TYPE 2 DIABETES

Due to a progressive loss of adequate β-cell insulin secretion frequently

on the background of insulin resistance.
 Diagnosing type 2 diabetes

Three laboratory tests can be used to diagnose type 2 diabetes:

1. FBG- Fasting (at least eight hours)

2. HbA1c- Non-fasting

3. OGTT- Fasting (at least eight hours)

OGTT
75 g glucose administered orally
Blood is collected from a fasting venous sample and two-hour post-glucose
challenge venous sample
FBG-Fasting blood glucose; OGTT- Oral glucose tolerance test; HbA1c glycated haemoglobin
 HbA1c (A1C)

Note that HbA1c may lack accuracy (specificity and/or sensitivity) in the following
cases, in which FBG or OGTT may assist diagnosis:

• acute-onset glycaemic states such as post-traumatic type 2 diabetes (e.g.,

pancreatitis), rapid onset of glycaemia with sepsis and steroid use, etc.

• pregnancy (second and third trimesters) and within four months post-partum

• people with haemoglobinopathy or haemolysis, or advanced chronic kidney

disease, blood loss

• people with iron deficiency (artificially elevated)

• people who have recently had a blood or iron transfusion

 OGTT

According to WHO requirements

Adults: 75 g of powdered glucose (sugar), dissolved in 300 ml of water and

administered orally in 5 minutes.

Children: 1.75 g sugar per kg body weight but total amount should not exceed 75g.

Patients must not anticipate physical exercise during test (120 min.). Blood is
collected from a fasting venous sample and from two-hour post-glucose challenge
venous sample.
 Criteria defining prediabetes

FPG- ≥ 6.1 до ≤ 6.9mmol/l

OR

2-h PG during 75-g OGTT- 7.8 mmol/L to 11.0 mmol/L

OR

A1C- 5.7–6.4% (39–47 mmol/mol)

FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; 2-h PG, 2-h plasma glucose.
 Clinical symptoms suggestive of diabetes

Symptoms of diabetes include:

• polyuria, polydipsia, polyphagia

• unexplainable fatigue (not so rare may be the only symptom, L. Kirov)

• frequent fungal or bacterial infections

• blurred vision

• loss of sensation (i.e., touch, vibration, cold)

• poor wound healing

• weight loss
 Criteria for the diagnosis of diabetes*

FPG≥7.0 mmol/L.

OR

2-h PG≥11.1 mmol/L during OGTT.

OR

A1C≥6.5% (48 mmol/mol).

OR

In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma

glucose≥11.1 mmol/L.

*In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the
same sample or in two separate test samples.
 Chronic kidney disease (CKD)

CKD is defined as abnormalities of kidney structure or function, present for at least 3 months,
with implications for health. Criteria for CKD is either of the following present for > 3 months:

• Albuminuria

• Urine sediment abnormalities

• Electrolyte and other abnormalities due to tubular disorders

• Abnormalities detected by histology

• Structural abnormalities detected by imaging

• History of kidney transplantation

• Decreased GFR <60 ml/min/1.73 m2 (GFR categories G3a–G5)

• eGFR can be calculated on http://www.nephron.com/cgi-bin/CGSIdefault.cgi

Staging the CKD according the KDIGO-2012 recommendations

eGFR (ml/min/1.73 m)
G1
> 90 Normal or high
G2
60–89 Mildly decreased
G3a
45–59 Mildly to moderately decreased
G3b
30–44 Moderately to severely decreased
G4
15–29 Severe decreased
G5
≤ 15 Kidney failure
 Staging the CKD according the KDIGO-2012 recommendations

When eGFR≤60 ml/min/1.73 m2 (category G3a-G5) or there are signs of renal

impairment, please specify the past history and tests to refine the duration of
renal disease.
If > 3 months - CKD,
If <3 months - CKD can not be confirmed and the patient may be either with CKD
or with acute renal impairment or both.
 LONG-TERM COMPLICATIONS IN DM TYPE 2

Long-term diabetes is associated with the development of a number of complications, broadly

divided into two groups:

Microvascular that affect the capillaries and arterioles throughout the body but particularly

involve the eyes (retinopathy), kidneys (nephropathy) and nerve (neuropathy)

AND

Macrovascular, which increase the risk of myocardial infarction, stroke and peripheral vascular

disease.

