Diabetic kidney disease (DKD)
- For more detail see diabetic kidney disease (in the nephrology section)
- DKD diagnosed if any of the following (for >3 months)
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- uACR > 3mg/mmol (ideally early morning sample)
- eGFR <60mL/min
- Retinopathy, especially in T1DM
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- Therefore the absence of albuminuria does not rule out DKD
- Biopsy some (mainly to rule out other causes)
- Ultrasound usually normal but do one
- Consider other renal disease if no retinopathy, very high BP, sudden proteinuria, systemic illness, persistent non-visible haematuria on dip, diabetes not long standing, rapid rise in creatinine, abnormal USS
- Treat with the 4 pillars (RASi, SGLT2i, MRA and GL-1 agonists) – all help slow progression of CKD
- Tight BP control, lipid-lowering and reducing CV risk all key
- Monitor urinary ACR
Diabetic retinopathy
- See retinal disease for more detail
- Screen every 2 years in type 2 DM if low risk of sight loss, otherwise annually or more often
- Urgent ophthalmology review if rubeosis iridis, pre-retinal/vitreous haemorrhage, suspected retinal detachment
- After 20 years, almost all type 1 diabetics will have some retinopathy
- Higher risk of glaucoma and cataracts too
Cardiovascular risk / disease in diabetes
- HbA1c correlates with risk of MI, PVD, HF and stroke
- Primary prevention includes lifestyle advice, statins, BP lowering, ACE-i/ARBs and glucose control
- Secondary prevention includes cardiac rehab, aspirin, HF drugs and hypoglycaemia avoidance
- Most diabetics have heart failure with preserved EF rather than reduced EF, and it’s frequently undiagnosed (up to 20% of diabetics have HFpEF)
- Both SGLT-2 and GLP-1 inhibitors reduce CV risk, especially in those with established CV disease
- Do not use standard risk assessment tools in T1DM
Hyperlipidaemia in diabetes
- Consider secondary causes of hyperlipidaemia – hypothyroidism, ETOH, liver disease, nephrotic syndrome
- Primary prevention – atorvastatin 20mg. Indicated if T2DM and
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- Patient aged <84 and 10 year CV risk is >10%
- Some patients aged >85
- History of CKD
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- Secondary prevention in T1DM and T2DM (ie history of CVD) – atorvastatin 80mg
- In T1DM, offer primary prevention (atorvastatin 20mg) if
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- Aged >40
- Or DM for > 10 years
- Or established nephropathy
- Or other CV risks eg obesity or HTN
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- Aim for reduction in non-HDL cholesterol by 40% (uptitrate statin if required)
- Before starting statin – check non-fasting lipids, LFTs, U&Es, TFTs. Only check CK if muscle pain
- See hyperlipidaemia and diabetic kidney disease for more detail
Diabetic neuropathy
- Clinical features
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- Typically distal, symmetrical, glove and stocking
- Pain (burning, shooting, stabbing)
- Numbness
- Allodynia, hyperesthesia, tingling, unusual sensations
- Often worse at night and relived by activity
- Can also be motor neuropathy – weakness, wasting, cramps, twitching, deformity
- See diabetic foot complications
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- Management
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- Manage progression of sensory loss to prevent ulcers
- Podiatry referral and foot protection
- Consider medications to treat neuropathic pain
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- Amitriptyline, gabapentin, pregabalin, duloxetine all first line. Switch to another if not effective
- Can try Capsaicin cream if can’t use/tolerate oral medications
- Podiatry can do little to help for pain
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- Autonomic neuropathy occurs in some
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- Postural hypotension – check whether other drugs contributing (especially alpha blockers)
- Gastroparesis
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- Advise small-particle size diet
- Consider prokinetic drugs
- Consider pump
- No strong evidence for antiemetics but best to alternate erythromycin and metoclopramide. Consider domperisone in exceptional circumstances (some CV risk and interactions)
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- Enteropathy with change in bowel habit (diarrhoea)
- Urinary symptoms
- Sexual dysfunction
- Reduced sweating (glove and stocking), or hyperhidrosis
- Hypoglcyaemia unawareness
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- Amyotrophy
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- Involves L2,3,4 nerve roots
- Gradual onset thigh pain and proximal weakness in one leg. Often in older patients
- Usually normal CRP and CK
- Usually recovers in one year. Can recur in the other leg
- Do an EMG / NCS – will shows muscle denervation and axonal degeneration
- Those at risk include people who have had a rapid correction of sugars and tight glycaemic control
- Methyprednisolone reduces pain but doesn’t speed up recovery
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- Thoracic polyradiculopathy – band like abdominal pain, lots of previous GI investigations. Do an EMG
