COMPLICATION

OF

DIABETES MELLITUS
R. BOWO PRAMONO
ENDOCRINOLOGY SUBDIVISION
INTERNAL MEDICINE DEPARTEMENT
GADJAH MADA UNIVERSITY

When you have diabetes, youre:

Twenty

times more likely to develop

KIDNEY disease
Four times more likely to have a STROKE
Four times more likely become BLIND
Two to four times more likely to have a
HEART attack

 Researchers

continue to make great

progress what triggers complication DM
& how to manage or prevent them

Blood

sugar close to normal reduce

risks of complication

Controlled

blood sugar not to late to

start (As soon as begin managing blood
sugar level slow the progression of
complication & reduce chances of
developing still more healthn problems

COMPLICATIONS of DM
ACUTE
1.Diabetic ketoacidosis (DKA)
2.Hyperglycemic hyperosmolar state (HHS)
3.Hypoglycemia 4. Lactic acidosis
CHRONIC
1.Microangiopathy (retinopathy, nephropathy,
neuropathy, Cardiomyopathy, Diabetic foot, etc)
2.Macroangiopathy (Heart attack/IMA, Stroke,
PAD)

Acute complications
Medical

emergencies, complications are

these spark medical emergencies
requiring immediate attention.
This include low blood sugar, high blood
sugar and excessive blood acids.

PATOFISIOLOGI KAD & HHS

laktic acid

DKA
Occurs

when muscle cells become so

starved for energy that body takes
emergency measures & breaks down fat
toxic acids as ketones
Most common type 1 DM insufficient
insulin to adjust raise of blood sugar
Cause by extreme stress or illness
Infection body produce adrenalin
works against insulin
Forget to take insulin

Sign & symptom of DKA

Deep,

rapid breathing
Sweet, fruity smell on breath
Loss of appetite
Nausea
Fatigue
Vomiting
Weakness
Fever
Confusion
Drowsiness
Stomach pain
Weight loss

Clinical presentation
Lost

more than 5% body weight

More than 35 breaths a minute
Cant control blood sugar
Become confused
Nausea and vomiting

What should you do?

Check

ketones if feeling especially

stressed or blood sugar persistently above
240mg/dL
High ketones in blood ketones excreted
in urine.
High ketones in urine must treatment &
stay in hospital
DKA can lead into coma and posibly
death.

Treatment
Replenishing

lost fluids through i.v. line

Insulin combined with glucose, injected
into iv stop making ketones
Gradually blood sugar level back to
normal, if quickly can produce swelling in
the Brain

HHS
Blood

sugar reaches such a high level that blood

become thick and syrupy (level >600 mg/dL)
Cells cant absorb much blood sugar, the sugar
passed from blood to urine draws tremenous
amounts of fluid from body and produces
dehydration
Common in type 2 DM, especially who dont
monitor blood sugar and who dont know have DM
Trigger factors: high-dose steroid, diuretics,
infection, illness, stress or drinking excessive
alcohol

HHS, sign & symptom

Excesive

thirst
Increased urination
Weakness
Leg cramps
Confusion
Rapid pulse
Convulsions
Coma

What should you do?

Check

blood sugar level (> 600mg/dL)

Emergency treatment can correct the
problem within hours
Give intravenous fluids to restore water to
the tissue
Short acting insulin to help cells can
absorb glucose
Without prompt treatment can be fatal

Hypoglycemia
Blood

sugar level <60mg/dL

Basssically from too much insulin and too little
glucose in blood
Most common among people taking insulin or
oral medication to release or action of insulin
Reasons:
Skipping the meal
Exercising longer or more strenuously than
normal
Not adjusting your medication to accommodate
changes in blood sugar

Sign & symptom of Hypoglycemia

Blood sugar level 40-55mg/dL:
Sweating
Shakiness
Visual disturbances
Weakness
Hunger
Dizziness
Nervousness
Headache
Fast heartbeat
Irritability
Cold, clammy skin

Sign & symptom of Hypoglycemia

Later symptomp (BG < 40mg/dL)
Slurred speech
Drunkenlike behavior
Drowsiness
Confusion
Emergency symptoms (BG <20 mg/dL)
Convulsions
Unconsiousness, wich can be fatal

Hypoglycemia unawareness
Some

people had DM for several years

dont experience early symptoms of hypo
glycemia, such as shakiness or
nervousness because chemical changes
from long standing DM may mask the
symptoms or keep them for occuring
This condition may not realize blood sugar
is low until later symptoms, such as
confusion or slurred speech, set in.

What should you do?

