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Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The goal in diagnosing diabetes mellitus is to identify those with significantly increased premature mortality and increased risk of microvascular and cardiovascular complications. No classification scheme is ideal, and all have some overlap and inconsistencies. Diabetes mellitus classification will continue to evolve as we work to fully understand the pathogenesis of the major forms.
Classification of diabetes mellitus;
• Secondary diabetes; Type 1 and Type 2 diabetes mellitus;
• Gestational diabetes mellitus;
• Latent autoimmune diabetes of adults;
• Monogenic diabetes;
• Maturity-onset diabetes of the young;
• Neonatal diabetes.
Management includes the following:
• Appropriate goal setting.
• Dietary and exercise modifications.
• Appropriate self-monitoring of blood glucose (SMBG).
• Regular monitoring for complications and lab assessment.
In view of the alarming increase in the number of people with diabetes mellitus (DM), a rising number of patients with diabetic kidney disease (DKD), end-stage renal disease (ESRD) and cardiovascular disease (CVD) are forecasted. It is therefore imperative to re-visit the natural history of DKD and to identify potential risk factors, which may enhance the progression of the disease and its complications.
People with progressive CKD but normal albuminuria have predominantly interstitial or vascular changes with much less glomerular changes. It seems likely that these histological abnormalities relate to blood pressure, aging, obesity, and intrarenal vascular disease.
Diabetic nephropathy is the leading cause of renal disease worldwide, occurring in 20%-40% of patients with diabetes. This condition is a distinct manifestation of diabetic renal disease seen in patients with type 1 and type 2 diabetes. Despite clear screening and management recommendations, diabetic nephropathy remains substantially underdiagnosed.
Hypertension is much more common in individuals with diabetes compared to individuals without diabetes . Hypertension frequently is already present at the time when type 2 diabetes is diagnosed, but typically does not manifest until microalbuminuria occurs in patients with type 1 diabetes. The multifactorial pathogenesis of hypertension in patients with diabetes and with diabetic nephropathy is complex.
The current recommendations outlined by the National Kidney Foundation are to target a blood pressure of 130/80 mmHg in diabetic patients. Either an ACE inhibitor or an ARB should be designated as the first line therapy given its renoprotective effects that extend beyond blood pressure lowering.
Diabetes mellitus has a number of long-term effects on the genitourinary system. These effects predispose to bacterial urinary tract infections (UTIs) in the patient with diabetes mellitus.
Complicated UTIs are also common and potentially life-threatening conditions. They include emphysematous pyelonephritis, emphysematouspyelitis/cystitis, xanthogranulomatous pyelonephritis XGP, renal/perirenal abscess, and renal papillary necrosis RPN. Improved outcomes of these entities may be achieved by early diagnosis, knowledge of common predisposing factors, appropriate clinical and radiological assessment, and prompt management.
The initial management of a patient with EPN is resuscitation; a three-pronged approach should be put into place to address fluid/hemodynamic status, diabetic control and an antibiotic regimen. A decision must then be made as to whether medical therapy alone, percutaneous drainage or nephrectomy is required.
Diabetes is a well-established independent risk factor for cardiovascular diseases (CVD). Compared with non-diabetic individuals, diabetic patients have 2 to 4 times increased risk for stroke and death from heart disease.
Managing diabetic dyslipidemia requires a multifaceted approach. Dietary modification and pharmacotherapy are integral components of management.
The term chronic kidney disease (CKD) is used to describe abnormal kidney function (or structure) and is defined according to the presence or absence of kidney damage and level of kidney function. There are no obvious symptoms of decreasing kidney function and, hence, diagnosis often occurs when patients present for other conditions related to CKD, such as cardiovascular disease (CVD) and diabetes.
The management includes multiple strategies by improving comprehensive care, initiating and maintaining healthy behaviors, promoting teamwork, eliminating barriers to achieve goals and improving the processes of care.
There is a strong association between chronic kidney disease (CKD) and an elevated blood pressure (BP) whereby each can cause or aggravate the other. BP control is fundamental to the care of patients with CKD and is relevant at all stages of CKD regardless of the underlying cause.
The essential goals of therapy in the management of diabetic nephropathy are treatment of hypertension and reduction of albuminuria. The presence of microalbuminuria is the first clinical manifestation of renal disease in patients with diabetes.
Hypertension leads to progression of kidney disease and increases CV risk in these patients. In spite of the high incidence of overt nephropathy and ESRD without treatment, pharmacologic lowering of blood pressure was shown to slow progression of kidney failure in patients with DM1 more than 20 years ago.
The current management of hypertension in diabetic nephropathy should include therapies that block the angiotensin production or action and blood pressure treatment goals with these drugs should be aimed at a blood pressure <130/80 mmHg. Importantly achieving this goal will require both non-pharmacologic interventions combined with multiple antihypertensive drugs.