Chronic Disease: Diabetes Mellitus

Introduction

Diabetes mellitus is a metabolic illness marked by hyperglycemia which derives from insulin action or insulin secretion deficiency. Chronic hyperglycemia may lead to such long-term harm as dysfunction or failure of the organs. Most frequently, diabetes impacts kidneys, nerves, eyes, blood vessels, and heart (American Diabetes Association, 2010).

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In the process of diabetes development, a range of pathogenic processes takes place. These may vary from autoimmune destruction of the pancreas cells to abnormal processes which cause resistance to the action of insulin (American Diabetes Association, 2010).

The most common diabetes types are gestational diabetes mellitus, type 1 diabetes, and type 2 diabetes. Other specific kinds are genetic defects of the β-cells, genetic defects in insulin action, diseases of the exocrine pancreas, endocrinopathies, drug- and chemical-induced diabetes, infections, and uncommon types of immune-mediated diabetes (American Diabetes Association, 2010).

Acute Illness in Renal System: Diabetic Kidney Disease

A consistent increase in diabetes mellitus cases leads to the development of many serious diseases. One of the most frequent complications of diabetes mellitus is diabetic kidney disease (DKD). This disease is the leading source of end-stage renal disease and cardiovascular disease. One of the difficulties presented by DKD is an extremely high cost of treatment.

When DKD occurs, the kidneys release an excessive amount of protein from the blood into the urine (Tuttle et al., 2014). In the most severe cases, DKD may cause kidney failure. In normal conditions, only a slight amount of albumin (the main protein) is found in urine. When a person has DKD, the level of albumin raises very rapidly (Tuttle et al., 2014).

Depending on the amount of albumin in urine, two types of DKD have identified: microalbuminuria (incipient nephropathy) and proteinuria (overt nephropathy). Microalbuminuria occurs when there is 30-300 mg of albumin in urine daily. Proteinuria is diagnosed when there are more than 300 mg of albumin in urine daily (Tuttle et al., 2014).

Pathophysiology of Diabetes Mellitus

Type 1 diabetes. Autoimmune destruction of the β-cells in the pancreas causes insulin secretion deficiency which leads to metabolic disorders. Apart from the deficit of insulin secretion, pancreatic α-cells also cannot operate properly. Thus, the patients experience a superfluous glucagons secretion (Ozougwu, Obimba, Belonwu, & Unakalamba, 2013). In normal conditions, hyperglycemia causes a decreased glucagons secretion. In patients with type 1 diabetes, such a process does not take place.

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Type 2 diabetes. Unlike patients with type 1 diabetes, circulating insulin in patients with type 2 can be detected. Based on the assessment of glucose tolerance, elements of type 2 diabetes may be divided into four types: (1) the ones with regular glucose tolerance, (2), chemical diabetes, (3) minimal fasting hyperglycemia, and (4) diabetes mellitus combined with obvious fasting hyperglycemia (Ozougwu et al., 2013).

Patients with defective glucose tolerance may have hyperglycemia notwithstanding the highest rate of plasma insulin which means that they are immune to insulin action.

Pathophysiological Impact on Renal System

The impact of diabetes mellitus on the renal system happens in stages. On the initial stage, the kidneys of the patients grow larger, and their glomerular filtration level becomes abnormally high, which means the likelihood of diabetic nephropathy (Vallon & Thomson, 2012). On the next stage, kidneys start to release blood proteins into the urine. The last stage is characterized by the development of diabetic kidney disease which impacts the whole urinary system.

Gradually, diabetes impacts all elements of the renal system: bladder, ureters, kidneys, and urethra. Kidneys are the so-called filters which clear away water and waste products from the blood. The urine which results from this filtration passes through ureters into the bladder. The bladder gathers and accumulates urine, and then the liquid passes the urethra and is released from the body through the genitals. When a person has diabetes, kidneys start releasing proteins into the urine (Vallon & Thomson, 2012). When such urine passes through the renal system, it gradually damages all urinary organs.

