Ruchi Mathur, MD, FRCP(C) is an Attending Physician with the Division of Endocrinology, Diabetes and Metabolism and Associate Director of Clinical Research, Recruitment and Phenotyping with the Center for Androgen Related Disorders, Department of Obstetrics and Gynecology at Cedars-Sinai Medical Center.
Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.
These diabetes complications are related to blood vessel
diseases and are generally classified into small vessel disease, such as those
involving the eyes, kidneys and nerves (microvascular disease), and large vessel
disease involving the heart and blood vessels (macrovascular disease). Diabetes
accelerates hardening of the arteries (atherosclerosis) of the larger blood
vessels, leading to coronary heart disease (angina or heart attack),
strokes,
and pain in the lower extremities because of lack of blood supply
(claudication).
Eye Complications
The major eye complication of diabetes is called
diabetic retinopathy.
Diabetic retinopathy occurs in patients who have had diabetes for at least five
years. Diseased small blood vessels in the back of the eye cause the leakage of
protein and blood in the retina. Disease in these blood vessels also causes the
formation of small aneurysms (microaneurysms), and new but brittle blood vessels
(neovascularization). Spontaneous bleeding from the new and brittle blood
vessels can lead to retinal scarring and retinal detachment, thus impairing
vision.
To treat diabetic retinopathy a laser is used to destroy and prevent the
recurrence of the development of these small aneurysms and brittle blood
vessels. Approximately 50% of patients with diabetes will develop some degree of
diabetic retinopathy after 10 years of diabetes, and 80% of diabetics have
retinopathy after 15 years of the disease. Poor control of blood sugar and blood
pressure further aggravates eye disease in diabetes.
Cataracts and glaucoma are also more common among
diabetics. It is also important to note that since the lens of the eye lets
water through, if blood sugar concentrations vary a lot, the lens of the eye
will shrink and swell with fluid accordingly. As a result, blurry vision is very
common in poorly controlled diabetes. Patients are usually discouraged from
getting a new eyeglass prescription until their blood sugar is controlled. This allows for a
more accurate assessment of what kind of glasses prescription is required.
Kidney damage
Kidney damage from diabetes is called diabetic nephropathy.
The onset of kidney disease and its progression is extremely variable.
Initially, diseased small blood vessels in the kidneys cause the leakage of
protein in the urine. Later on, the kidneys lose their ability to cleanse and
filter blood. The accumulation of toxic waste products in the blood leads to the
need for dialysis. Dialysis
involves using a machine that serves the function of the kidney by filtering and
cleaning the blood. In patients who do not want to undergo chronic dialysis,
kidney transplantation can be considered.
The progression of nephropathy in patients
can be significantly slowed by controlling high blood pressure, and by
aggressively treating high blood sugar levels. Angiotensin converting enzyme
inhibitors (ACE inhibitors) or
angiotensin receptor blockers (ARBs) used in
treating high blood pressure may also benefit
kidney disease in diabetic patients.
Nerve damage
Nerve damage from diabetes is called
diabetic neuropathy
and is also caused by
disease of small blood vessels. In essence, the blood flow to the nerves is
limited, leaving the nerves without blood flow, and they get damaged or die as a
result (a term known as ischemia). Symptoms of
diabetic nerve damage include numbness, burning, and aching of the feet and
lower extremities. When the nerve disease causes a complete loss of sensation in
the feet, patients may not be aware of injuries to the feet, and fail to
properly protect them. Shoes or other protection should be worn as much as
possible. Seemingly minor skin injuries should be attended to promptly to avoid
serious infections. Because of poor blood circulation, diabetic foot injuries may not heal. Sometimes, minor foot
injuries can lead to serious infection, ulcers, and even gangrene, necessitating
surgical amputation of toes, feet, and other infected parts.
Diabetic nerve damage can affect the nerves that are
important for penile erection, causing erectile dysfunction (ED, impotence).
Erectile dysfunction can
also be caused by poor blood flow to the penis from diabetic blood vessel
disease.
Diabetic neuropathy can also affect nerves to the stomach
and intestines, causing nausea, weight loss, diarrhea, and other symptoms of gastroparesis
(delayed emptying of food contents from the stomach into the intestines, due to
ineffective contraction of the stomach muscles).
The pain of diabetic nerve damage may respond to
traditional treatments with:
with topically-applied capsaicin (an extract of pepper).
Gabapentin (Neurontin), phenytoin (Dilantin), and carbamazepine (Tegretol) are
medications that are traditionally used in the treatment of
seizure disorders.
Amitriptyline (Elavil) and desipramine (Norpraminine) are medications that are traditionally used for
depression. While many of these medications are not FDA indicated specifically
for the treatment of diabetes related nerve pain, they are used by physicians
commonly.
The pain of diabetic nerve damage may also improve with better blood
sugar control, though unfortunately blood glucose control and the course of
neuropathy do not always go hand in hand. Newer medications for nerve pain have
recently come to market in the US.
Pregabalin (Lyrica) which has an indication
for diabetic neuropathic pain and
duloxetine (Cymbalta) are
newer agents used in the treatment of diabetic neuropathy.
