Chapter VII Complications of Diabetes MellitusNEUROPATHY Neuropathy or nerve damage as a result of chronically high blood sugars can be one of the most debilitating and frustrating complications of diabetes. Available treatments are not always successful, resulting in chronic pain, discomfort and disability. By keeping blood sugars as closely controlled as possible, exercising regularly, and maintaining weight control, patients are able to find some relief from their neuropathies. Neuropathy is more likely to affect people with long-standing diabetes who have poor glycemic control. Symptoms of neuropathies can be varied, although pain or numbness in the legs or feet may be the most common complaint. Neuropathy can cause many different complaints depending on whether nerves in the legs, GI tract, or elsewhere are affected. Symptoms related to neuropathy
TYPES OF NEUROPATHY (body parts affected) Motor neuropathy affects the nerve fibers that carry signals regulating muscles, allow motions such as walking and fine finger movements. Loss of motor fibers causes muscle weakness.
Sensory neuropathy or peripheral neuropathy affects the nerves that carry information to the brain about sensations from different parts of the body. Loss of sensory fibers ultimately causes visual changes, including an inability to interpret shapes, movements, texture, and pain caused by sharp objects and heat and cold.
Autonomic neuropathy affects the nerves that control involuntary activities of the body such as the action of the stomach intestines, bladder, heart and blood pressure. Autonomic neuropathy may lead to impotence in men, bladder neuropathy, diarrhea or a bloated stomach.
Neuropathic arthropathy
Cranial neuropathy affects the twelve pairs of nerves that are connected to the brain and control sight, eye movement, hearing and taste. Usually cranial neuropathy affects the nerves that control the eye muscles. It starts with pain on one side of the face near the affected eye. With time the eye muscle becomes paralyzed, resulting in double vision. Symptoms usually get better in 2-3 months. Compression mononeuropathy occurs when a single nerve is damaged, by blood vessel disease that restricts blood flow to a part of the nerve, or when nerves must pass through a tight tunnel or near a lump of bone. Carpel tunnel syndrome is probably the most common form of compression mononeuropathy known. This occurs when the median nerve of the forearm is compressed at the wrist. Symptoms include swelling, numbness, or prickling in the fingers with or without pain. Thoracic or lumbar radiculopathy occurs most often in people with Type 2 diabetes. It affects the torso as a band around the chest or abdominal wall on one or both sides. People with this neuropathy get better with time. CAUSES OF NEUROPATHY There are many theories as to why neuropathy occurs in people with diabetes. Generally, diabetic neuropathy is thought to be a result of chronic nerve damage caused by high blood sugars. One theory states that a covering of cells, called Schwann cells, surrounds nerves. Excess sugar circulating throughout the body interacts with an enzyme in the Schwann cells called aldose reductose. Aldose reductose transforms the sugar into sorbitol. This draws water into the Schwann cells, causing them to swell,. The swelling pinches the nerves, causing damage and at times pain. If this process is not stopped and reversed, the Schwann cells and nerves they surround may die. DIAGNOSING NEUROPATHY One way of diagnosing neuropathy is through symptoms being exhibited. A physician may detect early signs of neuropathy by observing decreased responsiveness to knee or ankle jerk tests or by observing orthostatic changes in blood pressure. There are specific tests used in diagnosing neuropathy. Electromyography is a test that measures the response of muscles to electrical impulses. Nerve conduction studies that study the flow of electrical currents through the nerve inserts a needle into the muscle to measure the electrical charges. This test can show whether a nerve fiber is breaking down or healing. To diagnose Charcot’s joint, the doctor may take an x-ray of the joint or possibly perform a bone scan. TREATMENT OF NEUROPATHY There are no cures or treatment for nerves damaged by neuropathy. Although there are a variety of treatments that are helpful, there is no way to heal or replace nerves that have been damaged. he most important things that people with neuropathy should do is:
