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C Lipodystrophy at Injection Sites
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Atrophy of subcutaneous fatty tissue leading to disfiguring excavations and depressed areas may rarely occur at the site of injection This complication results from an immune reaction, and it has become rarer with the development of pure insulin preparations Lipohypertrophy, on the other hand, is a consequence of the pharmacologic effects of insulin being deposited in the same location repeatedly It can occur with purified insulins and as well Rotation of injection sites will prevent lipohypertrophy There is a case report of a patient who had intractable lipohypertrophy with human insulin but no longer had the problem when he switched to insulin lispro
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Chronic Complications of Diabetes
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Late clinical manifestations of diabetes mellitus include a number of pathologic changes that involve small and large blood vessels, cranial and peripheral nerves, the skin, and the lens of the eye These lesions lead to hypertension, renal failure, blindness, autonomic and peripheral neuropathy, amputations of the lower extremities, myocardial infarction, and cerebrovascular accidents These late manifestations correlate with the duration of the diabetic state subsequent to the onset of puberty In type 1 diabetes, end-stage renal disease develops in up to 40% of patients, compared with less than 20% of patients with type 2 diabetes As regards proliferative retinopathy, it ultimately develops in both types of diabetes but has a slightly higher prevalence in type 1 patients (25% after 15 years duration) In patients with type 1 diabetes, complications from end-stage renal disease are a major cause of death, whereas patients with type 2 diabetes are more likely to have macrovascular diseases leading to myocardial infarction and stroke as the main causes of death Cigarette use adds
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B Diabetic Nephropathy
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As many as 4000 cases of end-stage renal disease occur each year among diabetic people in the United States This is about one-third of all patients being treated for end-stage renal disease and represents a considerable national health expense
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The cumulative incidence of nephropathy differs between the two major types of diabetes Patients with type 1 diabetes have a 30 40% chance of having nephropathy after 20 years in contrast to the much lower frequency in type 2 diabetes patients, in whom only about 15 20% develop clinical renal disease However, since there are many more individuals affected with type 2 diabetes, end-stage renal disease is much more prevalent in type 2 than in type 1 diabetes in the United States and especially throughout the rest of the world Improved glycemic control and more effective therapeutic measures to correct hypertension and with the beneficial effects of ACE inhibitors can reduce the development of end-stage renal disease among diabetics Diabetic nephropathy is initially manifested by proteinuria; subsequently, as kidney function declines, urea and creatinine accumulate in the blood 1 Microalbuminuria Sensitive radioimmunoassay methods of detecting small amounts of urinary albumin have permitted detection of microgram concentrations in contrast to the less sensitive dipstick strips, whose minimal detection limit is 03 05% Conventional 24-hour urine collections, in addition to being inconvenient for patients, also show wide variability of albumin excretion, since several factors such as sustained erect posture, dietary protein, and exercise tend to increase albumin excretion rates For these reasons, a timed overnight urine collection or albumin-creatinine ratio in an early morning spot urine collected upon awakening is preferable Normal subjects excrete less than 15 mcg/min during overnight urine collections; values of 20 mcg/min or higher are considered to represent abnormal microalbuminuria In the early morning spot urine, a ratio of albumin (mcg/L) to creatinine (mg/L) of < 30 mcg/mg creatinine is normal, and a ratio of 30 300 mcg/mg creatinine suggests abnormal microalbuminuria At least two of three timed overnight or early morning spot urine collections over a 3- to 6-month period should be abnormal before a diagnosis of microalbuminuria is justified Subsequent renal failure can be predicted by persistent urinary albumin excretion rates exceeding 30 mcg/min Increased microalbuminuria correlates with increased levels of blood pressure and increased LDL cholesterol, and this may explain why increased proteinuria in diabetic patients is associated with an increase in cardiovascular deaths even in the absence of renal failure Glycemic control as well as a lowprotein diet (08 g/kg/d) may reduce both the hyperfiltration and the elevated microalbuminuria in patients in the early stages of diabetes and those with incipient diabetic nephropathy Antihypertensive therapy also decreases microalbuminuria Evidence from some studies but not the UKPDS supports a specific role for ACE inhibitors in reducing intraglomerular pressure in addition to their lowering of systemic hypertension An ACE inhibitor (captopril, 50 mg twice daily) in normotensive diabetics impedes progression to proteinuria and prevents the increase in albumin excretion rate Since microalbuminuria has been shown to correlate with elevated nocturnal systolic blood pressure, it is possible that normotensive diabetic patients with microalbuminuria have slightly elevated systolic blood pressure during sleep, which is lowered during antihypertensive therapy This action may contribute
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