Diabetes - Symptoms at Onset of DiseaseQuestion: The symptoms of diabetes can vary greatly from patient to patient. What were your symptoms at the onset of your disease?
One in every 20 people develop a kidney stone at some point in their life. A kidney stone is a hard mineral and crystalline material formed within the kidney or urinary tract. Kidney stones symptoms and signs are, blood in the urine and pain in the abdomen, flank (lower back), or groin. A number of different conditions can lead to kidney stones including: gout, hypercalciuria, people with inflammatory bowel disease, kidney disease, and hypoparathyroidism. Some medications also increase the risk of kidney stones.
Liver cancer is the fifth most common cancer in the world and the majority of patients with liver cancer will die within one year as a result. Patients with associated cirrhosis caused by chronic hepatitis B or C infections, alcohol, and hemochromatosis are at the greatest risk of developing liver cancer. Many patients with liver cancer do not develop symptoms until the advanced stages of the tumor which usually makes prognosis poor. The combination of an imaging study (ultrasound, CT, or MRI scans) and an elevated blood level of alpha-fetoprotein will most effectively diagnose liver cancer, while a liver biopsy can make a definitive diagnosis. Medical treatments, including chemotherapy, chemoembolization, ablation, and proton beam therapy, are not very effective. Surgical removal of the tumor or a liver transplant may be most effective in certain cases.
Blood clots can occur in the venous and arterial vascular system. Blood clots can form in the heart, legs, arteries, veins, bladder, urinary tract and uterus. Risk factors for blood clots include high blood pressure and cholesterol, diabetes, smoking, and family history. Symptoms of a blood clot depend on the location of the clot. Some blood clots are a medical emergency. Blood clots are treated depending upon the cause of the clot. Blood clots can be prevented by lowering the risk factors for developing blood clots.
A sty (sometimes spelled stye) is a tender, painful red bump located at the base of an eyelash or on, inside, or under the eyelid, which is the result of an acute infection of the oil glands of the eyelid. Complications of a sty can be blepharitis and chalazion.
Cellulitis is an acute spreading bacterial infection below the surface of the skin characterized by redness, warmth, inflammation, and pain. The most common cause of cellulitis is the bacteria Staph (Staphylococcus aureus).
A stroke results from impaired oxygen delivery to brain cells via the bloodstream. A stroke is also referred to as a CVA, or cerebrovascular incident. Symptoms of stroke include: sudden numbness or weakness of the face, arm or leg. Sudden confusion, trouble speaking or understanding. Sudden trouble seeing in one or both eyes, sudden trouble walking, dizziness, or loss of balance, and/or sudden severe headache with no known cause. A TIA, or transient ischemic attack is a short-lived temporary impairment of the brain caused by loss of blood supply. Stroke is a medical emergency.
Athlete's foot (tinea pedis) is a skin infection caused by the ringworm fungus. Symptoms include itching, burning, cracking, peeling, and bleeding feet. Treatment involves keeping the feet dry and clean, wearing shoes that can breathe, and using medicated powders to keep your feet dry.
Cholesterol is naturally produced by the body, and is a building block for cell membranes and hormones. Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol, conversely, high-density lipoprotein (HDL) cholesterol is the "good" cholesterol. High cholesterol treatment includes lifestyle changes (diet and exercise), and medications such as statins, bile acid resins, and fibric acid derivatives.
Thrush is an infection of the mouth caused by the candida fungus. Symptoms of Thrush include pain or difficulty swallowing, a feeling that food gets stuck in the throat, and fever.
Itching can be a common problem. Itches can be localized or generalized. There are many causes of itching to include: infection (jock itch, vaginal itch), disease (hyperthyroidism, liver or kidney), reactions to drugs, and skin infestations (pubic or body lice). Treatment for itching varies depending on the cause of the itch.
Heart attack happens when a blood clot completely obstructs a coronary
artery supplying blood to the heart muscle. A heart attack can cause chest pain, heart failure, and electrical
instability of the heart.
Hypoglycemia is a syndrome caused by low blood sugar. Symptoms of hypoglycemia include palpitations, trembling, intense hunger, sweating, nervousness, and weakness. Consuming lifesavers, table sugar, soda, and juice are good treatment options for hypoglycemia.
Retinal detachment is the separation of the retina from its attachments to the underlying eye tissue. Symptoms of retinal detachment include flashing lights and floaters. Highly nearsighted young adults and those who've had cataract surgery are at higher risk for retinal detachment.
Restless leg syndrome (RLS or restless legs syndrome) is a common cause for painful legs that typically eases with motion, and becomes worse and more noticeable at rest. This characteristic nighttime worsening can frequently lead to insomnia. Treatment of the symptoms of restless leg syndrome is generally with medication as well as treating any underlying condition causing restless leg syndrome.
A miscarriage is any pregnancy that ends spontaneously before the fetus can survive. Miscarriage usually occurs before the 13th week of pregnancy. The cause of a miscarriage cannot always be determined. The most common causes of a miscarriage in the first trimester are collagen vascular disease (lupus), hormonal problems, diabetes, chromosomal abnormalities, and congenital abnormalities of the uterus.
