Diabetes by dr arshid rafiq

Diabetes Mellitus

Dr Arshid Rafiq(Diploma in diabetes. Fellowship in diabetes)

Under supervision of

Dr Rakesh Gupta MD (medicine).FIACM

Senior consultant physician

Indraprastha Apollo Hospitals

Respected doctor’s

Diabetes: A global emergency

Diabetes around the world

Pancreas secretes 40-50 units of insulin daily in two steps:

Secreted at low levels during fasting ( basal insulin secretion)

Increased levels after eating (prandial)

An early burst of insulin occurs within 10 minutes of eating

Then proceeds with increasing release as long as hyperglycemia is present

Insulin

Insulin allows glucose to move into cells to make energy

Inhibits glucagon activity

DIABETES MELLITUS

is a chronic disorder of carbohydrate, protein, and fat metabolism resulting from insulin deficiency or abnormality in the use of insulin

Types1.Type I

formerly known as Insulin –Dependent Diabetes Mellitus (IDDM)Autoimmune (Islet cell antibodies)

•Early introduction of cow’s milk and cereals•Intake of medicine during pregnancy •Indoor smoking of family members

destruction of beta cells of the pancreas little or no insulin productionrequires daily insulin admin. may occur at any age, usually appears below age 15

2. Type II formerly known as Non Insulin–Dependent

Diabetes Mellitus (NIDDM) probably caused by: disturbance in insulin reception in the cells number of insulin receptors loss of beta cell responsiveness to glucose

leading to slow or insulin release by the pancreas

occurs over age 40 but can occur in children common in overweight or obese w/ some circulating insulin present, often do

not require insulin

Gestational diabetes

3.Gestational Diabetes ;

a).blood sugar levels are high during

pregnancy in women

b) .Women who give birth to children over 9 lbs.

c). high risk of type 2 diabetes and cardiovascular disease

Pre-Diabetes

Impaired fasting glucose (IFG)

FPG- 100-125mg/dL

Impaired glucose tolerance (IGT)

OGTT 140-199mg/dL

HbA1c 5.7-6.4%

Who are at

risk? ?

Risk Factors Obesity

History of CVD

Physical inactivity

Familial history

Polycystic Ovary Syndrome

Gestational Diabetes

? ? ? ? ? ? ?

“Of course too much is bad for

you”

Fasting plasma glucose (FPG)≥126 mg/dL (7.0 mmol/L)

2-h plasma glucose ≥200 mg/dL(11.1 mmol/L) during an OGTT

A1C ≥6.5%

Random plasma glucose ≥200 mg/dL (11.1 mmol/L)

Criteria for the Diagnosis of Diabetes

American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S2216

Clinical Manifestations ( Signs and Symptoms)

- Polyuria - weakness- Polydipsia - fatigue- Polyphagia - blood sugar / glucose level- weight loss - (+) glucose in urine (glycosuria)- nausea / vomiting - changes in LOC (severe hyperglycemia)

(sleepiness, drowsiness coma)- recurrent infection, prolonged wound healing- altered immune and inflammatory response, prone to

infection (glucose inhibits the phagocytic action of WBC resistance)

- genital pruritus – (hyperglycemia and glycosuria favor fungalgrowth : candidal infection – resulting in pruritus, commonpresenting symptom in women)

- Erectile dysfunction

Diagnostics

Fasting Plasma Glucose

Oral Glucose Tolerance Test (OGTT)

Glycoselated Hemoglobin (HbA1c)

HbA1c is a test that measures the

amount of glycated hemoglobin in

your blood. Glycated hemoglobin is a

substance in red blood cells that is

formed when blood sugar (glucose)

attaches to hemoglobin.

Urinalysis

Glycosuria

Ketone bodies

Diabetes Mellitus

Summary Treatable, but not curable.

Preventable in obesity, adult client.

Controllable- DIET and EXERCISE

Diagnostic Tests

Signs and symptoms of hypoglycemia and hyperglycemia.

Treatment of hypoglycemia and hyperglycemia – diet and oral hypoglycemics.

Nursing implications – monitoring, teaching and assessing for complications.

