Diabetes complications & Diabetic foot

Diabetes complications

Diabetic vascular disease

Fortunately, by being aware of the potential risks, taking precautionary measures and most importantly by monitoring and keeping your blood sugar level under control, you can do a lot to prevent or keep these complications to a minimum. One of the major challenges for diabetes patients is diabetic vascular disease. If you are a diabetic it may well be that you had to start dialysis in the first place as a result of diabetic nephropathy. In this so-called micro vascular disease, long term high blood sugar has damaged the tiny blood vessels in the kidneys meaning they can no longer regulate water and salts. Another type of micro vascular disease is diabetic retinopathy which affects the eyes; we’ll look at this in more detail in the following pages but first let’s take a look at atherosclerosis and medial calcification, two macro vascular diseases, which affect the larger blood vessels in the body.

Atherosclerosis

Atherosclerosis, or hardening of the arteries, occurs when large blood vessels (e.g. arteries) become clogged with fatty deposits called plaques. These plaques take time to develop so the longer you have diabetes the higher the risk. The body sees these plaque deposits as intruders and sends out immune cells to attack them; this results in inflammation which causes the plaques to swell. This inflammation is worse if blood sugar levels are high therefore, therefore it is very important to monitor your blood sugar level well. It’s also good to do some sport or physical activities as this aids blood flow and helps keep your blood vessels as flexible as possible. While atherosclerosis causes your arteries to narrow, medial (or arterial) calcification stiffens them which can cause cardio-vascular problems. As a result the effectiveness of your dialysis treatment may not be as good as it should be, and you may also experience problems with the creation and maintenance of your vascular access. You can do a lot yourself to prevent medial calcification by managing what your nephrologist calls your mineral bone metabolism. This simply means that you should keep your phosphate and calcium levels in balance by watching your diet and taking your phosphate binders as prescribed by your doctor.

Blood pressure

As with all diabetes-related complications the best treatment is actually prevention. It is very important to monitor your blood sugar regularly and keep it at a healthy level, keep high blood pressure under control, and control your lipid levels by correct diet and medication. One of the side-effects of diabetic vascular disease is poor circulation. This can affect both your hands and feet but is particularly problematic for your feet – if they don’t get enough oxygenated blood you could develop sores and infections. This is commonly known as diabetic foot and if left untreated can have serious consequences – we will have a closer look at diabetic foot in the next issue of NephroCare for me.

Protect your eyesight

Our eyesight is precious and we should do everything we possibly can to protect it, so let’s take a closer look at how diabetes might damage your eyes and your eyesight, and what you can do to stop it happening. If you are diabetic and notice that your sight is getting worse or blurry, don’t think it must be time to go out and buy new glasses. This change could in fact be related to your blood sugar levels! When blood sugar levels are too high the lenses in our eyes swell causing our vision to become blurry. This is just a temporary change and your sight will return once your blood sugar levels go back to normal. This may however take a few months even after your blood sugar level is back in the norm. Blurred vision can however be a sign of a serious eye problem, so it’s very important to check with your doctor if you do notice changes in your vision. Diabetic eye disease is a term used to describe any eye disease which is caused as a result of diabetes. The most common ones are cataracts, diabetic retinopathy, and glaucoma.

Cataracts are perhaps the most well-known of these conditions and can affect anyone, whether they are diabetic or not, although diabetes patients often get cataracts at an earlier age than other people. Cataracts occur when the lens in the eye becomes cloudy or foggy and this makes your vision blurred. Fortunately cataracts can be treated quite easily these days by surgery, during which the surgeon replaces the lens of your eye with a man-made lens. Diabetic retinopathy, or damage to the retina of the eye is the diabetic eye condition and is caused by the abnormal growth of blood vessels in your retina. The retina is a light-sensitive layer in the back of the eye, which converts light into electrical signals.

