In most people's minds diabetes is sugar trouble. Yet most of the problems of diabetes arise, not from the ups and downs of the glucose concentration but from its many tissue complications. Diabetes is a chronic multisystem disorder of which one manifestation is hyperglycaemia.
The tissue complications of diabetes are preventable and while we still have much to learn about the causes of diabetic tissue damage, we can at least work on reducing the damage due to factors we have identified. Diabetes is for life. The quality of that life and its extent will be largely determined by the development of tissue damage and its extent. Only half the people with Type 1 diabetes diagnosed before the age of 30 survive beyond the age of 50 years. The mortality rate for Type 1 diabetes is about five times that of their peers. For people with Type 2 diabetes the situation is unclear. They are probably about twice as likely to die early as their peers. However, the mortality and morbidity of diabetes is improving with modern care.
Diabetic tissue damage is usually divided into that which occurs only (or predominantly) in diabetes and that which is commoner in people with diabetes but does occur in others.
Microvascular disease—thickening of the basement membrane of capillaries causing leakage or blockage to the transfer of nutrients and waste substances, is virtually specific to diabetes. This is associated with retinopathy, nephropathy, and neuropathy. These and other changes, such as cheiroarthropathy and dermopathy, may be linked to glycosylation of proteins (see p. 62).
Macrovascular disease—atherosclerosis—is common in Western man, but is more frequent in people with diabetes.
Table 13.1 Tissue complications of diabetes
Kidneys—nephropathy, renal failure, chronic pyelonephritis
Heart—ischaemic heart disease, cardiac failure
Legs—peripheral vascular disease
Brain—stroke, transient ischaemic attacks
Feet—ulcer, infection, gangrene, amputation
Skin—dermopathy, necrobiosis lipoidica
Ligaments—Dupuytren's contracture, cheiroarthropathy
Skeletal system—Charcot joint.
Table 13.2 Prevention of diabetic tissue damage
Treatment must be safe and practical for each patient
Help people with diabetes to learn how to work with the diabetes team:
♦ to reduce the risk of developing diabetic tissue damage
♦ to recognize tissue damage early, if present
♦ to slow deterioration of existing tissue damage Reduce risk factors
♦ Keep the blood pressure below 130/80
♦ Keep the cholesterol below 5 mmol/l
♦ Keep the triglyceride below 2.3 mmol/l
♦ Treat microalbuminuria
♦ Keep the body mass index between 18 and 25 kg/m2
♦ Exercise regularly
♦ Avoid added salt
♦ Or your laboratory's normal range
As most medical and nursing training relates to body systems the following discussion of tissue damage is considered by system rather than aetiology. In most instances symptoms are a late feature of diabetic complications. By the time the patient is aware of a problem it may be too late to treat it. Therefore a major part of diabetes care is screening patients for evidence of tissue damage and for risk factors of tissue damage (Table 13.2).
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