Management of DM

American Diabetes Association Standards of Medical Care in Diabetes. Classification and diagnosis of diabetes. Diabetes Care 2016; 39 (Suppl. 1): S13-S2225

The major components of the

treatment of diabetes are:

• Medical Nutrition Therapy (Diet and Exercise) [MNT]1

• Oral Antihyperglycemic Drug [OAD]2

• Insulin & Other Injectables326

Medical Nutrition Therapy (MNT)

● An individualized MNT program is

recommended for all people with type 1 and type 2

diabetes.

● For people with T1DM or those with T2DM who

are on a flexible insulin program, education on carb

counting or estimation.

American Diabetes Association Standards of Medical Care in Diabetes. Foundations of care and the comprehensive medical evaluation. Diabetes Care 2017; 39 (Suppl. 1): S23-S3527

…….MNT

● For patients on a fixed insulin

program, having a consistent pattern of

carbohydrate intake with respect to time

and amount can result in improved

glycemic control and a reduced risk of

hypoglycemia.

Adults with diabetes: at least 150 min/wk of

moderate-intensity aerobic activity or 30

minutes brisk walking over at least 3

days/week with no more than 2

consecutive days without exercise

Physical Activity

Children with diabetes/prediabetes:

at least 60 min/day physical activity

Physical Activity

All individuals, including those with diabetes,should reduce sedentary time, particularly bybreaking up extended amounts of time (>90min) spent sitting.

Physical Activity

Advise all patients not to use cigarettes, othertobacco products, or e-cigarettes.

Include smoking cessation counseling and otherforms of treatment as a routine component ofdiabetes care.

Smoking Cessation

A complete medical evaluation should be performedat the initial visit to:

Confirm & classify diagnosis

Detect complications & potential comorbidconditions

Comprehensive Medical Evaluation

Components of the Comprehensive Diabetes Evaluation

Laboratory Evaluation

A1C, if results not available within past 3months

….Components of the Comprehensive Diabetes Evaluation

If not performed/available within past year:

Fasting lipid profile

Liver function tests

Spot urine albumin-to-creatinine ratio

Serum creatinine and eGFR

Thyroid-stimulating hormone in patients with

type 1 diabetes or dyslipidemia or women aged

>50 years

Glycemic Targets

Two primary techniques available for health

providers and patients to assess effectiveness of

management plan on glycemic control

1. Patient self-monitoring of blood glucose

(SMBG)

2. A1C

..Glycemic Control

American Diabetes Association Standards of Medical Care in Diabetes. Glycemic targets. Diabetes Care 2017; 39 (Suppl. 1): S39-S4637

CGM or interstitial glucose may be a useful

adjunct to SMBG in selected patients.

Glycemic Control

Patients on multiple-dose insulin (MDI) or insulin pump therapy should do SMBG

Prior to meals and snacks

At bedtime

Prior to exercise

When they suspect low blood glucose

Glucose Monitoring

When they suspect low blood glucose

After treating low blood glucose until they are normoglycemic

Prior to critical tasks such as driving

Possibly also post-prandially

Glucose Monitoring

Perform the A1C test at least twice annually in

patients that meet treatment goals (and have stable

glycemic control).

Perform the A1C test quarterly in patients whose

therapy has changed or who are not meeting

glycemic goals.

A1C Testing

Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemicgoals.

Use of point-of-care (POC) testing for A1C provides the opportunity for more timely treatment changes.

A1C Testing

Lowering A1C to <7% has been shown to reduce

microvascular complications and, if implemented

soon after the diagnosis of diabetes, is associated

with long-term reduction in macrovascular

disease.

Glycemic Goals in Adults

Consider more stringent goals (e.g. <6.5%)

for select patients if achievable without

significant hypos or other adverse effects.

Glycemic Goals in Adults

A1C <7.0%*

Preprandial capillary plasma glucose

4.4–7.2 mmol/L*

(80–130 mg/dL)

Peak postprandial capillary plasma

glucose†

<10.0 mmol/L*

(<180 mg/dL)

Glycemic Recommendations forNonpregnant Adults with Diabetes

* Goals should be individualized.† Postprandial glucose measurements should be made 1–2 hours after the beginning of the meal.

An A1C goal of <7.5% is recommended across all pediatric age-groups.

