Type 2 Diabetes Assessment

Patient Information

• Mrs. Farah is a 58-year-old female
• She presented for a routine follow-up
• She has a history of type 2 diabetes, hypertension, and hyperlipidemia for 8 years
• She denies chest pain, shortness of breath, or palpitations
• She has mild tingling/numbness in her feet, but no ulcers or calf pain with exertion
• She has no visual disturbances but hasn't seen an ophthalmologist recently

Presenting Complaint

• Current symptoms and active problems are assessed
• Symptoms of hyperglycemia include increased thirst/urination, unintentional weight loss, fatigue
• Medication history includes recent changes and adherence
• Dietary and physical activity changes are noted
• Complications include assessing chest pain, headache, vision changes, numbness, or intermittent claudication
• Self-monitoring of blood glucose at home is assessed
• Psychological symptoms like depression and anxiety are considered

Further History

• Polyuria and polydipsia: Urinates 4-5 times during day and 2-3 times at night, drinking 3 liters of fluids daily
• Mild fatigue with no abdominal pain
• Sedentary lifestyle is reported
• Breakfast consists of 2-3 toasts, 2 fried eggs, and 8 oz of orange juice
• Snacks include tea with sugar and biscuits, or cake
• Lunch has half a plate of rice, protein, and a can of Coke
• Dinner includes McDonald's Big Mac 1-2 times weekly or a turkey sandwich with fruits
• Walks for 10-15 minutes daily

Social and Family History

• She is a non-smoker and drinks no alcohol
• Has no history of recreational drug use
• Married for 35 years
• Has 4 independent adult children
• Lives in a 2-story house
• Works as a substitute teacher
• Has no recent travel outside the country with vaccinations up to date
• Her father died at 55 from a heart attack, and mother at 60 from a stroke
• Two sisters have T2DM with obesity

Self-Monitoring and Vitals

• Checks glucose every few days in the morning
• Fasting blood sugar is 140 mg/dL (7.8 mmol/L)
• Mood is stable

Medical History and Allergies

• Diagnosed with T2DM, hypertension, and hyperlipidemia for 8 years
• Has GERD
• Has no other chronic diseases
• Takes Metformin, Gliclazide, Sitagliptin, Valsartan/HCTZ, Amlodipine, and Atorvastatin
• Adherent to medications and has no known drug allergies

Past Surgical and Admission History

• Had 2 LSCS (lower segment cesarean section) 20 and 25 years prior
• Previously admitted for COVID pneumonia 3 years prior

Definition of CKD

• Chronic kidney disease involves kidney structure/function abnormalities present for >3 months
• It has implications for health

Initial Investigations

• Fingerstick Glucose: Result is 12 mmol/L, exceeding normal range of 3.9-5.5 mmol/L
• Full Blood Count: Normocytic anemia is present

Renal Function and Acute Kidney Injury (AKI)

• Renal function tests, electrolytes, and glucose levels determine if acute or chronic kidney disease is present
• AKI Definition: Increase in serum creatinine by ≥0.3 mg/dL within 48 hours, or ≥1.5 times baseline within 7 days, or urine volume <0.5 mL/kg/hour for 6 hours

Tests for Acute or Chronic Kidney Disease

• Renal Function Test, Electrolytes, Glucose
• Liver Function Tests (LFT)
  • Alkaline Phosphatase = 152 μmol/L, above reference range of 50-135 μmol/L
• HbA1C = 10.2%, exceeding the reference of <5.7%
• Iron Studies
  • Total Iron-Binding Capacity (TIBC) is low at 220 µg/dL
  • Transferrin Saturation (TSAT) is 20%
  • Ferritin: elevated at 400 ng/mL

Diagnosis of CKD

• Classified based on Cause, GFR category (G1-G5), and Albuminuria category (A1-A3), abbreviated as CGA
• Markers of Kidney damage includes Albuminuria, Urinary sediment abnormalities and pathological or imaging abnormalities
• Decreased kidney function (GFR) is the hallmark of progressive kidney disease

ABG Results

• pH: 7.32 (Mild acidemia)
• PaCO2: 4.5 kPa (Mild respiratory compensation)
• HCO3: 20 mEq/L (Mild metabolic acidosis)
• PaO2: 12.0 kPa (Normal)
• Interpretation: Mild metabolic acidosis with partial respiratory compensation

Metabolic Acidosis in CKD

• There is an impairment in kidneys excreting hydrogen ions
• Bicarbonate levels are linked to faster CKD progression
• Early identification and correction of acidosis are crucial to improve outcomes
• Kidneys can't excrete enough acid, leading to acid retention as kidney function declines
• Acid buffering in blood and tissues becomes insufficient as CKD progresses, leading to metabolic acidosis

Anemia and Iron Deficiency

• Mild Anemia that is common in CKD due to reduced erythropoietin production by the kidneys
• Normocytic Anemia indicates normal-sized red blood cells
• Functional Iron Deficiency is indicated by low serum iron, low TIBC, and normal or low TSAT