With improved treatment of diabetes, the incidence of diabetes complications has fallen for

each individual but overall, the prevalence has gone up as the number of people with diabetes

has increased.
Kumar & Clark’s Clinical medicine, 2020
 LONG-TERM COMPLICATIONS IN DM TYPE 2

Microvascular complications are specific to diabetes and affect over 80% of

individuals with diabetes.

They are unusual in the first 10 years after the diagnosis of type 1 diabetes but are

found in 20–50% of people with newly diagnosed type 2 diabetes as a result of

the preceding undiagnosed hyperglycaemia.

With the advent of screening for type 2 diabetes, the numbers with complications

at presentation are falling.

Kumar & Clark’s Clinical medicine, 2020

 LONG-TERM COMPLICATIONS IN DM TYPE 2
Diabetic nephropathy

It is characterized by gradually increasing urinary albumin excretion and blood

pressure as the glomerular filtration rate falls insidiously towards end-stage renal

disease. It is slowly progressive and diabetic nephropathy usually manifests 15–25

years after the diagnosis of diabetes.

Albuminuria

Gradually increasing urinary albumin excretion is the hallmark of classical

diabetic nephropathy. The earliest evidence of this is ‘microalbuminuria’.

Kumar & Clark’s Clinical medicine, 2020

 LONG-TERM COMPLICATIONS IN DM TYPE 2
Diabetic nephropathy- Albuminuria

Microalbuminuria may, after some years, progress to intermittent albuminuria followed by

persistent proteinuria.

At the stage of persistent proteinuria, the plasma creatinine is normal but once this stage is

reached, end-stage kidney disease ensues within 5–10 years, although the rate of progression

varies widely between individuals. Rising plasma creatinine is a late feature.

The proteinuria may become so heavy as to induce a transient nephrotic syndrome, with

peripheral oedema and hypoalbuminaemia.

Up to 50% of those with type 2 diabetes have non-classical diabetic nephropathy. In this

situation, the glomerular filtration rates falls progressively but with little or no albuminuria.
Kumar & Clark’s Clinical medicine, 2020
 LONG-TERM COMPLICATIONS IN DM TYPE 2
Diabetic nephropathy

Other features of diabetic nephropathy

It is typically associated with a normochromic normocytic anaemia and raised

erythrocyte sedimentation rate and C-reactive protein. Hypertension is a common

development and may itself damage the kidney still further.

Clinical suspicion of a non-diabetic cause of nephropathy may be provoked by an

atypical history, the absence of diabetic retinopathy (usually, but not invariably,

present with diabetic nephropathy) and the presence of red-cell casts in the urine.

Plasma creatinine level and eGFR should be measured regularly.

Kumar & Clark’s Clinical medicine, 2020
 LONG-TERM COMPLICATIONS IN DM TYPE 2
Diabetic neuropathy

The earliest functional change in nerves of people with diabetes is delayed nerve

conduction velocity. Diabetic neuropathy can manifest in a number of different

ways.

One hypothesis postulates occlusion of the vasa nervorum as the prime cause

(possible explanation of mononeuropathy), another points to a metabolic cause

which fits to the diffuse symmetrical nature of the common forms of neuropathy.

Kumar & Clark’s Clinical medicine, 2020

 LONG-TERM COMPLICATIONS IN DM TYPE 2
Diabetic neuropathy

Symmetrical distal polyneuropathy

All patients should be screened for diabetic peripheral neuropathy, starting at diagnosis of type 2

diabetes and at least annually thereafter.