- Acute painful neuropathy due to rapid improvement of blood glucose control
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- Self-limiting, continue glycaemic control
- Use simple analgesia +/- drugs for neuropathic pain
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Diabetes and severe Covid infection
- Diabetes confers a higher risk of severe illness/death, especially if uncontrolled (odds of in-hospital death during the pandemic were 3.5x in T1DM and 2x in T2DM)
- Higher rates of DKA even in T2DM
- Poor glycaemic control may occur with steroids
- CBG >10 increases mortality in covid infection
- Management
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- More cautious IV fluid in DKA to avoid overloading
- Always hold SGLT1i’s (which rarely precipitate DKA)
- Hold metformin
- Continue gliclazide if eGFR > 30 (although some will always stop)
- If poor glycaemic control, could start Humulin I rather than increasing gliclazide, at a total daily dose of 0.3 units/kg, divided into 2/3 of the dose in the morning and 1/3 in the evening with food (‘twice-daily premixed regime’)
- Stop Humulin I once dexamethasone stopped (or it could cause hypoglycaemia)
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Diarrhoea in diabetes
- Causes to consider
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- Gastroenteritis
- Small bowel bacterial overgrowth
- Other autoimmune disease
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- Coeliacs is 6 x more common in T1DM
- Thyrotoxicosis
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- Drug-induced – metformin (25% of treated patients develop change in bowel habit, dose-related)
- Autonomic neuropathy
- Non-diabetes associated causes eg IBD, cancer
- Pancreatic exocrine insufficiency – can also causes flatulence, abdominal pain, steatorrhea, weight loss, poor glycaemic control
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- See diarrhoea
Skin disease in diabetes
- Infections including impetigo and candida
- Diabetic dermopathy – brown scaly macules and patches on legs, precipitated by trauma
- Diabetic bullae (Bullosus diabeticorum) – particularly on the legs. Exclude an autoimmune blistering disorder (which are often more itchy)
- Acanthosis nigricans – poor prognostic factor if associated with malignancy
- Necrobiosis lipiodica – see miscellaneous dermatology
- Granuloma annulare – see miscellaneous dermatology
- Acquired Reactive Perforating Dermatosis (ARPD) and Kyrle disease
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- Intensely itchy skin disorder characterized by the transepidermal elimination of altered collagen
- Red-brown papules or nodules with a central, adherent keratinous plug
- More common in DM and CKD
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- Eruptive xanthoma – especially if high triglcycerides
- Vitiligo
- Scleroderma diabeticorum
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- Thickening of skin on back and neck in advanced T2DM or poorly controlled T1DM
- Due to mucin deposits in thickened collagen bundles in the skin
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Fibrosing and musculoskeletal manifestations of diabetes
- Dupuytren’s contracture
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- Due to palmar fascia thickening
- Usually affects 3rd or 4th and can be bilateral
- More common in T2DM, and especially if poor glycaemic control
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- Diabetes cheiroarthropathy
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- Thickened skin and stiff fingers. Positive prayer sign
- Seen in long standing diabetes
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- Stenosing tenosynovitis eg trigger finger
- Carpal tunnel syndrome – twice as common in DM
- Frozen shoulder / adhesive capsulitis
- Peyronie’s disease
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- Gradual deformity of the penis due to fibrous plaque formation in the tunica albuginea
- 4-5x more common in diabetes
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- Diabetic muscle infarction
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- Sudden muscle swelling and pain in advanced diabetes
- No weakness
- Raised CRP, normal CK
- Oedema and necrosis on MRI
- Conservatively managed
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- Diffuse idiopathic skeletal hyperostosis (DISH)
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- Presents with calcification and ossification of ligaments and tendons, typically in older patients with diabetes
- Bridging osteophytes in four adjacent thoracic vertebra
- Causes spinal stiffness and pain
- Often diagnosed late
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- Stiff person syndrome
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- Muscle hyperexcitability with stiff muscles and spasms
- Associated with anti-GAD65 antibodies too
- 60% of those with SPS develop T1DM
- T1 diabetics are 100x more likely to develop it
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Other disease associations in diabetes
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- MASLD, MASH and MET-ALD
- Increased risk of Rheumatoid Arthritis – especially in type 1 DM
- Increased risk of osteoporosis
- Increased risk of peripheral vascular disease