Recommended Classes of Drug Therapies for Diabetes Mellitus

Therapy for diabetes involves glucose-lowering medications and other supplementary drugs and injections. Such medications include Metformin, Meglitinides, Sulfonylureas, Thiazolidinediones, SGLT2 inhibitors, DPP-4 inhibitors, GLP-1 receptor agonists, and Insulin therapy (American Diabetes Association, 2016).

Metformin enhances the body tissues’ insulin sensitivity. Meglitinides trigger the pancreas to secrete larger amounts of insulin. Sulfonylureas provide a similar result, but they have such side effects as a gain of weight and low blood sugar. Thiazolidinediones are not preferred by the doctors because of their side effects such as heart failure risk. However, their function is to make tissues more insulin-sensitive. SGLT2 inhibitors are the newest diabetes drugs available. They stop the process of reabsorbing sugar into the blood by kidneys. DPP-4 inhibitors also decrease blood sugar levels, but their action is rather moderate. GLP-1 receptor agonists procrastinate digestion and make blood sugar levels reduced (American Diabetes Association, 2016).

Insulin therapy is applied with the help of injections and is presented by various types each having particular effects. Apart from diabetes drugs, patients may be prescribed cholesterol and blood pressure-lowering medicine or aspirin therapy to minimize blood vessel disease and heart failure (American Diabetes Association, 2016).

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Recommended Classes of Drug Therapies for Diabetic Kidney Disease

Since patients with DKD have a higher risk of hypoglycemia, insulin clearance is administered. To achieve the best outcomes, it is necessary to perform self-monitoring of blood glucose levels (Tuttle et al., 2014). Many drugs are the same as in the case of diabetes mellitus, but they have different effects. Metformin should be prescribed with care to the patients who have problems with excretion of lactic acid and metabolism, for instance, liver disease or heart failure. Metformin should be interrupted when there is a threat of acute kidney injury. Sulfonylureas and Glidines should be prescribed cautiously to avoid hypoglycemia. Thiazolidinediones are almost fully metabolized by the liver, but their side effects include hypertension and the risk of fractures. α-Glucosidase Inhibitors are prescribed to prevent carbohydrates digestion. Incretins promote the reduction of blood glucose levels. The two types of Sodium-Glucose Cotransporter 2 Inhibitors available in the US are Canagliflozin and Dapagliflozin (Tuttle et al., 2014). They increase glucose disposal through urine.

Possible Use of Vitamins, Herbal Supplements, and Cultural-Based Therapies in Diabetes Mellitus

The most useful vitamins in diabetes mellitus treatment are D, C, and E (Garcia-Bailo et al., 2011). They are used both as a disease-relieving method and a preventative measure. Vitamin D has always been known for its crucial role in bone metabolism and phosphorous and calcium homeostasis. However, vitamin D has begun to be connected with several health conditions such as cancer and neuromuscular function, as well as with chronic diseases like obesity, cardiovascular diseases, atherosclerosis, and diabetes (Garcia-Bailo et al., 2011). Vitamin D improves the secretion and production of insulin. Vitamin C plays an important role in inflammatory processes and immune function. Vitamin E intensifies the proliferation of lymphocytes.

There is a great variety of suggested herbal supplements with anti-diabetic properties. These plants have a big specter of action, the most important one being the significant reduction of blood glucose levels (Patel, Kumar, Laloo, & Hemalatha, S., 2012). Some of the proposed plants are Afzelia Africana (Fabaceae), Allium cepa (Liliaceae), Asystasia gangetica (Acanthaceae), Litsea coreana (Lauraceae), Morus rubra (Moraceae), Rosa canina (Rosaceae), Tinospora cordifolia (Menispermaceae), Swietenia macrophylla (Meliaceae) (Patel et al., 2012).

Cultural-based therapies in diabetes are concerned with the racial and ethnic peculiarities of people. Since minorities are more frequently impacted by the disease, specific treatment approaches are necessary, such as overcoming cultural barriers and diabetes self-management educational interventions for the minorities (American Association of Diabetes Educators, 2015).