By keeping blood sugars closer to normal, the damage high blood sugars can cause to nerves is limited. Exercise will have the added advantage of keeping muscles that have been weakened by decreasing nerve activity to remain strong and toned. No one therapy works best for everyone. Treatment should be tailored to the location of the pain and the type of pain. A major goal of treatment for neuropathy is relieving pain. Acetaminophen, aspirin and ibuprofen are usually used before narcotics. Pain medications are best used throughout the day before the pain becomes severe. Narcotics can relieve pain, but they are used only as a last resort. Use of narcotics for a long period of time can lead to addiction. Creams that contain capsicum, an extract of hot peppers that includes cayenne and Tabasco peppers, are rubbed on the skin in the painful area. These creams block pain signals although they do not work for everyone. Anti-depressants are used to relieve the pain associated with neuropathy. Tricyclic drugs including Elavil, Norpramin or Imipramine are among the drugs prescribed to block neuropathy pain. Patients take these medications at night, as they help with depression, anxiety, and insomnia associated with neuropathy. These anti-depressants decrease the patient’s awareness of pain, which is usually more severe at night. Anti-depressants can take several weeks to become effective. Uncomfortable side effects can include dry couth, constipation, and nausea. There are other types of drugs that sometimes help. Anti-convulsants such as Dilantin, Tegretol, and Neurontin are used along with drugs such as Mexitil, normally used to treat irregular heart rhythm. Many of these drugs can have unpleasant side effects such as dizziness or confusion when taken in large doses, especially by the elderly. Gastroparesis Reglan or Propulsid are drugs used for gastroparesis in which the stomach is not emptying properly. These drugs help the stomach push food along and get it through the rest of the digestive process. Carafate is used in conjunction with these drugs to help control extra acid that may be sitting in the stomach. Bladder Neuropathy Urecholine treats bladder neuropathy that results in the bladder never completely emptying. Because patients with this problem are more susceptible to developing urinary tract infections, antibiotic therapy may be prescribed to try to keep the bacterial count in the bladder and urinary tract at a manageable level. Patients should be encouraged to urinate every 3-4 hours when they are awake even if they don’t feel the need. Erectile Dysfunction Erectile dysfunction as a result of neuropathy or blood vessel damage can be treated using certain drugs that are inserted into the end of the penis or injected to cause an erection before intercourse. Vacuum devices that enable an erection to be achieved or surgically implanted prosthesis are options to be explored. Viagra is another option that can be considered by patients with erectile dysfunction. Diabetics however, are more susceptible to heart and vessel disease that non-diabetics and use of Viagra by individuals with underlying cardiovascular disease should be reviewed thoroughly. In addition to its known side effects, the use of Viagra with nitroglycerin tablets has been associated with several reported deaths. Postural Hypotension Certain blood pressure-raising medications may be prescribed for patients with postural hypotension or they may benefit from support stockings to prevent pooling of blood in the legs. If the diabetic patient also has high blood pressure, the process of balancing blood pressure-lowering medication and medication that will keep the blood pressure from dropping while reclining or sitting can be very difficult and may require several adjustments. Charcot’s Treatment for Charcot’s joint is geared toward preventing further damage. The joint should be immobilized and weight bearing should be avoided while the joint is healing. The foot is usually put into a cast or a special brace for a period of weeks. This preserves the joint function and limits damage. As the foot heals, special shoes are worn. If the joints have healed into a deformed shape, surgery may be necessary to restore the joint to a more normal shape foot. DIABETIC RETINOPATHY Diabetic retinopathy is the leading cause of blindness and visual impairment in the diabetic population. Compared to non-diabetics, people with diabetes are four times more likely to become blind. 12% of new blindness diagnosed each year and 8% of the legally blind in the United States are attributed to diabetes as the underlying cause. New diagnosis of Type 2 diabetics’ show approximately 21% has some degree of eye damage. The main diabetes-related sys disease is retinopathy. Retinopathy is defined as impairment of the retina due to deterioration of the capillaries. According to the American Diabetic Association, after 15 years of diabetes, 2% of people become blind while 10% develop severe visual handicap. 