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KETOACIDOSIS – DKA
Consistently high blood glucose levels can lead to a condition called diabetic ketoacidosis (DKA). This happens when a severe lack of insulin means the body cannot use glucose for energy, and the body starts to break down other body tissue as an alternative energy source. Ketones are the by-product of this process. Ketones are poisonous chemicals which build up and, if left unchecked, will cause the body to become acidic – hence the name ‘acidosis’.
DKA is a life-threatening emergency
The most likely times for DKA to occur are:
- At diagnosis. (Some people who do not realise they have Type 1 diabetes do not get diagnosed until they are very unwell with DKA.)
- When you are ill.
- During a growth spurt/puberty.
- If you have not taken your insulin for any reason.
- DKA usually develops over 24 hours but can develop faster particularly in young children. Hospital admission and treatment is essential to correct the life-threatening acidosis. Treatment involves closely monitored intravenous fluids, insulin and glucose.
- High blood glucose levels: DKA is often (but not always) accompanied by high blood glucose levels. If your levels are consistently above 15mmol/l you should check for ketones
- Ketones in the blood
- Frequently passing urine
- Feeling tired and lethargic
- Blurry vision
- Abdominal pain, nausea, vomiting
- Breathing changes (deep sighing breaths)
- Smell of ketones on breath (likened to smell of pear drops)
If you have high blood glucose levels and any signs of DKA you must contact your diabetes team immediately. Left untreated, DKA can be fatal. If picked up early, it can be treated with extra insulin, glucose and fluid in hospital.
- Make sure you check for ketones if your blood glucose is over 15mmol/l.
- You may need to take extra insulin.
- You may need to test your blood glucose and ketone levels frequently (e.g. every two hours).
- Drink plenty of unsweetened fluid.
If you are unable to eat, replace meals with snacks and drinks containing carbohydrate to provide energy (e.g. sips of sugary drinks, sucking boiled sweets).
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Coeliac disease is a common autoimmune disease that affects 1 in 100 people, but only 10–15 per cent are diagnosed. Gluten triggers an immune reaction in people with coeliac disease and gluten damages the lining of the small intestine. Other parts of the body may be affected.
Coeliac disease is more common in people who already have Type 1 diabetes, as both are autoimmune conditions and so are genetically linked. Some people with Type 1 diabetes find it is only after starting insulin that the symptoms of coeliac disease become noticeable. Some people with Type 1 diabetes have a ‘silent’ form of coeliac disease, which means no symptoms are apparent and it is only diagnosed by screening. Screening is done by an annual blood test looking for coeliac antibodies.
If you think you may have coeliac disease you should:
- Discuss your symptoms with your GP, diabetes doctor or nurse
- You can then take a simple blood test to look for an antibody made by the body in response to eating gluten
- Your GP / diabetes doctor can refer you to a gut specialist doctor (gastroenterologist) for a simple test called a ‘gut biopsy’. Small samples of gut lining are collected and later examined under a microscope to check for abnormalities that are typical in coeliac disease. You need to be having gluten daily for the biopsy to show any signs of coeliac disease. 2 slices of bread daily is sufficient gluten intake prior to the biopsy being performed. It is done in hospital under light sedation and you are free to go once you have recovered from the sedation effects.
Current clinical guidelines recommend that all children and young people with Type 1 diabetes are screened for coeliac disease on diagnosis. It is also recommended that adults with Type 1 diabetes are assessed for coeliac disease. Testing should also be offered to anyone if signs and symptoms of coeliac disease are present.
The thyroid gland is a small butterfly shaped gland with two lobes. It is situated in the front of your neck, just below the Adams Apple. The two lobes are joined together by tissue called the isthmus. The thyroid gland is one of the glands of the endocrine system.
The thyroid gland has two main functions: the first function is to control metabolism. Metabolism is the rate at which all the chemistry of the body works. The second function is to control growth in early life.
The normal thyroid produces a number of different hormones. The main hormones are called thyroxine (T4) and triiodothyronine (T3). The thyroid produces approximately 80% T4 and 20% T3.
T4 is generally considered to be a pro-hormone because it is inactive and only becomes active when converted to T3.
T3 is an active hormone and does all the work of regulating the body’s metabolism.
There are two types of thyroid disorder: hypothyroidism (where the body doesn’t produce enough thyroid hormones) and hyperthyroidism (where it produces too much).
Thyroid problems are more common in people with diabetes than those without diabetes, especially those with Type 1, because the body’s cells can attack the thyroid and destroy the cells as they do the insulin producing cells in the pancreas. Adults and children can be affected, and hypothyroidism is more common in people with Type 1.
Neither hypo- nor hyperthyroidism can be cured, but both can be treated successfully with tablets. Once a year you should have a blood test to check your thyroid function.