As

soon realize blood sugar is low, eat or

drink something raise BG level quickly.
Example:
Hard candy, equal to about five live saving
A regular (not diet) soft drink
Half a cup of fruit juice
Glucose tablets, nonprescription sugar
pills made especially for treating low blood
sugar

What should you do?

If

after 15 minutes continue to experience

symptoms, repeat the treatment. If they
still, contact the doctor.
If lose consiousness or for some other
reason are unable to swallow, the
treatmen of choice is an injection D 40%
or glucagon injection (fast acting hormone
contra insulin to stimulate the release
sugar into the blood)

TERIMA KASIH

Alhamdullillah
Thank you for
your attention

CHRONIC
COMPLICATION
Of
DIABETES
MELLITUS

Chronic complications
Development

of other diseases
Long-term DM complications are those
that develop gradually and that may
become disabling or live-threatening. They
include nerve, kidney, eye, heart and
blood vessel disease

CHRONIC COMPLICATIONS
MICROVASCULAR

RETINOPATHY
NEPHROPATHY
CARDIOMYOPATHY
NEUROPATHY
AUTONOMIC

CARDIAC
GASTRIC
UROGENITAL

CHRONIC COMPLICATION
MACROVASCULAR
CHD

RISK

24x
DEATH 60 %

CEREBROVASCULAR

STROKE

: 4x

PERIPHERAL VD
40 50 % NON-TRAUMATIC AMPUTATION

Retinopathy
Retina

is back part of eye, is nourished by many

tiny vessel. The blood vessels are often among
the first to be damaged by blood sugar
Everyone with type 1 DM & 6/10 type 2 DM
developed retinopathy after 20 years
Most people only mild vision problems. For
others with severe including blindness
DM is leading cause blindness in adults (each
year 12000 24000 cases)

Nonproliferatif
Mild & most common
Blood vessel in retina become weak &
swell or bulges or fatty deposits
Doesnt affect in the vision unless
Responsible for sharpest vision
Proliferatif
Tiny blood vessel are damage, bleed or
close off
New & fragile of blood vessel in retina may
bleed

 If

bleeding is heavy or occurs in the

certain it can obscure your vision
New blood vessel (neo vascularisation)
also can form scar tissue can push & pull
on your retina and distour vision
Special treatment by an optalmologist wth
Laser or Vitrectomy
Important to cath the disease early so that
it can be treated

Sign & symptom

Spiders cobweb or tiny specks floating in an eye

A gray shadow in the filed vision
Blurred vision
Blurred word while reading
A dark or empty spot in the center vision
Dark streaks or red film that block vision
Eye pain
Flahes or light or rings around objects
Srait line that appear distorted
Vision loss

How is it Treated? (retinopathy)

Reguler

eye examinations to identity problem

early
Laser procedure to seal weak blood vessel
In most cases only one eye is treated at a time
may several treatments pain
Bleedin in the middle eye need surgical
procedure to remove the blood an replace with
clear fluid
Detached (ablatio) retina by scar tissue requires
surgery to position the retina in place

Nephropathy
Inside

kidney are million tiny blood vessel

filter waste from the blood disposed to
urine
DM can damage this delicate filtering
system, before developed any symptom
More 3/10 type 1 DM nephropathy
1/10 type 2 DM nephropathy
Type DM younger, longer have DM higher
risk of kidney damage

Sign & symptom

Swelling

of ankles, feet and hands

Shortness of breath
High blood pressure
Confusion or difficulty concentrating
Poor appetite
Nausea and vomiting
Dry, itchy skin
Fatigue

How is treated? (nephropathy)

Treatment

depends on how advance the disease

is. Keeping BG level normal can prevent your
condition from getting worse, possibly improve.
ACE inhibitors may help hypertension & heart
problem
ARB can improve kidney function and decrease
microalbuminuria
Low pretein diet seems to reduce workload of
kidney (consult doctors & dietician)
Severe damage with (ESRD) transplant,
Hemodialyse or CAPD (continous ambulatory
peritoneal dialyse)

Neuropathy
Have

an intricate network of nerves runs

throughout the body, connecting brain to
muscles, skin and other organs.
Brain senses pain, control the muscles,
and perform automatic task such as
breathing and digestion
Neuropathy affect 6/10 type 2 DM

Sign & symptom

Many kind of nerve damage
Weakened muscles & an unsteady walk
Autonomic nerves can increase heart rate
& perspiration level
In men can interfere to ability erection
In sensory nerves damage unable
detect sensation such as pain, warmth,
coolness and texture