97% of people on insulin and 80% of Type 2 diabetics show evidence of retinopathy. Retina The retina is a delicate layer of nerve tissues at the back of the eye. Light enters the eye and is focused b the lens through a clear gel-like fluid called the vitreous. This nerve-rich, light-sensing area in the back of the eye is crucial for sight, functioning by changing the image into electrical impulses that are transmitted to the brain via the optic nerve. The retina is composed of two parts. The macula is the middle portion closest to the optic nerve and is responsible for central vision and color vision. The peripheral or outer region is responsible for side vision and night vision. TYPES OF RETINOPATHY Background Retinopathy Background retinopathy or nonprohliferative diabetic neuropathy is an early stage of retinopathy that usually involves no apparent damage. In this type of retinopathy, blood vessels within the retina develop tiny bulges or micro aneurysms, which leak fluid and hemorrhage. This causes swelling and forms deposits or exudates. If the macula, the part of the retina where central vision occurs, becomes swollen, distorted vision is the result. Mild background retinopathy is normally not treated. This type affects approximately 90-95% of long-term diabetics to some degree. This is generally perceived as a warning sign and can progress to the more severe form proliferate retinopathy. Proliferate Retinopathy Proliferate retinopathy is a more advanced and severe form of retinopathy. In this form of retinopathy, the retinal vessels close, causing growth of abnormal blood vessels over the retina and into the vitreous. These abnormal vessels block light from reaching the retina. Connective tissue growing along with the abnormal vessels may grow into the vitreous and contract causing the retina to detach. This is called traction retinal detachment. The patient may notice a dark shadow and vision is poor. The corrective procedure for this condition is surgery to release the traction, remove scar tissue, and re-attach the retina. Surgery must be performed as soon as possible to preserve vision. If the retinopathy affects the peripheral retina, the patient may notice no signs and symptoms aside from difficulty with night vision. Patients will generally notice more difficulty if the macula is affected. Prevention of Retinopathy To minimize the risk of diabetic retinopathy it is essential to:
Treatment of Retinopathy Laser treatment of leaking blood vessels for macular edema reduces the risk of future loss by 50%. Laser treatment to the peripheral retina or pan-retinal photocoagulation is used for proliferative diabetic retinopathy. Brief intense bursts of laser light can repair leaking blood vessels, destroy those that cannot be fixed, and prevent formation of new ones. Laser surgery does not reverse retinopathy. Non-proliferative diabetic retinopathy may reduce further loss of vision and delay the onset of proliferative retinopathy. A vitrectomy is used when massive bleeding into the vitreous has occurred. In this procedure, the bloody vitreous is removed and replaced with clear, sterile fluids, which restores vision. Fluorescein angiography is ordered if after an eye examination diabetic retinopathy is suspected. This is a series of pictures taken as iodine-based dye travels through the retinal vessels. In conjunction, an ultrasound may be used to detect retinal detachment. CATARACTS Cataracts are clouding of the normally clear lens. A cataract develops over years and causes progressive blurred vision. Causes of cataracts include aging, eye injuries, disease, heredity and birth defects. Senile cataracts are common eye problems among the elderly. Poor diabetic control can hasten the formation of senile cataracts. Metabolic cataracts are sometimes found in younger people with diabetes. Treatment for senile and metabolic cataracts is surgical removal of the lens. Vision is restored after surgery by using eyeglasses, contact lenses, or intraocular lens implants. GLAUCOMA The neovascularization of proliferative retinopathy can cause blood vessels to grow into the iris, leading to glaucoma. Glaucoma is a group of diseases characterized by damage to the nerve due to increased pressure in the eye. The vision loss from glaucoma is permanent. The best protection against glaucoma is prevention and early detection. Early detection and treatment of diabetic eye disease is essential to prevent blindness. Early diabetic eye disease initially may have no symptoms. An initial eye examination with an ophthalmologist, keeping regularly scheduled appointments, along with proper management of diabetics can help prevent the devastating complication of blindness. DIABETES AND NEPHROPATHY Diabetic nephropathy is a complication of long-term diabetes that affects nearly one million Americans. This secondary complication of diabetes is characterized by progressive loss of kidney function, which ultimately requires dialysis and frequently leads to end-stage renal disease requiring kidney transplant. The kidneys filter waste products from the blood through capillaries. As the blood passes through the capillaries, the kidneys draw waste out and produce urine. In people with nephropathy, capillaries become blocked and leaky. Waste stays in the blood and protein, which should remain in the blood, leaks into the urine. One-third of people with Type 1 diabetes develop kidney complications within 15 years of diagnosis. 