Long term risks /Chronic Complications

Long-term changes associated with insulin deficiency or its action lead to a number of pathologic changes that involve alterations in structure and function of vessels and nerves and occur in all types of diabetes.

Macrovascular Changes

Persons with diabetes mellitus develop macrovascular changes from atherosclerosis that are the same as those seen in persons with diabetes. Macrovascular changes result in decreased lumen size, compromised with blood flow, and decreased delivery of oxygen to tissues, resulting in tissue ischemia. The result is usually cerebrovascular disease, coronary artery disease, renal artery stenosis, or peripheral vascular disease.

Microvascular Changes

Microvascular changes seen in persons with diabetes do not occur in persons without diabetes. These changes are characterized by thickening of the capillaries and are characterized by thickening of the capillaries and damage to the basement membrane and result in diabetic neuropathy and retinopathy.

Diabetic Nephropathy

One of the major results of microvascular changes is alteration in renal structure and function. Renal failure frequently results from the changes and diabetic nephropathy may account for 30% of the persons receiving long term renal dialysis.

Hypertension is the factor that most often accelerates nephropathy associated with diabetes mellitus. Aggressive treatment of hypertension is necessary, and the blood pressure should be normalized.

Diabetic Retinopathy

Retinopathy will affect 50% to 80% of all persons with diabetes 10 to 15 years after diagnosis. The primary lesion is the formation of microaneurysm in the retinal vessels, followed by hemorrhage and exudate formation. These early retinal changes, called the background or simple retinopathy, may progress to a more serious state, proliferative retinopathy. Cataracts also occur in persons with diabetes. Cataracts may be caused by prolonged hyperglycemia.

Neuropathy

Persons with IDDM or NIDDM usually have one or more alterations that affect peripheral nerves, the autonomic nervous system, the spinal cord, or the CNS. Neuropathies unique to diabetes may occur from increased metabolism via the polyol pathway that results from hyperglycemia. The result of the nerve changes is altered nerve conduction.

The Diabetic Foot (Insensitive Foot)

The macrovascular and microvascular changes and the neuropathy all contribute to changes in the lower extremity called the diabetic foot.  One major factor is sensory neuropathy, which may lead to painless trauma, ulceration, and infection. Sensory and motor neuropathy contributes to bone changes and deformed feet that change gait and pressure distribution and contribute to infection. It is important to note that the vascular changes (angiopathy) may actually worsen neuropathy, and vice versa. Either may contribute to the occurrence of foot lesions.

Gangrene can be either dry or wet. Dry gangrene occurs when tissue death is not associated with inflammatory changes. Autoamputation of affected toes is the treatment of choice. The area must be kept dry, or wet gangrene can occur. The area must be kept dry, or wet gangrene can occur. Wet gangrene is gangrene coupled with inflammation, septicemia and septic shock may occur.

Prevention is the key to take care of the insensitive diabetic foot. It is estimated that prevention could result in a 50% to 75% reduction in the need for amputation.