Sign & symptom

Commonly

damage often in the legs, less in the

arm
Tingling feeling, numbness, pain or combination
these sensation
Burning pain comes and goes
Discomfort as a crawling sensation
Begin in tips of toe or finger or both and gradualy
spread upward
Damage nerve in toe, if untreated can lose of all
sensation high risk for injury without realizing

Sign & symptom

Foot

care very important

If lost feeling in the feet and not to check
them each day, may not realize have a cut
or open wound until serious infection
The main cause of amputations in DM
60.000 amputation each year in DM

How is it treated? (neuropathy)

Good

BG control will reduce your symptoms

To relieve pain: pain reliever or antidepressantor
antiseizure medication
Capsaicin cream (hot pepper extract)
Other therapy: accupuncture, biofeedback and
relaxation techniques
Type 2 DM patients dont burn themself when
bathing or electric blanket or heating pad. Guard
against frost bite in cold temperature

Heart and blood vessel

DM dramatically increased your risk of developing
one of many cardiovascular problems, including:
Chest pain (angina)
Heart attack
Stroke
Narrowing of the arteries (legs and brain poor
blood circulation) peripheral vascular disease
High blood pressure
DM can damage mayor arteries (supply heart &
brain) easier for fatty deposits (plaques)
increase pressure in arteries & reduce blood
circulation

Sign & symptom

Symptoms heart disease vary. Early stage produce no
symptom. Later may include:
Shortnss of breath
Pain of the chest, jaw or arm
Fatigue or weakness
Swelling (edema)
Lightaheadness
Rapid or irreguler heart beat (palpitation)
Excessive perspiration
People with DM are particular risk for silent (asymptomatic)
heart attacks without typical symtomps (painless)

How it is treated?
Many

forms of heart disease are treated

with medicationto prevent symptom from
worsening
If accumulation of plaques in the arteries
may procedure angioplasty to open
arteries sometimes bypass arteries
surgery
To prevent including healthy diet, more
exercise, stopping smoking, losing weight
(if over weight)

Risk of infection
High

BG impaired function the immune

cells to fight off germ & bacteriainfection
Location: mouth, gums, lungs, skin, feet,
bladder and genital
High BG damage nerve otherwise
alert infection
damage nerves to control bladder
sensation fail alert bladder is full
overstreched lose muscle tone ability
yo empty completely bacteria may grow
infection

Sign and symptom

Many

vary depending location of infection

Low grade fever
Gum : red and bleeding
Bladder: frequent urination, urgency and
burning sensation
Vagina: itching &/or discharge in vagina
Foot: redness & pus are warning an
infection

How it is treated?
Antibiotic

to kill bacteria
A foot injury: procedure to clean the
injured area and remove infected tissue
Reduce risk of gum disease by brushing
and flossing the teeth regularly
Reduce risk of bladder infection by going
the bathroom regularly and making sure to
empty the bladder

IMPOTENCE in DM
Refers:

inability an erection of the penis

or inability an erection long enough
for sexual intercourse
Physical: excess blood sugar can damage the
nerves & blood vessel no longer
communication nerves to small blood vessel &
large blood vessel narrowed or blocked not
enough blood to erection (common in DM)
Psychological: anxiety, stress or depression
impaired Brain and Hormones respond
Medication: drugs for hypertension, anxiety &
depression

MEDICATION of IMPOTENCE
I. Sildenafil (Viagra, Androz, Edegra,Silagra) isnt effective
for everyone
1hour before activity effective 4 hours
II. Alprostadil (synthetic of prostaglandin E-1)
not a pill self intraurethral (a grain rice)
or self injection therapy (5-20 minutes before and 1 hour
erection)
III. Vacuum device
IV. Penile implant
a. semirigid, benabled rod (permanent erection)
b. inflantable (with pump in scrotum produce an erection
only when you want)
V. Counseling (if psychologycal factors)

Preventing complication
Tight

BG control normal or near-normal

Diabetes Control and Complication Trial (DCCT):
Tight BG control reduce 50% risk of many
complication
United Kingdom Prospective Diabetes Study
(UKPDS):
Keep BG normal: 1/4 fewer complications (eyes,
kidneys and nerves) and reduce risk of heart
disease
Kumamoto study: the intensive insulin therapy
have delay in the start and progression of eye,
kidney and nerve complication

SELF CARE:
Reducing risk of complication
Have

a yearly physical examination

Get a yearly eye examination
See the dentist regularly
Keep up to date vaccination (flu, pneumonia)
Care the feet
Dont smoke
Take a daily aspirin
Monitor blood pressure
Manage stress

THANK YOU