similar to blood without cells, proteins, lipids and some other complex salts. The dialysate consists mainly of water and various main salts and ions eg sodium, potassium, chloride , bicarbonate, calcium etc.

The dialysate is freed of dissolved gases, and is heated to body temperature. Very low temperature may cause hypothremia and high temperature of dialysated may cause fever.

These machines has a self cleaning mechanism with hot water and various chemicals to take care of various pathogens.

It pulls blood at speeds set by the dialysis personnel and also supplies dialysate at required rate. It can also create negative pressure so that extra fluid can be removed from the body.

During dialysis a person may require various medicines to be administered. This is facilitated by the machine.

Additionally, machines have safety measures. It can detect air in blood so that air does not enter patients’ blood vessels. The machines go into auto shut mode if air is detected in returning blood.

If blood gets hemolysed (hemoglobin leaks out of RBCs) a serious situation for a patient may develop. Machines can detect leaked hemoglobin and sound an alarm.

Most newer machines have built in blood pressure monitoring system. If blood pressure becomes lower or higher than set range, an alarm is sounded and corrective measures can be taken.

Machines also monitor the flow of blood from the patient. If the pressure in the tubing is recorded higher or lower than set limits, alarms sound for the call to dialysis nurse or technician.

Modern machines can also measure dialysis dose. (more about this later in dialysis adequacy)

Next topic in dialysis series is dialysers.

Diabetes mellitus

Diabetes Mellitus

Diabetes is a condition where a person either does not produce required amounts of insulin or is unable to utilise insulin appropriately. It is a common (about 10% of the population), complex disease. It can cause complications if not treated and controlled well.

Types of Diabetes:

There are 2 common types of diabetes Type I and Type II. There are other rare varieties due to pancreatic diseases, hormonal disorders, in pregnancy, after drugs and even rarer genetic disorders.

Type I is the cause in about 10 % of cases, onset is in childhood or young age and insulin is required for treatment.

Type II is the common variety, onset is usually around 50 Yrs of age, often associated with overweight and the risk is high if one parent is diabetic (30 %) and if both parents are diabetic (50 %). During initial stages, diet modification and oral drugs may control sugars but later insulin may be required.

Symptoms:

Classically symptoms in diabetes are polyuria (more urine), polydypsia (more thirst ) and polyphagia ( more eating). In children very high sugars may develop suddenly and patient may become unconscious at the onset (DKA etc). Infections both recurrent and difficult to treat may occur. However in a large no the disease remains without many symptoms and found out accidentally or when complecations arise.

Signs are seen only in advanced and long standing diseases. These are few and may include eye, heart, nerve changes, dehydration and very rapid breathing due to acid accumulation in the body.

Diagnosis of diabetes:

Diabetes is diagnosed by blood glucose testing or glycated hemoglobin levels.

Normal Plasma glucose level after 8 hrs of fasting is < 100 mg/dl. Normal 2 hrs after breakfast (called PP) or after 75 gms of glucose orally is <140 mg.   Diabetes is diagnosed if either fasting plasma glucose is >126 or PP or oral GTT (after 75 gms of glucose is >200 mg/dl.

If fasting value is 100 -125 it is called impaired fasting glucose and if PP or Oral GTT is between 140 and 199 mg/dl it is called impaired glucose tolerance( IGT).

In a person with symptoms of diabetes a random value of plasma sugar >200 mg /dl or fasing plasma sugar >126 mg/dl qualifies for diagnosis of diabetes.

Lab tests for diabetes  

For common types of diabetes the following tests may be required at the time of initial diagnosis.

Complete blood counts, Blood sugar, kidney and liver function tests, urine routine and urine for microalbumin, lipid profile, Chest X Ray, ECG. Ultrasonography of abdomen, fundus examination, foot examination and blood pressure is noted.

In Type I cases or where genetic, pancreatic or hormonal disorders are suspected, tests for these are carried out as appropriate.

This is a chronic disease and lifelong follow up and treatment are required.

 

 

Coming next ~

Complications of diabetes

Treatment of diabetes.