15% of people with Type 2 diabetes develop nephropathy within 15 years of diagnosis. The first sign of kidney complications is microalbuminuria, or small amounts of protein in the urine. Microalbuminuria generally appears around ten years after diabetes has been diagnosed. Over a period of time, the protein content of the urine increases. When the protein content reaches 30mg/dl, which is generally after 15 to 20 years as a diabetic, the diagnosis of nephropathy is made. As kidney function decreases over the years, kidney functions declines and the protein content of the urine continues to increase. Microalbuminuria becomes proteinuria. After 25 to 30 years of diabetes, the kidneys no longer function, resulting in end-stage renal disease. (ESRD) People with diabetes are twenty times more likely to develop ESRD than non-diabetics. ESRD is fatal unless a kidney transplant is performed or dialysis is started About 15% of kidney transplant recipients die within two years, and about 35% of diabetics on dialysis die within two years. Diabetics should have their urine checked regularly for protein along with watching for symptoms of nephropathy including fatigue, insomnia, weakness, vomiting, and body swelling due to fluid build-up. Heredity: In families where some family members develop kidney complications, other diabetics in the family are at higher risk for nephropathy. High blood pressure: Hypertension stresses the kidney capillaries, increasing risk of capillary leakage. High protein intake: The more protein eaten, the more protein passes into the urine. Most people consume far more protein than necessary to maintain good health. PREVENTION AND TREATMENT OF NEPHROPATHY Reduce blood pressure: Blood pressure medications slow the progression of nephropathy along with a low-salt diet. It is also advisable to reduce protein consumption and to keep the blood sugar level under control. Treatment choices for ESRD There are new and better treatments for ESRD that replace the function of healthy kidneys. There will be changes in the patient’s life no matter which treatment is chosen. The health care team plus the patient will discuss the various options, and together choose the best treatment. Hemodialysis Hemodialysis cleans and filters the blood. It cleans the body of metabolic wastes and extra fluid. This procedure is done approximately 3 to 4 times a week. Each treatment can last anywhere from 4 to 6 hours at a time. Complications of Hemodialysis Due to rapid changes in the body’s chemical and fluid balance, side effects may include muscle cramps, along with nausea, dizziness, and weakness associated with hypotension. By following a proper diet and taking medications as directed, many of the side effects can be avoided. Diet A proper diet can help reduce the wastes that build up in the blood. The following points should be considered when choosing foods:
Peritoneal Dialysis Peritoneal dialysis is a procedure that replaces the work of the kidneys. This procedure removes wastes, extra water, and chemicals from the body. The peritoneal membrane of the abdomen is used to filter the blood. Dialysate, a cleansing solution, is introduced through a tube into the abdomen. Fluid, wastes, and chemicals pass from tiny blood vessels in the peritoneal membrane into the dialysate. The dialysate is drained from the abdomen after several hours, taking with it the wastes from the blood. There three different types of peritoneal dialysis.
The most common type of peritoneal dialysis is CAPD. With CAPD the blood is being clean continuously. The dialystate passes from a plastic bag through a tube into the abdomen, The dialysate stays in the abdomen for four to six hours via a sealed catheter. The solution is drained back into the bag bringing with it the waste products. The abdomen is refilled with fresh solution through the same catheter and the process begins again. The process of draining the dialysate and replacing fresh solution takes approximately 30 to 40 minutes. The solution is changed four times a day. While the solution is in the body, the plastic bag may be folded and hidden under the clothes and the waist or in a pocket.
CCPD is similar to CAPD except that a machine is connected to the catheter. The machine allows the abdomen to be filled and drained with dialysate automatically. The procedure takes 10-12 hours and is done at night to minimize inconvenience to the patient.