Carpal tunnel syndrome is a condition in which irritation of the wrist's median nerve causes tingling and numbness of the thumb, index, and the middle fingers. This condition is known as tarsal tunnel syndrome in the ankles and feet. Treatment of carpal tunnel syndrome depends on the severity of the symptoms and the nature of any disease that might be causing the symptoms.
Impotence, also known as erectile dysfunction, is a common
problem among men characterized by the consistent inability to sustain an
erection sufficient for sexual intercourse or the inability to achieve
ejaculation, or both. Impotence can have emotional causes but most often it is
due to a physical problem.
Insulin resistance is the diminished ability of cells to respond to the action of insulin in transporting glucose (sugar) from the bloodstream into muscle and other tissues. Causes of insulin can include conditions such as stress, obesity, metabolic syndrome, and steroid use. Some of the risk factors for insulin resistance include fatty liver, heart disease, strokes, peripheral vascular disease, high cholesterol, and smoking. Treatment for insulin resistance are lifestyle changes and if necessary, medication.
Overactive bladder is a sudden involuntary contraction of the muscle wall of the bladder causing urinary urgency (an immediate unstoppable need to urinate). Overactive bladder is is a form of urinary incontinence. Treatment options may include Kegel exercises, biofeedback, vaginal weight training, pelvic floor electrical stimulation, behavioral therapy, and medications.
Vancomycin-resistant enterococci (VRE) infection is the most common type of infection acquired by patients while hospitalized. Patients at risk for VRE are those who are already ill, and hospitalized, including individuals with diabetes, elderly, ICU patients, kidney failure patients, or patients requiring catheters. Enterococci can survive for months in the digestive tract and female genital tract. Other risk factors for acquiring VRE include those how have been previously treated with vancomycin and combinations of other antibiotics. Treatment of VRE is generally with other antibiotics other than vancomycin. Prevention of VRE can be achieved by proper hand hygiene.
Dysphagia or difficulty in swallowing, swallowing problems. Dysphagia is due to problems in nerve or muscle control. It is common, for example, after a stroke. Dysphagia compromises nutrition and hydration and may lead to aspiration pneumonia and dehydration.
Heart disease (coronary artery disease) is caused by a buildup of cholesterol deposits in the coronary arteries. Risk factors for heart disease include smoking, high blood pressure, heredity, diabetes, peripheral artery disease, and obesity. Symptoms include chest pain and shortness of breath. There are a variety of tests used to diagnose coronary artery disease. Treatment includes life-style changes, medications, procedures, or surgery.
Hyperglycemia is a serious health problem for diabetics. There are two types of hyperglycemia, 1) fasting, and 2)postprandial or after meal hyperglycemia. Hyperglycemia can also lead to ketoacidosis or hyperglycemic hyperosmolar nonketotic syndrome (HHNS). There are a variety of causes of hyperglycemia in people with diabetes. Symptoms include increased thirst, headaches, blurred vision, frequent urination and more. Treatment can be achieved through lifestyle changes or medications changes. Carefully monitoring blood glucose levels is key to prevention.
Encephalopathy means brain disease, damage, or malfunction. Causes of encephalopathy are varied and numerous. The main symptom of encephalopathy is an altered mental state. Other symptoms include lethargy, dementia, seizures, tremors, and coma. Treatment of encephalopathy depends on the type of encephalopathy (anoxia, diabetic, Hashimoto's, hepatic, hyper - hypotensive, infectious, metabolic, infections, uremic, or Wernicke's) are examples of types of encephalopathy.
Obesity is the state of being well above one's normal weight. A person has traditionally been
considered to be obese if they are more than 20 percent over their ideal weight.
That ideal weight must take into account the person's height, age, sex, and
build.
The major goal in treating diabetes is controlling elevated blood sugar without causing abnormally low levels of blood sugar. Treatment for type 1 diabetes is with insulin, exercise, and a diabetic diet. Treatment for type 2 diabetes is first treated with weight reduction, a diabetic diet, and exercise. When these measures fail to control the elevated blood sugar, oral medications are used. If oral medications are still insufficient, insulin medications are considered.
Diabetic Neuropathy is a complication of diabetes that causes damage to the nerves; this is related to the blood glucose of the body being too high for a long period of time. The four types of neuropathy include peripheral, autonomic, proximal and focal.
The main features of metabolic syndrome include insulin resistance, hypertension (high blood pressure), cholesterol abnormalities, and an increased risk for clotting. Patients are most often overweight or obese. Lifestyle modification such as the Mediterranean diet, exercise, and quitting smoking are the preferred treatment of metabolic syndrome.
Radiculopathy, a condition in which a nerve or nerves along the spine are compressed causing pain, numbness, weakenss, and tingling along the nerve(s). Some causes of radiculopathy include bone spurs, disc hernation, osteoarthritis, tumors, infection, and neuropathy. Treatment depends on the are of nerve compression. Surgery is generally not required.
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