A LONG standing diabetes mellitus and uncontrolled high blood pressure are the leading causes of dialysis worldwide. Nephropathy which is abnormality in structure and function of the kidneys is one of the microvascular complications of diabetes mellitus.
The diabetic patient is prone to develop any one or any combination of the following- with the kind indulgence of our dear readers, since the column apparently is also read by students; diabetic fatty nephrosis, pyelonephritis- infection of the kidneys, which is among the illness that gives toxic high fever and severe flank pains, with pyuria-many pus cells in the urine, with the usual TNTC findings, meaning too numerous to count, and various types of glomerular involvements.
Diabetic glomerulosclerosis, also known as Kimmelstiel-Wilson disease is a form of nodular intercapillary glomerulosclerosis. About 20-25% of diabetics have this form of kidney involvement, in which males predominate in the ratio of two to one.
Then, it was believed that the occurrence in diabetics appears to be related to the duration of the disease but now, experts agree that it is the severity of the abnormally high blood sugar poorly controlled that is the more significant issue in the fast deterioration of kidney function.
Patients with these kidney lesions classically have diabetes, hypertension, albuminuria and edema. Albuminuria is a protein secreted by the liver.
It is important in maintaining the so-called plasma colloid oncotic pressure, which prevents the escape of fluid from the blood into the neighboring interstitial space. In diabetes, since their glomerulus – in simple terms, serves as a filter or like a sieve, had undergone structural deformity like sclerosis or thickening, its pores now allow substances which normally should not pass through, will now leak out into the urine in massive amounts.
Thus, with less albumin in the blood, it’s easier for fluid to move into the interstitial space, accumulating excess fluid in a situation called edema (pagma manas in Pilipino.) The term “bipedal edema” refers to swelling of the feet up to the ankle.
Doctors have a grading system for edema, that’s why patients should not be surprised if your family physician ask you to remove your shoes, presses lightly your shin bone and see if there is an indentation space. Of course, rales or moist lung sounds indicate pulmonary congestion, which necessitates aggressive removal of fluid and oxygen inhalation.
Anasarca is the term for generalized edema in which the patient has bloated abdomen, with an enlarged liver and probably also with an enlarged heart, now in congestive heart failure.
Thus, the scenario of a patient whose diabetes mellitus was poorly controlled and allowed to deteriorate includes propped up bed, with two or three pillows, swollen feet, continuous oxygen inhalation, dietary restriction especially with sodium and water, an obviously, since OHA-oral hypoglycemic agents- may not work in such dire situations, the only recourse is insulin injections.
And to think that these multi-organ involvement- liver, heart, the lungs- came about just because of a primary defect in the kidneys, among its many causes is diabetes mellitus.