The same machine is used for IPU as in CCPD. Whereas CAPD and CCPD are done at home, IPD is usually performed in the hospital. IPD treatments are done several times a week for a total of 36 to 42 hours per week. Sessions may last as long as 24 hours. Complications of Peritoneal Dialysis Peritonitis, or infection of the peritoneum, occurs if the opening where the catheter enters the body becomes infected. It can also occur if the catheter bag is not connected or disconnected correctly. Peritonitis can be a very serious problem with peritoneal dialysis. It may cause fever and abdominal pain. Signs include reddening or swelling around the catheter, discharge around the catheter and cloudy dialysate. Diet The diet for peritoneal dialysis is slightly different than the diet for Hemodialysis.
Kidney Transplant Kidneys used in transplantation may come from different sources. A kidney received from a family member is called a living-related donor. A kidney received from a person who has recently died is called a cadaver donor. If a spouse or a close friend donates a kidney, it is called a living-unrelated donor. In order for the transplant to be successful, the donor’s tissue and blood must match the recipient’s tissue and blood. This will help prevent the body’s immune system from rejecting the new kidney. The new kidney is placed between the upper thigh and abdomen. The artery and vein of the new kidney is connected to the recipient’s artery and vein. Blood flows through the new kidney and functions like the old kidney when it was healthy. The old kidneys are left in place unless they are causing infection or high blood pressure. The new kidneys may start working immediately or it may take up to a few weeks. The transplant surgery takes approximately 3 to 6 hours, with the usual hospital stay of 10 to 14 days. Complications The most severe complication is the possibility of rejection,. The chance of the body accepting the new kidney depends on age, race, and overall medical condition. 75 to 80 percent of transplants from cadaver donors are working one year after surgery. Transplants from living relatives usually work better than the cadaver donor, since living relative donors form a closer match. Immunosuppressant drugs are given to help prevent rejection. These drugs must be taken every day for the rest of the patient’s life. However, even with these drugs there is the possibility that the kidney will be rejected. Treatment with these drugs can cause side effects. The most serious side effect is the weakening of the immune system. Other side effects include weight gain, facial hair, and a fuller face along with cataracts and his disease. There are also a small number of patients that may develop liver or kidney damage when these drugs are used over an extended period of time. Diet The diet of a transplant patient is less restrictive than a dialysis patient. The diet will probably change, as the medication, blood values, weight and blood pressure would dictate:
BLOOD VESSEL COMPLICATIONS Macrovascular Disease Macrovascular disease refers to changes in the medium to large size blood vessels. The blood vessel walls thicken and become hard and arteriosclerotic. Atherosclerosis also becomes a problem, eventually blocking flow. Peripheral vascular disease refers to diseased blood vessels that supply the legs and feet. When blood flow is partially interrupted, cramps, weakness, or claudication may result. If the artery is completely blocked, severe pain accompanied by cold and discoloration will occur in the legs. Treatment includes replacing the artery surgically or performing an angioplasty. Coronary artery disease refers to diseased arteries of the heart. When blood flow is decreased, angina may occur. Complete blockage of an artery results in myocardial infarction. Symptoms include chest pressure, cramping, a heavy feeling in the chest, shortness of breath, and extreme fatigue. Suggested treatments include coronary bypass surgery and angioplasty. Cerebral vascular disease refers to partial or complete blockage of arteries in the brain. Arterial blockage may result in temporary reductions of blood supply to a part of the brain or transient ischemic attacks. When a complete blockage occurs or a blood vessel breaks, a cerebral vascular accident occurs. Symptoms include lightheadedness, dizziness, confusion, aphasia, and inappropriate behavior. Minimizing Risk of Macrovascular Disease In order to minimize the risk of Macrovascular disease followed these guidelines as closely as possible:
SUMMARY OF COMPLICATIONS The principal concern for people with diabetes has always been to avoid both acute and chronic complications. It is important to understand the risks of complications the disease can cause. With this knowledge, the patient is better equipped to make decisions regarding health and maintaining good health.
|
|||||||||||||||||||||||||||||||||||||||||