Type 1 Diabetes: GlycemicControl

American Diabetes Association Standards of Medical Care in Diabetes.

Children and adolescents. Diabetes Care 2017; 39 (Suppl. 1): S86-S9346

Blood glucose goal range

A1C Rationale

Before mealsBedtime/

overnight

5.0–7.2 mmol/L

(90–130 mg/dL)

5.0–8.3 mmol/L

(90–150 mg/dL)<7.5%

A lower goal (<7.0%)

is reasonable if it can

be achieved without

excessive hypos

T1 DM: Glycemic Control

1. Goals should be individualized; lower goals may be reasonable.

2. Modify BG goals in youth w/ frequent hypos or hypoglycemia unawareness.

3. Measure postprandial BG if discrepancy between preprandial BG and A1C & to

assess glycemia in basal–bolus regimens. American Diabetes Association Standards of Medical Care in Diabetes.

Children and adolescents. Diabetes Care 2017; 39 (Suppl. 1): S86-S9347

Approaches to Glycemic Treatment

Most people with T1DM should be treated with

multiple dose insulin (MDI) injections (3–4 injections

/day of basal & prandial insulin) or continuous

subcutaneous insulin infusion (CSII).

Individuals who have been successfully using CSII

should have continued access after they turn 65 years

Pharmacological Therapy for T1DM

American Diabetes Association Standards of Medical Care in Diabetes. Approaches to

glycemic treatment. Diabetes Care 2017; 39 (Suppl. 1): S52-S5949

Pharmacological Therapy for T1DM

Consider educating individuals with T1DM on

matching prandial insulin dose to carbohydrate

intake, premeal blood glucose, and anticipated

activity.

Most individuals with T1DM should use insulin

analogs to reduce hypoglycemia risk.

Pramlintide FDA approved for T1DM

Amylin analog

Delays gastric emptying, blunts pancreatic

glucose secretion, enhances satiety

Induces weight loss, lowers insulin dose

Requires reduction in prandial insulin to reduce

risk of severe hypos

Can normalize glucose but require lifelong

immunosuppression.

Reserve for T1D patients:

Undergoing renal transplant

Following renal transplant

With recurrent ketoacidosis or severe hypos

Pancreas and Islet Cell Transplantation

Can normalize glucose but require lifelong

Islet cell transplant investigational

Consider for patients requiring pancreatectomy

who meet eligibility criteria.

Pancreas and Islet Cell Transplantation

Pharmacological

Therapy for T2DM

Noninsulin Agents Available for T2D

Class Primary Mechanism of Action Agent(s) Available as

-Glucosidase inhibitors

Delay carbohydrate absorption from

intestine

AcarboseMiglitol

Precose or genericGlyset

Amylin analogue

Decrease glucagon secretion

Slow gastric emptying

Increase satiety

Pramlintide Symlin

Biguanide Decrease HGP

Increase glucose uptake in muscleMetformin Glucophage or generic

Bile acid sequestrant Decrease HGP?

Increase incretin levels?Colesevelam WelChol

DPP-4 inhibitors

Increase glucose-dependent insulin

secretion

AlogliptinLinagliptinSaxagliptinSitagliptin

NesinaTradjentaOnglyzaJanuvia

Dopamine-2 agonist Activates dopaminergic receptors Bromocriptine Cycloset

Glinides Increase insulin secretionNateglinideRepaglinide

Starlix or genericPrandin

DPP-4 = dipeptidyl peptidase; HGP = hepatic glucose production.

Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.

. How are glycemic targets achieved for T2D?

Continued on next slide

Noninsulin Agents Available for T2D

Class Primary Mechanism of Action Agent(s) Available as

GLP-1 receptor agonists

Increase glucose-dependent insulin

secretion

Slow gastric emptying

Increase satiety

AlbiglutideDulaglutideExenatideExenatide XRLiraglutide

TanzeumTrulicityByettaBydureonVictoza

SGLT2 inhibitors Increase urinary excretion of glucoseCanagliflozinDapagliflozinEmpagliflozin

InvokanaFarxigaJardiance

Sulfonylureas Increase insulin secretion

GlimepirideGlipizideGlyburide

Amaryl or genericGlucotrol or genericDiaeta, Glynase, Micronase, or generic

Thiazolidinediones

Increase glucose uptake in muscle

and fat

Decrease HGP

PioglitazoneRosiglitazone

ActosAvandia

Q4. How are glycemic targets achieved for T2D?

