Complications Screening
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Transcript of Complications Screening
Complications and ScreeningBy Renee E. Amori, MD FACE
Acute◦ Diabetic Ketoacidosis (DKA)◦ Hyperglycemic Hyperosmolar Non-Ketotic states
(HHNK) Chronic
◦ Microvascular complications◦ Macrovascular complications
Diabetic Ketoacidosis (DKA) Hyperglycemic, Hyperosmolar Non-Ketotic
States (HHNK) This section only introduces the concepts Specific treatments for these conditions will
be reviewed during your critical care rotations
Hyperglycemia: ◦ increased gluconeogenesis, glycogenolysis◦ decreased glucose utilization
Ketonemia: ◦ Lack of insulin (insulinopenia) stimulates
breakdown of fats to free fatty acids to make ketones
Acidemia: ◦ ketone acids exceed the buffering capacity of
the system◦ blood pH drops
Where is typically just enough insulin to prevent lipolysis and ketogenesis
But there’s not quite enough insulin for appropriate utilization of glucose at a cellular level
High glucose levels increase the osmolarity of the blood
From Kitabchi et al “Hyperglycemic Crisis in the Adult Patient with Diabetes: a consensus statement from the American Diabetes Association.” Diabetes Care 2006; 29(12): 2739-2748.
DKA – typically seen in patients with type 1 diabetes
HHNK– seen in patients with type 2 diabetes BUT:
◦ There is a subset of type 2 patients who can develop DKA
◦ These are Ketosis-prone type 2
DKADKAAgeAge Usually <40Usually <40
DurationDurationOf SxOf Sx Usually <2daysUsually <2daysGlucoseGlucoseUsually <600mg/dL Usually <600mg/dL
pHpH LowLowHCO3HCO3 LowLowKetonesKetones At least 4+At least 4+SOsmSOsm Usually <330Usually <330
HHNKHHNKUsually >40Usually >40
Usually >2 daysUsually >2 daysUsually Usually
>600mg/dL>600mg/dL
NormalNormalNormalNormal<2+<2+Usually >330Usually >330
Generally there is a decompensation that results in the hyperglycemic emergency
Common factors (include, but are not limited to):◦ Infection◦ Myocardial Infarction◦ Stroke◦ New onset of diabetes◦ Medication non-compliance
These patients are volume depleted and need fluids
ICU management with IV insulin and hourly glucose checks is safest◦ Monitoring of electrolytes including potassium
and phosphate Correct glucose at 50-70 mg/DL per hour
◦ Rapid correction can lead to cerebral edema
The result of chronic, uncontrolled glucose◦ Microvascular complications
Triopathy: retinopathy, nephropathy, neuropathy◦ Macrovascular complications
Leading to disability and ultimately death
Diabetes Mellitus is the leading cause of blindness in the USA
Intensive glycemic control:◦ decreases risk of developing retinopathy◦ slows progression of existing disease*see DCCT and UKPDS trial data
Screen with a dilated fundus examination annually
Type 1: screening should begin 5 years after diagnosis
Type 2: screening should begin at the time of diagnosis
Eye disease correlates with duration of diabetes!
Non-Proliferative Diabetic Retinopathy (NPDR)◦ Includes microaneurysms◦ More advanced – “cotton wool” spots
Proliferative Diabetic Retinopathy (PDR)◦ Vitreous hemorrhage, neovascularization
Diabetic Macular Edema◦ Is a manifestation of NPDR
Glycemic control At the discretion of Ophthalmology, it can
include:◦ Photocoagulation of the retina
Ex: using argon laser◦ Vitrectomy◦ Intraocular anti-vascular endothelial growth factor
(VEGF) injection Bevacizumab (Avastin) or other agents
Cataracts – ◦ more common in diabetes◦ occur earlier than in people without diabetes
Cranial Neuropathies◦ Palsies of CN III, IV or VI can occur
Diabetic Nephropathy is the most common cause of ESRD in the USA.