These signals are sent via the optic nerve to the brain where they are then interpreted to produce the images we see – our sight! In order to function properly the retina needs a constant supply of blood which it gets from a network of small blood vessels. These tiny blood vessels are vulnerable to poor blood sugar control, and if levels of glucose in the blood are too high these vessels can be damaged. The excess blood sugar can make them expand, causing balloon-like bulges called aneurisms which can become blocked or even burst, leading to loss of vision. Diabetic retinopathy usually affects both eyes and as a rule it has no early warning signs. Often there are no symptoms either although some patients do experience blurred vision or the darkening/distortion of images in the field of vision. Other symptoms may include floaters (spots or dark strings floating in your vision), fluctuating vision, dark or empty areas in vision, loss of vision, and difficulties with colour perception. The good news is that if detected in time, some of these early changes are reversible so it is extremely important that you have your eyes checked regularly.

In the early stages of diabetic retinopathy damaged blood vessels may begin to leak small amounts of blood into the eye. As the disease advances many blood vessels in the retina are already damaged and thus the blood supply is not sufficient. To compensate this loss new blood vessels begin to grow, however these new blood vessels are often abnormal and do not provide an adequate blood flow. They may also grow or leak into the vitreous (the gel-like substance in the centre of the eye), and may be accompanied by scar tissue which can cause the retina to detach, leading to distorted vision or loss of vision. The growth of these new blood vessels can also block the normal flow of fluid out of the eye, causing pressure to build up. This condition, called glaucoma, can cause damage to the optic nerve. If caught in the early stages, there is treatment available for some symptoms of diabetic retinopathy. Although they cannot cure the disease completely, these treatments help to slow down or stop further loss of vision.

Prevention is the best medicine

The age old maxim "prevention is better than cure" is valid here too. As diabetic eye disease can develop without any pain or symptoms, if you are diabetic it is very important that you have you an annual eye examination. This medical check is very simple and painless. Using special special drops the doctor will dilate your pupils so he can examine the retina at the back of your eye. If he finds any signs of diabetic retinopathy, he will advise you what treatment is best suited for you. As you can see there are a number of health complications related to diabetes, however by being aware of what these risks are and acting accordingly there is a lot you can do towards preventing any serious problems. First and foremost you should take care to manage your blood sugar on a daily basis, and keep your blood pressure and cholesterol under control. Ask your doctor which other regular health checks you need and discuss any unusual signs, symptoms or concerns you may have with him. He will help you to do everything possible to keep these complications to a minimum and stay in the best possible health.

Diabetic foot

Diabetic foot can affect anyone with diabetes and refers to any complication or pathology which occurs as a direct result of diabetes mellitus. There are various complaints including ulcers, infection and neuropathic osteoarthropathy, also known as Charcot’s Foot. The two main problems that frequently affect diabetics – nerve damage and poor circulation – can both lead to blisters and skin lesions which, if left untreated, can become infected and cause serious problems, in very extreme cases to the amputation of toes or feet. Prevention and appropriate foot care are therefore essential in order to detect problems early and minimise the consequences through appropriate therapy and care. Let’s first try to understand the causes and see what you can do to take good care of your feet.

The most frequent component of diabetic foot is diabetic foot ulcer. An ulcer is a sore or wound that does not heal: the skin has broken down and the tissue beneath is exposed. Diabetes interferes with the body’s natural wound healing process which means that lesions and blisters that heal quickly in a healthy person can quickly become infected if you have diabetes. Ulcers frequently start as the result of small cuts, blisters, or burns. They can also occur due to an ill-fitting shoe, a stone or a rough edge in your shoe that continuously rubs against your foot until the skin blisters or breaks. Diabetes patients are also prone to nerve damage (neuropathy) which occurs as a result of having higher blood sugar levels over an extended period of time. Chronic nerve damage can cause dry skin, and on your feet this can result in calluses and cracked skin. When the skin cracks bacteria can enter and cause infection. As nerve damage also leads to a loss of sensation in the feet, the blisters and sores which appear on calluses or other numb areas of your feet may go unnoticed and as you continue to walk on the “injured” foot their condition is aggravated and the wounds can easily become infected by bacteria.