Dialysis Water

Dialysis water

During hemo-dialysis about 500 ml (range 50-800 ml) of dialysate flows through the dialyer (The plastic casing that contains dialysis membrane and which partitions blood on one side and dialysate on the other).

Water treatment is an essential requisite for safe dialysis.

In a 4 to 5 hrs session about 120 to 150 liters of water thus comes into contact with blood.

A very small impurity in this water thus can get magnified and produce serious consequences in the renal failure patient.

If dialysis water is unfit, it results in recurrent fever, poor health and nutrition of patient, electrolyte abnormalities etc. High aluminium levels can produce brain disorder called dementia and aluminium related bone disease. High chlorine levels can cause severe reactions.

Water treatment is done for ensuring safe dialysis water.

If ground or municipal supply provides hard water it is softened by machine.

Particulate matter is removed by filters consisting of pebbles, sand and other materials first so that large particles are removed, small particles than are removed by microfilters which can remove 5-micron size particles.

Chlorine is removed by adsorption on to carbon particles. It should be present in water before it is treated but removed during water treatment.

Excessive salts are measured as TDS (total dissolved solids) expressed as parts per million or ppm in short.Both cations and anions measured and TDS is equal to about 100 X total ions expressed as milliequivalents. It is usually 0.5 to 1 times the conductivity value.

Bacteria and their products produce harmful substances. These need to be removed and water prevented from letting them grow again by regular maintenance of the pipes and drainage system.

To produce water of sufficiently good quality, various criteria have been laid by different countries. AAMI dialysis criteria is one such criteria. In these acceptable levels of various chemicals and other impurities are mentioned.

Good quality dialysis water reduces morbidity, mortality, and complications in dialysis. It results in better overall health and quality of life for the patient.

Treatment of Hypertension

Treatment of Hypertension

Why should hypertension be treated ?

The following are the benefits of treating hypertension:-

  • 50 % reduction in risk of heart failure
  • 30-40% reduction of risk of strokes of brain
  • 20-30 % reduction in risk of heart attacks.

The benefit occurs in all age groups including elderly. If a cause has been found (as happens in very few cases) treatment of underlying cause is useful e.g. treating kidney disease, removing adrenal tumours, stopping steroids, analgesics, contraceptive pills, certain anti depressants etc.

In the majority of cases, no cause is found. In these, we suggest non-pharmacologic ways as well as medicines to lower blood pressure.

Non-pharmacological methods may reduce blood pressure by 5- 10 mm on their own. These include

Reduction of weight if overweight

Reduction of salt in diet (avoid pickles, salted foods, preserved foods). Do not take salt substitutes if there is associated kidney disease.

Dash diet ( dietary approaches to stop hypertension diet ). Increase vegetables, whole grain cereals, low fat, low sugar and sweets, more fruits, fish and chicken if you are a non vegetarian

Increase physical activity, both physical aerobic activity and relaxation exercises may help

Stop or cut down on alcohol and smoking

Learn about Hypertension.

Pharmacological methods may reduce blood pressure

2 or more drugs are required if BP is >20/10 above the normal range. More medicines and higher doses are needed if blood pressure is due to kidney disease. These drugs may cause side effects and hence prescriptions are tailor made to suit particular requirements of the patient.

The drugs include

Diuretics : – which increase salt and water excretion in the body. These work only if salt is cut down in the diet.

ACE- inhibitors and ARB’s : -These are a class of medicines which protects against ill effects of high BP on kidneys, heart and brain. However, treatment is complicated and always should be under the guidance of a competent physician. These drugs are known to cause fetal malformations. Inform your doctor if you are pregnant or are planning to have a child,

Calcium Channel Blockers :- Very useful and often used class of drugs. Some times these may cause feet to swell otherwise these are well tolerated.

Betablockers:- These reduce heart rate and blood pressure. This is useful in reducing stress on the heart. However, these may cause serious worsening in asthma and may aggravate prostate symptoms, and may cause impotence.

Centrally acting and alfa blockers:- These are also useful in controlling BP. Some of these may cause or worsen depression.