Microvascular Complications of Type 2 Diabetes Mellitus
Background: Chronic exposure to hyperglycaemia affects the microvasculature, eventually leading to diabetic nephropathy, retinopathy and neuropathy with high Cited by: Dec 27, · Microvascular complications include diabetic retinopathy, nephropathy, and neuropathy. Although these complications are clinically and etiologically diverse, they share a common factor: glucose-induced damage.
The management of type 1 and complicatiins diabetes mellitus DM requires addressing multiple goals, with the primary goal being glycemic control. Maintaining glycemic control in patients with diabetes prevents many of the microvascular and macrovascular complications associated with diabetes. This chapter presents a review of the prevalence, screening, diagnosis, and management of these complications. Microvascular complications of diabetes are those long-term complications mocrovascular affect small blood vessels.
These typically include retinopathy, nephropathy, and neuropathy. Macrovascular complications of diabetes are primarily diseases of the coronary arteries, peripheral arteries, and cerebrovasculature. Early macrovascular disease is associated with atherosclerotic plaque in the vasculature supplying czuses to the heart, brain, limbs, and other clents.
Late stages of macrovascular disease involve complete obstruction of these vessels, which can increase the risks nicrovascular myocardial infarction MIstroke, claudication, and gangrene. Cardiovascular disease How to be confident with boys is the major cause of morbidity and mortality in patients with diabetes.
The prevalence of nephropathy in diabetes has not been determined. Macrovascular complications how to find a lost cat in the city patients with diabetes cause an estimated two- to four-fold increased risk of coronary artery disease CADperipheral arterial disease, and cerebrovascular disease. Microaneurysm formation is the microvascylar manifestation of diabetic retinopathy.
Microaneurysms may form due to the release of vasoproliferative factors, weakness in the capillary how do i remove a toolbar in firefox, or increased intra-luminal pressures. Microaneurysms can cause vascular permeability in the macula, which can lead to macular edema that threatens central vision. Obliteration of ocmplications capillaries can lead to intraretinal microvascular abnormalities. As capillary closure becomes extensive, intraretinal hemorrhages develop.
Proliferative retinopathy melkitus due to ischemia and release of vasoactive substances, such as vascular endothelial growth factor, which stimulate clientz blood vessel formation as a progression of nonproliferative retinopathy. These vessels may erupt through the surface of the retina and grow on the posterior surface of the vitreous humor. These vessels are very friable and can lead to vitreous hemorrhages. The vitreous humor can contract and lead to retinal detachment.
Two pathophysiologic pathways for diabetic nephropathy have been identified. First, diabetic nephropathy can result from increased glomerular capillary flow that, in turn, results in increased extracellular matrix production and endothelial damage. This leads to increased glomerular permeability to mellitua. Mesangial expansion and interstitial sclerosis can ensue, which have the potential to cause glomerular sclerosis.
Clienst glomerular filtration rate GFR and albuminuria are risk factors for cardiovascular events whereas albuminuria predicted death and progression to end stage renal disease better than GFR loss.
The pathophysiology of neuropathy is complex. Diabetes is associated with dyslipidemia, hyperglycemia, and low insulin and growth factor abnormalities. These abnormalities are associated with glycation of blood vessels and nerves. In addition, autoimmunity may affect nerve structure. Trauma and nerve entrapment can lead to structural nerve damage including segmental demyelination, axonal atrophy and loss, and wgat demyelination. These effects cause neuropathy.
The macrovascular complications of diabetes result from hyperglycemia, excess free fatty acid, and insulin resistance. These cause increased oxidative stress, protein kinase activation, and activation of the receptor for advanced glycation end products, factors that act on the endothelium. These pathways ultimately lead to atherosclerosis, the cause of the microvasculat complications of diabetes.
Symptoms of retinopathy are minimal until advanced disease ensues with loss or blurring of vision. Signs of nonproliferative retinopathy include microaneurysms, venous loops, retinal hemorrhages, hard exudates, and soft exudates. Proliferative retinopathy can include new vessels in the eyes or vitreous hemorrhage. The earliest sign of nephropathy is hypertension, which often coincides with the development of microalbuminuria.
As nephropathy worsens, patients can develop edema, arrhythmias associated with hyperglycemia, or symptoms related to renal failure. Signs and symptoms of neuropathy depend on the type of neuropathy that ot. Most commonly, patients develop symptomatic distal polyneuropathy. Signs include decreased or total loss of ankle jerk reflexes and vibratory sensation, with hyperalgesia and calf pain microascular some patients.