GLP-1 = glucagon-like peptide; HGP = hepatic glucose production; SGLT2 = sodium glucose cotransporter 2.

Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.

Continued from previous slide

Effects of Agents Available for T2D

AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors;

FPG = fasting plasma glucose; GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; Mod = moderate; PPG =

postprandial glucose; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones.

*Mild: albiglutide and exenatide; moderate: dulaglutide, exenatide extended release, and liraglutide.

Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QRSU/

GlinideInsulin Pram

FPG lowering

ModMild to mod*

Mod Mild Mod Neutral Mild NeutralSU: modGlinide:

Mod to marked (basal

insulin or premixed)

PPG lowering

MildMod to marked

Mild Mod Mild Mod Mild Mild Mod

Mod to marked (short/ rapid-acting

insulin or premixed)

Mod to marked

Continued on next slide

AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors;

GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; Mod = moderate; NAFLD, nonalcoholic fatty liver disease;

SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones.

*Especially with short/ rapid-acting or premixed.

GlinideInsulin Pram

NAFLD benefit

Mild Mild Neutral Neutral Mod Neutral Neutral Neutral Neutral Neutral Neutral

Hypo-glycemia

Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral

SU: mod to severeGlinide: mild to

Mod to severe*

Neutral

Weight Slight loss Loss Loss Neutral Gain Neutral Neutral Neutral Gain Gain Loss

. How are glycemic targets achieved for T2D?

GlinideInsulin Pram

Renal impair-ment/ GU

Contra-indicated in stage 3B, 4, 5

Exenatide contra-

indicated CrCl <30 mg/mL

GU infection

Dose adjust-ment

(except lina-

gliptin)

May worsen

fluid retention

Neutral Neutral Neutral

Increased hypo-

glycemia risk

Increased risks of hypo-

glycemia and fluid retention

Neutral

GI adverse effects

Mod Mod* Neutral Neutral* Neutral Mod Mild Mod Neutral Neutral Mod

CHF Neutral Neutral Neutral Neutral† Mod Neutral Neutral Neutral Neutral Neutral Neutral

CVDPossible benefit

Neutral Neutral Neutral Neutral Neutral Neutral Safe ? Neutral Neutral

Bone Neutral Neutral Bone loss NeutralMod bone

lossNeutral Neutral Neutral Neutral Neutral Neutral

AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; CHF = congestive heart failure; CVD =

cardiovascular disease; DPP4I = dipeptidyl peptidase 4 inhibitors; GI = gastrointestinal; GLP1RA = glucagon-like peptide 1 receptor

agonists; GU = genitourinary; Met = metformin; Mod = moderate; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU =

sulfonylureas; TZD = thiazolidinediones.

*Caution in labeling about pancreatitis.†Caution: possibly increased CHF hospitalization risk seen in CV safety trial.

The progressive nature of T2DM should be

regularly & objectively explained to T2DM

patients.

For T2DM patients not achieving glycemic goals,

promptly initiate insulin therapy.

Avoid using insulin as a threat, describing it as a

failure or punishment.

Give patients a self-titration algorithm.

Insulin Therapy in T2DM

Insulin

injection

Insulin initiation in Type 2 DM:

1. HbA1c ≥ 10% [start combination insulins] (ADA 2017) but if

HbA1c ≥ 9%, Basal alone may be initiated

2. Symptomatic hyperglycemia

3. PPG > 19.4 mmol/L, FPG> 16.6 moml/L

4. If the glycemic target is not achieved by using three non-insulin

agents (metformine/pioglitazone, secretagogue,

ɑGi/DPP4i/SGLT2i) by at least 3 months

5. In some specific situations

Short term use of insulin therapy in patients

with T2DM may also be considered in the

following conditions:

• Acute illness, surgery, stress and emergencies

• Pregnancy and lactation

• As initial therapy in T2DM with severe

hyperglycemia

• Severe metabolic decompensation (eg. DKA,

Types of insulin;

Type of Insulin Onset Peak DurationRole in Blood Sugar

Management

Rapid-Acting

Lispro 15-30 min. 30-90 min 3-5 hours Covers insulin needs for

meals eaten at the same

time as the injection.Aspart 10-20 min.40-50

min.3-5 hours

Glulisine 20-30 min.30-90

min.1-2½ hours

Short-Acting

Regular (R)30 min- 60

min2-5 hours 5-8 hours

Covers insulin needs for

meals eaten within 30-60

minutes

Intermediate-Acting

NPH (N) 1-2 hours4-12

hours18-24 hours

Covers insulin needs for

about half the day or

overnight.

