1. Šafárik University, Košice, Slovakia
Acute and chronic complications of diabetes mellitus Lecture from pathological physiology
© Oliver Rácz, A. Chmelárová
Šafárik University, Košice, Slovakia
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2. Definition of diabetes mellitus
Diabetes mellitus is a group of metabolic diseases
characterized by hyperglycemia
resulting from defects in insulin secretion,
insulin action, or both.
The chronic hyperglycemia of diabetes is associated
with long-term damage, dysfunction, and failure
of various organs, especially the eyes, kidneys,
nerves, heart, and blood vessels.
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3. Acute complications of DM
HYPOGLYCAEMIA
DIABETIC COMA
HYPEROSMOLAR NONKETOTIC STATE
LACTIC ACIDOSIS
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4. Acute complications of DM
HYPOGLYCAEMIA VERY COMMON
DIABETIC COMA HISTORY
HYPEROSMOLAR NONKETOTIC STATE RARE
LACTIC ACIDOSIS RARE
BAD COMPENSATION???
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5. DIABETIC HYPOGLYCAEMIA
BG < 3,5 mmol∙L-1 (INDIVIDUAL)
CAUSES
higher dose of insulin or OAD (sulfonylurea) as necessary (rare)
inadequate food intake (common)
Alcohol (!!!)
Physical exercise (without adequate nutrient intake)
SYMPTOMS (ALSO INDIVIDUAL)
vegetative – sweating, palpitations, anxiety, shakiness, pallor
neuroglycopenic – confusion, weakness, atypical
behaviour, impaired concentration, sleepiness, double vision,
incoordination, difficult speaking, coma
other – hunger, nausea and vomiting, headache
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6. DIABETIC HYPOGLYCAEMIA
Symptoms
vegetative – sweating, palpitations, anxiety, shakiness, pallor
THESE ARE CAUSED BY SYMPATHETIC ACTIVATION,
AN ATTEMPT TO INCREASE BLOOD GLUCOSE
confusion, weakness, atypical behaviour,
impaired concentration, sleepiness, double vision,
incoordination, difficult speaking, coma
IN LONG-TERM UNCONTROLLED DIABETES WITH
NEUROPATHY HYPOGLYCAEMIA UNAWARENESS,
A DANGEROUS SITUATION (NEUROGLYCOPENIA)
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7. DIABETIC HYPOGLYCAEMIA ???
UNCONSCIOUS DIABETIC PATIENT???
DIABETIC COMA? – PROBABLY NOT
HYPO? – PROBABLY YES BUT???
STROKE?
ANAPHYLACTIC SHOCK?
TRAUMA
CARDIOVASCULAR?
ALCOHOL !!! WITH HYPO !!!
NO TIME TO LOSS – GIVE HIM/HER SUGAR OR
GLUCAGON AND MAKE PROPER DIAGNOSIS LATER
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8. A NEW POSSIBILITY: GLUCAGON INJECTION AND IMMEDIATELY SUGAR INTAKE
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9. DIABETIC KETOACIDOSIS
Classic acute complication of type 1 DM patients before the
insulin era
Today rare (nondiagnosed type 1, intercurrent diseases)
SLOW ONSET – DAYS!
Mechanism
No insulin, no glycolysis, increased lipid breakdown
 release of free fatty acids from adipose tissue
 converted in the liver into ketone bodies
(acetoacetate, acetone, b-hydroxybutyrate)  metabolic
acidosis  diabetic coma
Dehydration from uncontrolled glycosuria
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10. DIABETIC KETOACIDOSIS
Symptoms
nausea, vomiting, abdominal pain
polyuria, polydipsia, hyperglycemia, dehydratation
tachycardia, hypotension
hyperventilation (Kussmaul respiration)
acetone smell of breath
MAC – pH, AG
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11. NONKETOTIC HYPEROSMOLAR STATE
Mostly in T2DM patients
Mechanism
hyperglycemia  hyperosmolarity  polyuria  dehydratation
the presence of insulin inhibits lipolysis – no ketoacidosis
Symptoms
Extreme hyperglycemia (> 30 mmol∙L-1), hyperosmolarity
dehydratation – hypotension
renal insuficiency, mental and neurologic signs, thrombosis
coma, death (high mortality)
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12. LACTIC ACIDOSIS TYPE 1 & 2 (hypoxic and non-hypoxic)
Hypoxic is not associated with DM
Mild lactate increase also in anaerobic exercise
Dangerous in severe trauma, shock, cardiac arrest,
respiratory failure, etc.
Non-hypoxic
Low activity of pyruvate dehydrogenase,
increased glyocytic flux, thiamine deficiency,
Renal and kidney failure, cyanide, salicylate,
methanol, ethylenglycol intoxication
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13. LACTIC ACIDOSIS NON-HYPOXIC IN DIABETES
Low activity of pyruvate dehydrogenase,
increased glyocytic flux, thiamine deficiency,
In the past in some older patients treated with metformin,
an oral biguanide drug
Diabetic pseudohypoxia – metabolic disturbance
SYMPTOMS
dyspnea
abdominal pain
Metabolic (lactate) acidosis
Unconsciousness
NOTE
Metformin was introduced again as an highly effective drug
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