Possible Use of Vitamins, Herbal Supplements, and Cultural-Based Therapies in Diabetic Kidney Disease

The most common vitamins suggested for DKD are vitamin D and vitamin B. The significance of vitamin D is represented via its antiproteinuric impact on podocytes which occupy the major place in the regulation of kidneys’ glomerular filtration (Wang et al., 2012). Treatment with vitamin D decreases albuminuria and averts podocyte injury. This vitamin helps to normalize the kidneys’ activity and improve the health condition of patients who suffer from diabetic kidney disease.

The positive impact of vitamin B on patients with DKD has been proved by a randomized control trial performed by House et al. (2010). As a result of their research, the scholars note that therapy incorporating vitamin B can decrease the progress of diabetic kidney disease and avert complications connected with the vascular system (House et al., 2010). Patients receiving vitamin B are reported to have a much better renal analysis. Additionally, the intake of this vitamin leads to the improvement of health in patients with cardiovascular disease (House et al., 2010).

Herbal medicine is also getting popular among DKD patients and doctors. The core benefit of such treatment is that it produces much less harm to people’s organisms that drugs do. Such herbal medicines as Vitis vinifera, curcumin from Curcuma longa, glycosides from Stelechocarpus cauliflowers, and Panax quinquefolium have demonstrated an ability to protect against renal damage (Mardani, Nasri, Rafieian-Kopaei, & Hajian, 2013). Some herbs improve kidney function and help to decrease blood pressure. Antioxidants in herbal supplements protect against kidney impairments which are the main cause of DKD.

Cultural-based therapies for DKD are concerned with a higher susceptibility of people from certain racial and ethnic backgrounds to the disease. For instance, South Asian and Black populations are more exposed to DKD than white people. Therefore, these populations need special attention and education about the risks of DKD (Muthuppalaniappan, Yaqoob, Navarro-González, & Luis, 2015).

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Patient Monitoring Strategies for Diabetes Mellitus

To successfully manage diabetes and eliminate the danger of serious complications, doctors and patients must employ various monitoring strategies. Self-management methods include medical nutritional therapy, home blood glucose monitoring, and increased physical activity (Unger, 2008). Medical nutritional therapy involves detailed planning of what products should be consumed by the patient to maintain the proper glucose level. Home blood glucose monitoring is a crucial strategy that allows the patients and their doctors to see how the disease is progressing and helps them notice any significant changes. Increased physical activity is a frequently advised measure for diabetes patients. Active physical life allows them to keep the necessary shape and reduce the outcomes of weight gain which may occur because of diabetes drugs.

A good monitoring approach is appointing authorized diabetes educators who can teach patients the skills necessary for proper disease management. If diabetes education is performed in groups, it is a rather time-efficient and cost-effective method of enhancing people’s glycemic control (Unger, 2008).

No matter what drug therapy is chosen, a doctor needs to observe the patient’s glycemic control. Diabetes is an evolving disease, and physicians need to adjust their monitoring strategies regularly. They have to take care of maintaining glycemic control and at the same time eliminate problems such as hypoglycemia and gain of weight (Unger, 2008). Resolutions concerning drugs and ways of treatment should be made according to the patients’ symptoms.

Patient Monitoring Strategies for Diabetic Kidney Disease

DKD may lead to serious complications in the patient’s health. Thus, it is necessary to perform regular monitoring and self-monitoring activities which make it possible to identify the complications in the disease’s progress. The most common monitoring strategies for DKD are blood and urine tests (Tuttle et al., 2014). Urine test allows seeing any modifications in albumin levels in urine. Blood test shows whether the kidneys are coping with their blood filtering role.

Other monitoring strategies are checking blood glucose levels, controlling blood pressure, developing and keeping a healthy lifestyle, taking the prescribed drugs, and managing stress (Tuttle et al., 2014). Quitting any bad habits is crucial for patients with DKD since their kidney is already damaged, and they should not put these organs under a bigger threat. Thus, people with DKD are advised to have a regular sleep pattern, engage in physical activities, consult with a dietician, and quit smoking (Tuttle et al., 2014).

Regular doctor’s appointments are necessary to provide the best control of self-monitoring strategies and prevent any complications. In the course of the disease, a physician may choose to change some aspects of treatment.