Types of insulin

Name of

InsulinOnset Duration

Role in Blood

Management

Long-Acting

Long-acting

insulin covers

insulin needs

for about one

full day.

Degludec 30-90 min

No peak:

insulin is

delivered at a

steady level.

Longer than 24

Glargine 30-90 min Up to 24 hours

Detemir 1-120 min 20-24 hours

Types of insulin

Type of Insulin Onset Peak DurationRole in Blood Sugar

Management

Pre-Mixed*

30/70 30 min. 2-4 hours 14-24 hours These products are

generally taken two

or three times a day

before mealtime.50/50 30 min. 2-5 hours 18-24 hours

25/75 15 min.30 min.-2½

hours16-20 hours

Inhaler

Exubera Banned

Afrezza With in min 12 to 15 min 2-3 hoursPost prandial

effects.

*Premixed insulins are a combination of specific proportions of intermediate-

acting and short-acting insulin in one bottle or insulin pen (the numbers the brand

name indicate the percentage of each type of insulin).

Common Insulin Regimens

Split Mix Regimens

Two injections (intermediate + soluble) per day

* before breakfast & before bedtime

Proportion/dosage of insulin titrated based on

BG profile

Drawback

Mixing insulins is tedious and problematic

Inaccuracy of dose

Not preferred –more problems for patients

Basal insulin

Usually given at night

Proportion/dosage of insulin titrated based on FBG

Drawback

Expensive

Fasting blood glucose is primary targeted

May be with sensitizer and or secretagogue

Basal PlusBasal insulin at night

Any rapid acting insulin premeal.

May be useful during early years of T2DM and in

uncomplicated well motivated patients.

May be needed to shifted to Basal bolus

regimen

titrated based on BG profile

Drawback

Mixing insulins is tedious and problematic

Inaccuracy of dose 71

Common Insulin Regimens (4)

Basal Bolus

Basal insulin at night and one rapid acting insulin

immediately before each major meal (3 times).

Basal insulin is titrated following FBG

Rapid acting insulin is titrated by post meal BGs

Drawback Expensive

4 times needle prick a day.

Most preferred –most flexible 72

Management of Diabetes in Pregnancy

Provide preconception counseling that

addresses the importance of tight glycemic

control, ideally <6.5%, to reduce the risk of

congenital anomalies.

Pregestational Diabetes

American Diabetes Association. Management of diabetes in pregnancy.

Standards of Medical Care in Diabetes-2016. Diabetes Care 2017;39(Suppl. 1):S94–S9874

• Family planning should be discussed

and effective contraception should be

prescribed and used until a woman is

prepared and ready to become

pregnant.

Women preexisting type 1 or type 2 diabetes

who are pregnant or planning to become

pregnant should be counseled on the risk of

development and/or progression of diabetic

retinopathy. Eye exams should occur before

pregnancy or in the first trimester & then be

monitored every trimester and for 1 year

postpartum as indicated by degree of

retinopathy.

Pregestational Diabetes

Lifestyle change is an essential part GDM

mgmt. and may suffice for many women.

Add medications if needed to achieve

glycemic targets.