Peripheral neuropathy is often unrecognized by the person with diabetes in its early stages. Early

clinical signs are mainly sensory and include loss of vibration sense, pain sensation (deep before

superficial) and temperature sensation in the feet. At later stages, people may complain of a feeling of

“walking on cotton wool” and can lose their balance when washing the face or walking in the dark

owing to impaired proprioception. Early involvement of the hands is less common and should

prompt a search for non-diabetic causes. Complications include unrecognized trauma because of the

loss of pain sensation. Kumar & Clark’s Clinical medicine, 2020

 LONG-TERM COMPLICATIONS IN DM TYPE 2
Diabetic neuropathy

Autonomic neuropathy

Symptomatic autonomic neuropathy is rare. It affects both the sympathetic and parasympathetic

nervous systems and can cause disabling postural hypotension.

• The cardiovascular system

Vagal neuropathy results in tachycardia at rest and loss of sinus arrhythmia. At a later stage, the

heart may become denervated (resembling a transplanted heart). Cardiovascular reflexes, such as

the Valsalva manoeuvre, are impaired. Postural hypotension occurs owing to loss of sympathetic

tone to peripheral arterioles. A warm foot with a bounding pulse is often seen in a

polyneuropathy as a result of peripheral vasodilation.

Kumar & Clark’s Clinical medicine, 2020
 LONG-TERM COMPLICATIONS IN DM TYPE 2
Diabetic neuropathy

Autonomic neuropathy may result in:

• orthostatic hypotension with >20 mmHg drop

• impaired and unpredictable gastric emptying (gastroparesis), which can cause a

• person’s blood glucose levels to be erratic and difficult to control. Pro-kinetic agents

• such as metoclopramide, domperidone or erythromycin may improve symptoms

• diarrhoea, chronic constipation, reduced anal sphincter control

• delayed/incomplete bladder emptying, urinary incontinence

 Autonomic neuropathy-continued

• erectile dysfunction and retrograde ejaculation in males

• reduced vaginal lubrication with arousal in women

• loss of cardiac pain, “silent” ischaemia or myocardial infarction (if any, even vague
suspicion about MI in a diabetic patient do ECG)

• sudden, unexpected cardiorespiratory arrest, especially under anaesthetic or

treatment with respiratory-depressant medications

• difficulty recognising hypoglycaemia (hypoglycaemic unawareness)

• unexplained ankle oedema

 LONG-TERM COMPLICATIONS IN DM TYPE 2
Diabetic foot

Up to 50% of older people with type 2 diabetes have risk factors for foot problems

and 10–15% of people with diabetes develop foot ulcers at some stage in their lives.

Diabetic foot problems are responsible for nearly 50% of all diabetes-related hospital

admissions.

Diabetes is the most common cause of non-traumatic lower limb amputation, but

many diabetic amputations could be delayed or prevented by more effective self-

management education and medical supervision.

Kumar & Clark’s Clinical medicine, 2020

 LONG-TERM COMPLICATIONS IN DM TYPE 2
Diabetic foot

Ischaemia, resulting from peripheral vascular disease, neuropathy and infection,

combine to produce tissue necrosis and ulceration.

Pain is a protective mechanism and the diminished sensation that results from

peripheral neuropathy means that the individual is less able to perceive trauma and

may continue to walk on a wounded foot thereby worsening the injury.

Kumar & Clark’s Clinical medicine, 2020

 LONG-TERM COMPLICATIONS IN DM TYPE 2
Diabetic foot- Principles of diabetic foot care

• Inspect feet daily; Moisturize dry skin
• Seek early advice for any damage
• Take care if walking barefoot
• Keep feet away from sources of heat (hot
sand, hot-water bottles, radiators, fires)
• Check the bath temperature before
stepping in

• Check shoes inside and out for sharp
bodies/areas before wearing
• Ensure shoes fit well with plenty of
room for the toes
• Do not treat corns/callosities without
professional help
• Attend a podiatrist regularly: Older people
with diabetes may require help to cut their
toenails
Kumar & Clark’s Clinical medicine, 2020