Tests and Results

• CKD-Mineral & Bone Disorders (CKD-MBD)
• Vitamin D= 22 ng/mL which is below reference range of 30-100 ng/mL
• Parathyroid Hormone (PTH) = 85 pg/mL which is above the reference range of 10-65 pg/mL

CKD-Mineral and Bone Disorders (CKD-MBD)

• Abnormal levels of calcium, phosphorus, PTH, or vitamin D
• Secondary Hyperparathyroidism driven by high phosphorus, low vitamin D, and low calcium

Ultrasound Results

• Right Kidney: 8.5 cm in length with increased cortical echogenicity and poorly defined corticomedullary differentiation
• Left Kidney: 8.2 cm in length with increased cortical echogenicity and poorly defined corticomedullary differentiation
• Bilateral Renal Atrophy is evident

Assessment of Medical Issues

• Chronic Kidney Disease, likely due to uncontrolled Type 2 Diabetes, Hypertension and Hyperlipidemia

Causes of CKD

• Diabetes, Hypertension, Glomerulonephritis may be causes
• Autosomal dominant polycystic kidney disease and Alport's syndrome may be causes
• Chronic pyelonephritis and Obstructive uropathy may be causes

Management of CKD

• Aim to slow decline in eGFR with aggressive risk factor management
• Optimize diabetes control and blood pressure control
• Blood pressure control includes <140/90mmHg or <130/80mmHg if proteinuria/diabetes ACE-I or ARB
• Smoking cessation and avoid nephrotoxins (e.g.- NSAIDs)

Kidney Biopsy Findings

• Excess glucose excreted in urine (glycosuria) due to type 1 or type 2 diabetes
• Hyaline arteriolosclerosis results and causes an increase in glomerular pressure
• Mesangial cells try to regenerate, developing Kimmelstiel-Wilson nodules
• Damaged, diffusely scarred glomeruli result and the GFR declines

Management of CKD Complications

• Anemia is managed with Erythropoiesis-stimulating agents (ESAs) which is Recombinant human EPO, Iron transfusion, or B12/Folate replacement
• CKD-Mineral & Bone Disorders is managed with restricted dietary phosphate, Calcium supplements, Vitamin D analogues, or Phosphate Binders

Treatment of Anemia

• Erythropoietin-stimulating agent, hemodialysis, high-protein diet, sodium bicarbonate supplement, or peritoneal dialysis can be used as a possible treatment

Fluid Balance

• Diuresis with Furosemide and restrict Sodium

What happens as Kidney function worsens?

• Uraemia in CKD is characterized by Gastrointestinal symptoms (Anorexia, nausea, vomiting)
• Cardiac symptoms like Pericarditis, Neurological Peripheral neuropathy or CNS issues can occur
• Persistent itching (uraemic pruritus) can happen as kidney function worsens
• Uraemia can be treated through kidney replacement therapy

Renal Replacement Therapy (Dialysis)

• Treatment that replicates some kidney functions, removing waste, excess fluid, and balancing electrolytes
• Indications for RRT are remembered by the mnemonic AEIOU which includes Acidosis, Electrolyte imbalance, Intoxication, Overload, or Uraemia symptoms

Dialysis

• Kidneys can no longer do so effectively
• Decision-Making to start dialysis is made by both patient and nephrologist when its benefits outweigh the risks and eGFR decreases
• Renal Replacement Therapy (Dialysis) includes Kidney Transplant, Haemodialysis, or Peritoneal Dialysis

Treatment Strategies for T2D

• Lifestyle changes which involve Diet and Exercise, Weight loss and Sleep management
• Oral medications and non-insulin injections like Insulin can be used
• Additionally, Weight loss medications or Bariatric Surgery ,cardiovascular risk factor modification or blood pressure control can be implemented

Medication Action of Metformin

• Acts on the liver (activates AMPK)
• Decreases glucose absorption in the large intestine and Increases insulin-mediated glucose utilisation in peripheral tissues

Benefits of Metformin

• Associated with mild weight loss
• Does not cause hypoglycemia
• Can lower HbA1c as much as 2%
• Side effects include GI upset, and B12 deficiency

Contraindication of Metformin

• Lactic Acidosis is rare, but a concern

SGLT-2 Inhibitors

• Name: Empagliflozin, canagliflozin, dapagliflozin
• Mechanism: Excretion of 50-100 grams glucose/day
• Metabolism: Mainly hepatic with some metabolites excreted via kidney
• Efficacy: lowers A1c by as much as 0.7% and + Cardiovascular risk benefit
• also approved for heart failure and CKD

General Information

• Multiple drugs that are available each have tissue-specific action
• All of these drugs, except insulin, are used for type 2 diabetes only
• All are contraindicated in pregnancy except glyburide (sulfonylurea) and metformin
• Can be used in any combination except sulfonylureas should not be used with meglitinides

Current Medication Review

• Correct matches are: Metformin -> C / Gliclazide -> A / Sitagliptin -> F / Valsartan -> B / Amlodipine -> D / Atorvastatin -> E
• Complications of Diabetes Mellitus can be Acute or Chronic (Macrovascular or Microvascular)