RETINOPATHY – EYE DISEASE
Diabetic retinopathy or ‘retinopathy’ is damage to the retina (the ‘seeing’ part at the back of the eye) and is a complication that can affect people with diabetes. Retinopathy is the most common cause of blindness among people of working age in New Zealand. Every one who has diabetes is entitled to a free eye photo in the retinal screening programme which is run through nominated providers. Your GP / diabetes doctor / diabetes nurse / practice nurse can refer you for this. You are screened every 2 years. If there are any changes to your eye you may be screened more often and can be referred to the ophthamology department at the hospital.
WHAT CAUSES RETINOPATHY?
To see, light must be able to pass from the front of the eye through to the retina, being focused by the lens. The retina is the light-sensitive layer of cells at the back of the eye – the ‘seeing’ part of the eye. It converts the light into electrical signals. These signals are sent to your brain through the optic nerve and your brain interprets them to produce the images that you see.
A delicate network of blood vessels supplies the retina with blood. When those blood vessels become blocked, leaky or grow haphazardly, the retina becomes damaged and is unable to work properly. Retinopathy is damage to the retina.
RISKS TO YOUR EYES
Persistent high levels of glucose can lead to damage in your eyes. To reduce the risk of eye problems, blood glucose, blood pressure and blood fats need to be kept within a target range, which should be agreed by you and your healthcare team. The aim of your diabetes treatment, with a healthy lifestyle, is to achieve these agreed targets.
Smoking also plays a major part in eye damage so, if you do smoke, stopping will be extremely helpful.
TYPES OF RETINOPATHY
There are different types of retinopathy: background retinopathy, maculopathy and proliferative retinopathy.
The earliest visible change to the retina is known as background retinopathy. This will not affect your eyesight, but it needs to be carefully monitored. The capillaries (small blood vessels) in the retina become blocked, they may bulge slightly (microaneurysm) and may leak blood (haemorrhages) or fluid (exudates).
Maculopathy is when the background retinopathy (see above) is at or around the macula. The macula is the most used area of the retina. It provides our central vision and is essential for clear, detailed vision. If fluid leaks from the enlarged blood vessels it can build up and causes swelling (oedema). This can lead to some loss of vision, particularly for reading and seeing fine details, and everything may appear blurred, as if you are looking through a layer of fluid not quite as clear as water.
Proliferative retinopathy occurs as background retinopathy develops and large areas of the retina are deprived of a proper blood supply because of blocked and damaged blood vessels. This stimulates the growth of new blood vessels to replace the blocked ones. These growing blood vessels are very delicate and bleed easily. The bleeding (haemorrhage) causes scar tissue that starts to shrink and pull on the retina, leading to it becoming detached and possibly causing vision loss or blindness.
Once the retinopathy has reached this stage it will be treated with laser therapy. Beams of bright laser light make tiny burns to stop the leaking and to stop the growth of new blood vessels.
KIDNEY PROBLEMS – NEPHROPATHY
Your kidneys are like a big sieve and they sieve out the normal constituents that make up urine. If your kidneys come under pressure from prolonged periods of high blood glucose levels and/or high blood pressure then the sieve can get holes in it and sieve out larger molecules not normally found in urine. These molecules are protein. In the early stages it is referred to as microalbuminuria – small amounts of protein in the urine. Left unchecked it can progress over years tomacroalbuminuria – large amounts of protein in the urine – and eventually dialysis will be needed.
However, prevention is better! This is why we give you that annoying urine container once a year, annual blood tests and monitor your blood pressure at each appointment.
Taking care of your kidneys is an essential part of managing your diabetes.
- Attend all your medical appointments
- Keep your blood glucose levels and blood pressure levels within your target range
- Have your urine tested for protein and a blood test to measure kidney function at least once a year
- Get help to stop smoking
- Eat healthily and keep active
If protein is detected more than one time on a test, then your doctor may talk to you about treatment. Usually you are prescribed an ACE inhibitor which lowers blood pressure and has a protective effect on the kidneys to prevent further damage. It is suggested that you take the tablet at bedtime so if it does make you feel dizzy due to lowered blood pressure, you will be lying down and not be affected. A common side effect of ACE inhibitor tablets is a dry annoying cough and if you get that you should go back to your GP and ask for a “cousin” of the tablet you have which hopefully won’t cause a cough. Sometimes you can come off these tablets after a period of treatment depending on your urine test results. Working on your blood glucose management will really help.
Kidney disease is not the only reason for protein to appear in the urine. If you have a urinary tract infection (UTI) this can lead to protein being passed out in the urine. People with poorly controlled diabetes can be more prone to urinary tract infections because glucose in the urine provides a breeding ground for bacteria. This might need treatment with antibiotics. And if you are female, don’t do a urine test for protein if you have your period.