Treatment for foot ulcers

If left untreated the consequences of foot ulcers can be serious, but luckily ulcers usually respond very well to treatment. If you suspect that you have a foot ulcer, speak to your doctor straightaway. The first step will be to put a protective dressing on the ulcer to prevent infection and give it the chance to heal. A nurse will replace the dressing regularly. You may also be referred to a podiatrist to remove any hard skin that could prevent the ulcer from healing, and if there is infection you may be prescribed antibiotics. Depending on the position and severity of the ulcer you may be advised to wear special diabetic shoes, or may be fitted with a brace or cast to take pressure off the ulcer and allow it to heal faster. In some cases a hospital stay for specialist treatment could be necessary, e.g. a small operation to remove dead tissue or to drain off pus. In order to prevent ulcers it is very important that you check your glucose levels regularly and keep them under control. You should also inspect your feet every day and check for cuts, blisters or any other changes. As poor-fitting shoes are the main source of cuts and blisters on your feet, take care to choose your shoes wisely. Always wear leather, suede or canvas shoes and avoid shoes made of plastic or other materials that don’t allow your feet to "breathe". Make sure your shoes fit well, aren’t too tight and don’t rub. Shoes with laces or Velcro are ideal, so you can adjust them easily as needed.

Neuropathic osteoarthropathy

Neuropathic osteoarthropathy is another condition which can affect the feet of diabetics as a result of damaged nerves. Also called Charcot’s foot (after Jean-Martin Charcot, a French neurologist), this condition causes weakening of the bones of the foot in patients who have significant nerve damage. As the bones get weaker micro-fractures can occur and in severe cases this may cause the joints to collapse. As a result of the nerve damage you will have reduced sensation in your feet and may not be able to feel pain, trauma or changes in temperature. This means that you will likely continue walking on the injured foot, compounding the fracture and making the injury worse. As you continue to walk your foot may also change shape and become deformed. These deformities are a further risk factor for foot ulcers to occur. If your foot starts to feel hot or swollen after a minor bump or trauma it could be a first sign of Charcot’s foot. The foot may or may not be painful, there may be redness and/or swelling and the affected foot may feel warmer to the touch than the other. If you notice these symptoms you should contact a doctor immediately for advice.

Treatment for Charcot’s foot

In the early stages where the bones are weaker but not fractured your foot may be put in a cast to limit damage and prevent deformity. The cast will immobilise your foot and give it the chance to heal. In more advanced cases, surgery may be needed to realign the broken and deformed bones.

Foot care

If you are a diabetes patient it is very important that you take good care of your feet by following a good foot care regime. You should also inspect your feet daily to check for any possible signs of ulcers or other problems and discuss any symptoms you find with your doctor. If you have a podologist or a diabetologist, discuss any issues or doubts with him, otherwise please speak to a doctor at your NephroCare centre.

You should consult a doctor if you have any of the following symptoms:

  • Sore, red, swollen, or painful lesions or blisters on toes or feet
  • Cracked skin which doesn’t heal
  • Nail tenderness or thickening
  • Foot or nail fungus
  • Any signs of infection, swelling, or discharge
  • Changes to existing ulcers or surrounding skin

If you carry out these checks regularly you will be able to detect any potential problems early, and by initiating prompt and effective treatment you can minimise the development of complications. If you have difficulties seeing or reaching your feet to do this, ask a member of your family to help you check your feet every day or speak to a doctor or nurse at your dialysis centre. Remember: It is also very important that you talk to your doctor if you are having difficulty keeping your glucose levels under control.

Your daily foot routine

  • Check for foot injuries every day
  • Wash your feet daily with soap and warm water and dry carefully.
  • Keep your feet warm and dry. Use a neutral cream to keep your skin soft and prevent it from cracking,  Use antifungal spray or talcum powder to prevent fungal infections
  • Cut your nails regularly and use a pumice stone (never use sharp instruments) to remove calluses
  • Don’t walk barefoot,
  • Choose comfortable leather or canvas shoes
  • Disinfect your shoes regularly (with a formalin swab
  • Don’t smoke: smoking reduces oxygen supply to your feet and increases the risk of complications.