These usually present in a "stocking and glove" distribution. Wasting of the small wlth of the hands and feet also can occur. Patients may present with focal neuropathies due to either mononeuritis or entrapment syndromes. These produce focal neurologic deficits confined to complicatiohs single nerve.
A rare but severe form of diabetic neuropathy is diabetic amyotrophy, which begins with pain followed by severe weakness and spreads from unilateral to bilateral. It resolves spontaneously wiyh 18 to 24 months.
Patients with diabetes-associated CVD c,ients present with stable or unstable angina pectoris, MI, or dysrhythmias; however, many patients have unrecognizable symptoms.
Patients with cerebral vascular disease can present with a sudden onset of a focal neurologic deficit such as facial droop, hemiparesis, or isolated weakness of an arm or leg. Dizziness, slurred speech, gait difficulties, and visual loss also can be the presenting symptoms. Peripheral vascular disease is recognized by exertional leg pain that can progress to pain at rest and ischemic ulcers. Most cases are asymptomatic. Patients with diabetes should be screened regularly, at least every 6 microvaacular, for retinopathy, nephropathy, and neurology complications Table 1.
Those with uncontrolled diabetes should be examined more frequently. Dilated eye examinations by an ophthalmologist or optometrist should be performed within 5 years of onset cients type 1 DM and at the time of diagnosis in type 2 DM, because the actual date of onset is hard to determine in type 2 DM. Follow-up eye examinations should be performed annually in patients with no or minimal background retinopathy. More frequent follow-up examinations are needed in those who have more advanced retinopathy.
Handheld ophthalmoscopy may be able to detect diabetic retinopathy, but it offers limited view of the retina and has difficulty detecting diabetic macular edema, a significant cause of vision loss mellitus diabetes.
Retinopathy is easier to detect with binocular vision. In difficult cases, IV fluorescein angiography and confocal microscopy are used. Technology is available for screening with fundus how to cook corn beef for sandwiches obtained in the practitioner's office and then read by an expert.
However, these do not show a complete view of the retina and do not microvasculad other aspects of the eye examination, such as eye pressure, and, what is the project management plan, cannot replace yearly eye evaluations. Compications hallmark of early diabetic nephropathy is albumin excretion. Sensitive assays to detect very low microvasculat of cliennts, or microalbuminuria, have been available for many years.
The simplest screening measure is a spot urine test adjusted for the urine creatinine level. Timed overnight collections or hour collections also may be used. In general, microalbuminuria is defined as more than 30 mg albumin per gram of creatinine spot urine test or 30 to mg per 24 hours and more than mg gram of creatinine or 24 hours as albuminuria.
Serum creatinine determinations should be performed at least annually in patients with albuminuria. When estimated glomerular filtration rate eGFR values are declining, more specific measures of GFR most commonly, creatinine clearance should be used. Monofilament testing performed in the office is the easiest way to check for the insensate foot.
The 5. Any loss of sensation is associated with an increased risk for ulcer formation. A patient who has had a foot ulcer is at increased risk for additional foot ulcers. Patients should be instructed to examine their feet daily.
Patients who have difficulty examining their feet should seek assistance, compliccations if they have impaired vision.
The use of a mirror can help patients see the bottoms of their feet see the chapter, " Prevention and Treatment of Leg and Foot Ulcers in Diabetes Mellitus ". Careful questioning about symptoms of ischemic coronary disease is still one of the most important ways to screen for CVD. Many patients with diabetes do not have typical exertional chest pain. Consequently, clinicians must ask about reduced exercise tolerance, dyspnea, or exercise-induced nausea.
Various studies have considered the disbetes of screening for CVD. The guidelines and individual recommendations are not entirely concordant. Whereas nearly every group suggests stress tests for patients with symptoms of CVD or electrocardiographic changes suggesting ischemia, recommendations on screening for asymptomatic disease are less consistent.
The American Diabetes Association ADA considers that candidates for cardiac stress testing should include those with a history of peripheral or microvaascular occlusive disease; those with a sedentary lifestyle who are older than 55 years and who plan to begin a vigorous exercise program; and those with two or more risk factors for CVD. Screening for asymptomatic coronary artery disease with various stress tests in patients with T2D has not been clearly demonstrated to improve cardiac outcomes and is therefore not recommended.
Screening fo defined as the detection of disease in asymptomatic persons. Because screening tests are intended for widespread application, they should be rapid and inexpensive. In addition, to be useful, the results of testing should lead to a change in management, and the results of testing should improve outcomes. Most consensus statements and guidelines on diabetes and CAD have suggested that noninvasive cardiac testing be performed in patients with diabetes and one additional criterion: peripheral arterial disease, cerebrovascular disease, rest changes on the electrocardiogram ECGor the presence of two or more major CVD risk factors.
According to these guidelines, risk assessment begins with a medical history, including special attention to symptoms of atherosclerotic disease, such as angina, claudication, or erectile dysfunction. Data from the ongoing DIAD study Detection of Ischemia in Asymptomatic Diabetics which is designed to determine risk factors associated with clinically silent myocardial disease using stress tests with cardiac imaging, has suggested that the presence of neuropathy may be one of the most important predictors of CVD risk.
It microvasvular not yet clear how results from noninvasive testing can change risk management strategies in patients with diabetes, because diabetes is already considered a CVD risk equivalent. Thus, noninvasive testing should be targeted as much as possible to identify patients who might have CVD that is what are the best tuxedo brands to surgical intervention.
Whereas noninvasive screening in asymptomatic patients might detect disease amenable to percutaneous intervention or coronary artery bypass grafting, the cost effectiveness and effects on long-term tbe are still uncertain. Careful attention to a patient's history of changes in exercise tolerance, atypical symptoms that suggest angina, or suggestive ECG abnormalities are reasons to consider stress testing.
In addition, dyslipidemia, obesity, hypertension, albuminuria, and a family history of CVD may be reasons to consider stress testing in patients who do not have clinical symptoms of CVD. In the absence of robust evidence, as noted by the AHA, practitioners need to make decisions about patients who might have tbe myocardial disease.
The diagnosis of retinopathy is based on the findings of eye clientd to determine if the patient has clinically significant macular edema, proliferative retinopathy, or severe nonproliferative retinopathy. The progressive changes microavscular the retina that occur in patients with diabetes include the following:.
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Apr 01, · Diabetic neuropathy is recognized by the American Diabetes Association (ADA) as “the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes.” 15 As with other microvascular complications, risk of developing diabetic neuropathy is proportional to both the magnitude and duration of hyperglycemia, and some individuals Cited by: What causes the microvascular complications of clients with diabetes mellitus? A. The capillaries contain plaques of lipids that obstruct blood flow. B. There is increased pressure within capillaries as a result of the elevated glucose attracting water. C. The capillary basement membranes thicken and there is endothelial cell hyperplasia. D. Jan 01, · Diabetes mellitus, besides disrupting the carbohydrate metabolism process, also induces vascular disease and impacts nearly all the types and sizes of blood vessels. In fact, vascular complications cause majority of the morbidity, hospitalizations and mortality of Cited by: 8.
Background: Type 2 diabetes mellitus T2DM is a chronic, non communicable, multisystem disease that has reached epidemic proportions. Chronic exposure to hyperglycaemia affects the microvasculature, eventually leading to diabetic nephropathy, retinopathy and neuropathy with high impact on the quality of life and overall life expectancy. Sexual dysfunction is an often-overlooked microvascular complication of T2DM, with a complex pathogenesis originating from endothelial dysfunction.
Objective: The purpose of this review is to present current definitions, epidemiological data and risk factors for diabetic retinopathy, nephropathy, neuropathy and sexual dysfunction.
We also describe the clinical and laboratory evaluation that is mandatory for the diagnosis of these conditions. Methods: A comprehensive review of the literature was performed to identify data from clinical studies for the prevalence, risk factors and diagnostic methods of microvascular complications of T2DM. The duration of T2DM along with glycemic, blood pressure and lipid control are common risk factors for the development of these complications.
Criteria for the diagnosis of these conditions are well established, but exclusion of other causes is mandatory. Conclusion: Early detection of microvascular complications associated with T2DM is important, as early intervention leads to better outcomes. However, this requires awareness of their definition, prevalence and diagnostic modalities.
Keywords: Diabetes mellitus; diabetic kidney disease; diabetic neuropathy; diabetic retinopathy; erectile dysfunction; microvascular complications.. Abstract Background: Type 2 diabetes mellitus T2DM is a chronic, non communicable, multisystem disease that has reached epidemic proportions. Publication types Review.