Factors influencing nephropathy include:◦ genetics/race◦ hypertensive control◦ glycemic control
1. Hyperfiltration2. “Silent Stage”3. Microalbuminuria: 30-300mg in 24hrs4. Macroalbuminuria: >300mg in 24hrs5. Uremia
Annual assessment of urine albumin excretion◦ Multiple ways to screen:
spot urine microalbumin –to– creatinine ratio (must order BOTH) OR
24hr urine collection (more burdensome)◦ Make sure abnormal values are repeated before
labeling someone with nephropathy Measure serum creatinine at least once
per year in adults A simple urinalysis is not sufficient to
screen
When to screen? Type 1: screening should begin 5 years
after diagnosis Type 2: screening should begin at the time
of diagnosis
Glycemic control Hypertensive control Modification of the renin-angiotensis-
aldosterone system (RAAS)
From Williams’ Textbook of Endocrinology. 12th edition
Important in mediating renal damage in diabetes
ACE Inhibitors (ACEI) Angiotensin Receptor Blockers (ARBs) Both have been used to confer renal
protection in diabetes related kidney disease, and control BP
ACEI vs placebo/no treatment ◦ Significant reduction in the risk of ESRD
( Analysis 1.4 (10 studies, 6819 patients): RR 0.60, 95% CI 0.39 to 0.93)
AIIRA [ARB] vs placebo/no treatment ◦ Significant reduction in the risk of ESRD
( Analysis 2.4 (3 studies, 3251 patients): RR 0.78, 95% CI 0.67 to 0.91)
Strippoli GF et al. “Angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists for preventing the progression of diabetic kidney disease” Cochran Database Syst Rev. 2006 Oct 18;(4):CD006257
ACEI vs. placebo/no treatment ◦ Significantly reduced the risk of progression from
micro- to macroalbuminuria ◦ ( Analysis 1.5 (17 studies, 2036 patients): RR 0.45,
95% CI 0.29 to 0.69). AIIRA [ARB] vs. placebo/no treatment
◦ Significant reduction in risk of progression from micro- to macroalbuminuria
◦ ( Analysis 2.5 (3 studies, 761 patients): RR 0.49, 95% CI 0.32 to 0.75)
Strippoli GF et al. “Angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists for preventing the progression of diabetic kidney disease” Cochran Database Syst Rev. 2006 Oct 18;(4):CD006257
Many types of neuropathies can occur Diabetic Sensorimotor Peripheral
Neuropathy Acute mononeuropathies Autonomic neuropathies
Type 1: screening should begin 5 years after diagnosis
Type 2: screening should begin at the time of diagnosis
Ask for symptoms at each visit and examine feet for ulcers, calluses and deformities◦ Offer Podiatry evaluation
Screen by examining sensory function in the feet & ankle reflexes
Use 1 or more to assess sensory function: ◦ Pinprick◦ Temperature◦ vibration perception (using a 128-Hz tuning fork)◦ pressure sensation (using a 10-g monofilament)
Screening is challenging Neuropathy of the GI tract (gastroparesis)
◦ Often misunderstood Neuropathy of the cardiac system
◦ Resting HR >100 is concerning for cardiac neuropathy
Neuropathy of the bladder
Coronary Artery Disease Peripheral Arterial Disease Cerebrovascular disease
Heart Disease and Stroke are the leading cause of death among people with diabetes
In patients with heart disease, people with diabetes have a mortality rate 2-4x higher than people without diabetes
Risk of stroke is also 2-4x higher with diabetes
Very common, especially in people who also smoke cigarettes
Symptoms suggestive of claudication should be screened
Can order Ankle-Brachial Index to screen◦ Can be ordered through the Drexel Vascular Lab
(219 8th Floor, 215-762-5510)◦ Compares BPs in arms to those in legs
Risk of lower extremity amputation in people with diabetes is markedly higher than in those without diabetes
The vast majority of lower extremity amputations are preceded by ulcerations
Higher A1c is associated with increased risk of limb loss, based on meta-analysis◦ Adler et al. Diabetologia 2010; 53(5): 840-849
Poor glyceic control Peripheral sensory neuropathy Arterial insufficiency Foot deformity and callus Obesity Impaired vision Impaired wound healing Improper footwear History of foot ulcer or lower
extremity amputation
Daily inspection of the feet Inspection of the feet at office visits Proper footwear (supportive shoes etc…) Prompt treatment of any injury