Six Acute Complications in Diabetes

Diabetic ketoacidosis (DKA) is a serious condition in which uncontrolled hyperglycemia (usually due to complete lack of insulin or a relative deficiency of insulin) over time creates a build up of ketones (acidic waste products) in the blood. Low insulin levels causes the liver to turn fatty acid to ketone for fuel (ketosis); ketone bodies are intermediate substrates in that metabolic sequence. This is normal when periodic, but can become a serious problem if sustained. Elevated levels of ketone bodies in the blood decrease the blood's pH, leading to DKA. High levels of ketones can be very harmful. Diabetic ketoacidosis can be precipitated by infection, stress, trauma, missing medications like insulin, or medical emergencies such as a stroke and heart attack. the patient with DKA is typically dehydrated, and breathes rapidly and deeply. Abdominal pain is common and may be severe. The level of consciousness is typically normal until late in the process, when lethargy may progress to coma. Ketoacidosis can easily become severe enough to cause hypotension, shock, and death. Ketoacidosis is much more common in type 1 diabetes than type 2.

Hyperosmolar hyperglycemic nonketotic syndrome (HNS) is a serious condition in which the blood sugar level gets very high. The body tries to get rid of the excess blood sugar by eliminating it in the urine, water is osmotically drawn out of cells into the blood and the kidneys eventually begin to dump glucose into the urine. This results in loss of water and an increase in blood osmolarity. If fluid is not replaced (orally or intravenously), the osmotic effect of high glucose levels, combined with the loss of water, will eventually lead to dehydration. The body's cells become progressively dehydrated as water is taken from them and excreted. Electrolyte imbalances are also common and are always dangerous. This increases the amount of urine significantly, and often leads to dehydration so severe that it can cause seizures, coma, and even death. This syndrome typically occurs in patients with type 2 diabetes who are not controlling their blood sugar levels, who have become dehydrated, or who have stress, injury, stroke, or are taking certain medications, like steroids. Lethargy may ultimately progress to a coma though this is more common in type 2 diabetes than type 1.

Patients with poorly controlled DM are prone to bacterial and fungal infections because of adverse effects of hyperglycemia on granulocyte and T-cell function. Most common are mucocutaneous fungal infections (eg, oral and vaginal candidiasis) and bacterial foot infections (including osteomyelitis), which are typically exacerbated by lower extremity vascular insufficiency and diabetic neuropathy.

Hypoglycemia, or abnormally low blood glucose, is an acute complication of several diabetes treatments. It is rare otherwise, either in diabetic or non-diabetic patients. The patient may become agitated, sweaty, weak, and have many symptoms of sympathetic activation of the autonomic nervous system resulting in feelings akin to dread and immobilized panic. Consciousness can be altered or even lost in extreme cases, leading to coma, seizures, or even brain damage and death. In patients with diabetes, this may be caused by several factors, such as too much or incorrectly timed insulin, too much or incorrectly timed exercise (exercise decreases insulin requirements) or not enough food (specifically glucose containing carbohydrates). Iatrogenic hypoglycemia is typically the result of the interplay of absolute (or relative) insulin excess and compromised glucose counterregulation in type 1 and advanced type 2 diabetes. Decrements in insulin, increments in glucagon, and increments in epinephrine are the primary glucose counterregulatory factors that normally prevent or correct hypoglycemia. In insulin-deficient diabetes (exogenous) insulin levels do not decrease as glucose levels fall, and the combination of deficient glucagon and epinephrine responses causes defective glucose counterregulation.

Furthermore, reduced sympathoadrenal responses can cause hypoglycemia unawareness. The concept of hypoglycemia-associated autonomic failure (HAAF) in diabetes posits that recent incidents of hypoglycemia causes both defective glucose counterregulation and hypoglycemia unawareness. By shifting glycemic thresholds for the sympathoadrenal (including epinephrine) and the resulting neurogenic responses to lower plasma glucose concentrations, antecedent hypoglycemia leads to a vicious cycle of recurrent hypoglycemia and further impairment of glucose counter regulation.

Diabetic coma is a medical emergency in which a person with diabetes mellitus is comatose (unconscious) because of one of the acute complications of diabetes:

Severe diabetic hypoglycemia: An estimated 2 to 15 percent of diabetics will suffer from at least one episode of diabetic coma in their lifetimes as a result of severe hypoglycemia.

Diabetic ketoacidosis advanced enough to result in unconsciousness from a combination of severe hyperglycemia, dehydration, shock, and exhaustionHyperosmolar nonketotic coma in which extreme hyperglycemia and dehydration alone are sufficient to cause unconsciousness.

The immune response is impaired in individuals with diabetes mellitus. Cellular studies have shown that hyperglycemia both reduces the function of immune cells and increases inflammation. The vascular effects of diabetes also tend to alter lung function, all of which leads to an increase in susceptibility to respiratory infections such as pneumonia and influenza among patients with diabetes. Several studies showed diabetes to be associated with a worse disease course and slower recovery from respiratory infections (Ahmed et al., 2008)

Diabetes is associated with periodontal disease (gum disease) (Mealey, 2006) and may make diabetes more difficult to Treat (Lakschevitz et al., 2011). Gum disease is frequently related to bacterial infection by organisms such as Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans (Mombelli, 2012). A number of trials have found improved blood sugar levels in type 2 diabetics who have undergone peridontal treatment (Lakschevitz et al., 2011).