Patient Education Strategies for Diabetes Mellitus and Diabetic Kidney Disease

To provide the best management and treatment of diabetes and DKD, a Diabetes Self-Management Education Program (DSME) has been implemented. This program outlines the basic education activities which should be performed by the people (American Diabetes Association, 2016). There are four significant stages in the delivery of DSME: when the disease is being diagnosed, every year at the examination, when complications occur, and when there are care transitions.

DSME incorporates recommendations for diabetes self-management and explains the aspects of medical nutrition and physical activity. Education strategies also involve providing information about immunizations and define the need for smoking cessation. Finally, patient education promotes addressing the psychological issues of the patients. Medical nutrition therapy aims to help people find a suitable nutrition pattern corresponding to a particular diagnosis and aspects of a disease. Physical activity recommendations include instructions on appropriate physical exercises that help the patients to attain the necessary amount of training and avoid a sedentary lifestyle. The educational purpose of explaining the need for smoking cessation is the elimination of danger presented by tobacco products to the patients. Instructing on immunizations includes teaching people about the importance of routine vaccinations, as well as other vaccinations about diabetes patients. Psychological education is vital as people frequently feel depressed because of their disease and do not know how to cope with their stress. Thus, psychological assessment of diabetes patients is recommended by DSME (American Diabetes Association, 2016).

In addition to DSME regulations, there is a National Kidney Disease Education Program (NKDEP) (Tuttle et al., 2014). This program deals with the specific needs of DKD patients and includes such aspects as regular tests for albuminuria. Educating patients about diabetes and its complications allows to eliminate the serious complications and avert the risks of disease development

References

American Association of Diabetes Educators. (2015). Cultural considerations in diabetes education. Web.

American Diabetes Association. (2010). Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, 33(Suppl. 1), S62-S69.

American Diabetes Association. (2016). Standards of Medical Care in Diabetes – 2016. Abridged for Primary Care Providers. Diabetes Care, 39(Suppl. 1), S1-S21.

Garcia-Bailo, B., El-Sohemy, A., Haddad, P. S., Arora, P., Benzaied, F., Karmali, M., & Badawi, A. (2011). Vitamins D, C, and E in the prevention of type 2 diabetes mellitus: modulation of inflammation and oxidative stress. Biologics: Targets and Therapy, 5, 7-19.

House, A. A., Eliasziw, M., Cattran, D. C., Churchill, D. N., Oliver, M. J., Fine, A.,… Spence, J. D. (2010). Effect of B-vitamin therapy on progression of diabetic nephropathy. JAMA, 303(16), 1603-1609.

Mardani, S., Nasri, H., Rafieian-Kopaei, M., & Hajian, S. (2013). Herbal medicine and diabetic kidney disease. Journal of Nephropharmacology, 2(1), 1-2.

Muthuppalaniappan, V. M., Yaqoob, M. M., Navarro-González, J. F., & Luis, D. (2015). Ethnic/race diversity and diabetic kidney disease. Journal of Clinical Medicine, 4(8), 1561-1565.

Ozougwu, J. C., Obimba, K. C., Belonwu, C. D., & Unakalamba, C. B. (2013). The pathogenesis and pathophysiology of type 1 and type 2 diabetes mellitus. Journal of Physiology and Pathophysiology, 4(4), 46-57.

Patel, D. K., Kumar, R., Laloo, D., & Hemalatha, S. (2012). Natural medicines from plant source used for therapy of diabetes mellitus: An overview of its pharmacological aspects. Asian Pacific Journal of Tropical Disease, 2(3), 239-250.

Tuttle, K. R., Bakris, G. L., Bilous, R. W., Chiang, J. L., Boer, I. H., Goldstein-Fuchs, J.,… Molitch, M. E. (2014). Diabetic kidney disease: A report from an ADA consensus conference. American Journal of Kidney Diseases, 64(4), 510-533.

Unger, J. (2008). Current Strategies for Evaluating, Monitoring, and Treating Type 2 Diabetes Mellitus. The American Journal of Medicine, 121(6), S3-S8.

Vallon, V., & Thomson, S. C. (2012). