Complications
Chronic kidney disease is a well-known complication of type 2 diabetes mellitus (T2DM) in adults. Risk in children and adolescents is not known, although studies have indicated that there is evidence of early renal disease appearing at or soon after diagnosis in young people with T2DM and it appears to be more prevalent than in those with type 1 diabetes.[102][103] One study showed the prevalence of moderately increased albuminuria in adolescents with type 2 diabetes to increase over time regardless of which diabetes treatment is used.[97] The study found that the risk for moderately increased albuminuria was related to glycaemic control.
Nephropathy results from hypertension and abnormal glucose homeostasis.
Assessment of renal function with a test for urine albumin-to-creatinine ratio and estimated glomerular filtration rate (eGFR) should be performed at diagnosis and annually thereafter.[1] An elevated urine albumin-to-creatinine ratio (>30 mg/g creatinine) should be confirmed on two of three samples.[1] Referral to a nephrologist is warranted if there is uncertain aetiology, in the presence of worsening albumin-to-creatinine ratio, or if there is a decrease in eGFR.[1]
Retinopathy is a long-term complication of type 2 diabetes mellitus in adults. Risk in children and adolescents is increased in some races or ethnic groups, higher haemoglobin A1c (HbA1c), increased insulin resistance, hypertension, and hyperlipidaemia.[100]
Causes include hypertension and poor glucose control.
Dilated fundoscopy should be performed at diagnosis and annually thereafter in most patients.[1] Examination every 2 years may be appropriate if glycaemic targets are met and the previous eye exam is normal.[1]
Cardiovascular disease is the major cause of morbidity and mortality in diabetes. To reduce cardiovascular risk, blood pressure, lipids, glucose, and smoking should be monitored and aggressively addressed.[96] Note that electronic cigarettes are also discouraged. One study showed the prevalence of hypertension in adolescents with type 2 diabetes to increase over time regardless of which diabetes treatment is used.[97] The study found the greatest risk for hypertension to be male sex and a higher body mass index.
Blood pressure should be measured at diagnosis and every follow-up visit, and compared with age- and height-appropriate standards.[1] Ambulatory blood pressure monitoring should be strongly considered if blood pressure is high (blood pressure ≥90th percentile for age, sex, and height or, in adolescents ages ≥13 years, ≥120/80 mmHg) on three separate measurements. Persistent elevations above the usual percentile for the child or above the 90th percentile for either systolic or diastolic pressure must be treated aggressively.
ACE inhibitors are the initial drug of choice, and many physicians also use them prophylactically.[98]
Cardiovascular disease is the major cause of morbidity and mortality in diabetes. To reduce cardiovascular risk, blood pressure, lipids, glucose, and smoking should be monitored and aggressively addressed.[96] Note that electronic cigarettes are also discouraged. One study found that dyslipidaemia and elevated cardiovascular inflammatory markers are common in children and adolescents with type 2 diabetes and worsen over time.[99] The study found that diabetes treatment does not control this worsening risk.[100]
Lipid-lowering medicines should be commenced if lipid levels do not reduce satisfactorily after 3 to 6 months of dietary modifications and optimal diabetic control.
Statins are the most commonly used lipid-lowering agents in children when the elevation of low-density lipoprotein cholesterol is the primary concern. However, they are contraindicated in pregnancy or if there is risk of pregnancy.[101] Contraceptive use or abstinence should be discussed with adolescents on these medicines.
Fish oil or fibrate therapy is preferred when elevated triglycerides are the primary lipid abnormality.
SDB encompasses a range of breathing abnormalities that occur during sleep. These include obstructive sleep apnoea, central sleep apnoea, and periodic breathing. SDB is commonly found in patients with type 2 diabetes mellitus; research demonstrates that the likelihood is independent of obesity.[105]
Symptoms of sleep apnoea should be screened for at every follow-up visit.[1] Referral to a sleep specialist for evaluation and a polysomnogram may be indicated in the presence of symptoms.[1]
Hypoglycaemia occurs with blood glucose levels <3.9 mmol/L (<70 mg/dL).[1]
Patients need to be taught how to promptly identify the signs and symptoms (i.e., shakiness, irritability, hunger, sweating, tachycardia, mood changes, confusion, dizziness).[1]
Hypoglycaemia should be promptly treated orally with approximately 15-20 g of pure glucose (i.e. glucose tablets) or, if this is unavailable, with ingestion of any form of carbohydrate-containing food containing glucose.[1] Fifteen minutes after treatment, the patient or carer should re-check the blood glucose, and if there is continued hypoglycaemia, they should repeat the treatment. Once the blood glucose pattern is trending up, the patient should eat a meal or a snack, to prevent recurrence of hypoglycaemia.[1]
Patients on insulin and sulfonylurea treatment are more susceptible to hypoglycaemia. Insulin-treated patients need to monitor blood glucose more frequently (before meals and before bedtime) than patients on oral medicines. The American Diabetes Association recommends that continuous glucose monitoring should be offered to children and adolescents with type 2 diabetes who are on multiple daily injections, or insulin pumps, and who are capable of using the device safely (either by themself or with a carer).[1] The Endocrine Society recommends using continuous glucose monitoring for patients with type 2 diabetes who take insulin (and/or sulfonylureas) and are at risk of hypoglycaemia.[86] Structured education should be offered to all diabetes patients at risk of hypoglycaemia (e.g., those receiving insulin or sulfonylureas).[86] Hypoglycaemia unawareness, or one or more episode(s) of level 3 hypoglycaemia, should trigger hypoglycaemic avoidance education and re-evaluation and adjustment of the treatment plan to decrease hypoglycaemia.[1]
Glucagon should be prescribed for all patients at increased risk of level 2 or 3 hypoglycaemia, and used on an as needed basis. Carers, school personnel, or family members providing support to children should know where it is and be advised when and how to administer it.[1]
Patients with diabetes are more prone to infections, particularly of the skin and urinary tract. Hyperglycaemia compromises the body's defence against bacterial infections, and normalisation of blood glucose reduces this risk.
Current evidence on diabetes and periodontal disease is of variable quality.[104] A meta-analysis of 23 cross-sectional or cohort studies reported between 1970 and 2003 found greater severity but the same extent of periodontal disease in people with diabetes compared with those without diabetes.
Education of people with diabetes should include explanation of the implications of diabetes, particularly poorly controlled diabetes, for oral health, especially gum disease. Patients with diabetes should follow local recommendations for day-to-day dental care for the general population, and (where access permits) attend a dental professional regularly for oral health check-ups.
Occurs with insulinopenia.
Hydration, intravenous insulin therapy, and correction of electrolyte abnormalities are important for successful treatment.
Occurs with dehydration.
Hydration, intravenous insulin therapy, and correction of electrolyte abnormalities are important.
High risk of mortality in children.[95]
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