Gestational Diabetes Mellitus (GDM)

Preferred medications in GDM are insulin and

metformin; glyburide may be used but may have

higher rate of neonatal hypoglycemia &

macrosomia than insulin or metformin. Other

agents have not been adequately studied. Most

oral agents cross the placenta and all lack long-

term safety data. A

Gestational Diabetes Mellitus (GDM)

The following targets for women with

pregestational type 1 or type 2 diabetes:

Fasting ≤90 mg/dL (5.0 mmol/L)

One-hour postprandial ≤130–140mg/dL (7.2–7.8

mmol/L)

Two-hour postprandial ≤120 mg/dL (6.7 mmol/L)

Glycemic Targets in Pregnancy(Preexisting Type 1 or Type 2)

Treatment of GDM

MNT [Dietary Therapy, Exercise]

Self BG monitoring

Administration of Insulin if target blood

glucose level are not met by diet alone

Fetal surveillance

Intrapartum care

Post partum care

Insulin therapy

Recommendations for starting Insulin (ADA

guideline)

FPG> 5.8mmol/l or

1 hr PG> 8.6 mmol/l

2hr PG > 7.2 mmol/l

Target blood glucose:

Pre prandial <5.3mmol/l

1 hr post prandial <7.8 mmol/l

2 hr post prandial <6.7 mmol/l

Insulin therapy cont.

Calculating dose:

Total insulin- 20-30 U/day

½ Basal or 2/3rd intermediate acting

½ Bolus or 1/3rd regular Insulin

Calculated daily dose of insulin:

1st trimester-0.8 unit ×kg BW

2nd trimester- 1 unit ×kg BW

3rd trimester- 1.3 unit×kg BW

The dose and type of insulin used is calculated

according to the blood glucose level

If the FBG is high then, a long acting (or

intermediate- acting insulin), is given before

bedtime.

If postprandial blood glucose levels are high,

then regular rapid-acting insulin are added before

meals.

Insulin Therapy cont.

Regular Insulin is withheld during labor; a

sliding scale of soluble insulin should be started

(or infusion pump as may be fit)

Maternal hyperglycemia should be avoided

during labor to prevent fetal hyperinsulinemia

and subsequent neonatal hypoglycemia

Maternal blood glucose should be maintained

between 4- 5 mmol/L.

Peripartum Management:

Key Take-Home Messages

MNT is the corner stone of diabetes

management.

MNT is also essential to reach optimal

glycemic control with fewer hypoglycemic

episodes

Key Take-Home Messages

OADs may attain or maintain good glycemic

control for a variable periods

Insulin may need to be started in any time

mean while.

Diabetes Mellitus -Complications

Complications of diabetes mellitus

Acute (Metabolic) Chronic (Angiopathy)

Macro Vascular Complications

Micro Vascular Complications

Risk factors and complications

Microvascular

disease

Kidneys

Nerves

Macrovascular disease

Ischaemic heart disease

Strokes

Peripheral vascular

disease

HypertensionHyperglycaemia

DyslipidaemiaCoagulopathy

Smoking

Acute Complications

Diabetic Ketoacidosis (DKA)

Hyperosmolar non-ketomic Coma (HONK)

Hypoglycemia

Metabolic injury to large vessels

Heart Brain Extremities

Coronary artery disease– Coronary

syndrome– MI– CHF

Cerebrovascular disease

Peripheral vascular disease– Ulceration– Gangrene–Amputation

Biology of MacrovascularInjury

Hyperglycemia

Neuropathy

– Peripheral

– Autonomic

Kidney Nerves

Retinopathy- Cataract- Glaucoma

Nephropathy– Microalbuminuria– Gross albuminuria

Blindness Kidney failure Amputation

Death and/or disability

Biology of MicrovascularInjury

Microvascular Complications of Diabetes-1

Retinopathy: Damage to blood vessels in and around the retina. It could occur with varying degrees of severity.

Normal ------------- Small hemorrhages --------- Large hemorrhage

Nephropathy:

Glomeruli are damaged in the kidneys.

Results in loss of protein

DIAGNOSTIC VALUE-Normal microalbumin level is 30mg/24 hours.

May lead to kidney failure

Neuropathy

Nerve fibres degenerate

Blood vessels supplying the nerves are ‘grossly diseased’

Diabetes is Managed,But it Does Not Go Away.

To maintain target blood glucose

Thanks to All

Diabetes by dr arshid rafiq

Career

Transcript of Diabetes by dr arshid rafiq

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Nida Firdous1,2,*, Moazzam Rafiq Khan1, Masood Sadiq Butt1 … · 2019. 11. 17. · Nida Firdous1,2,*, Moazzam Rafiq Khan1, Masood Sadiq Butt1 and Muhammad Shahid3 1National Institute

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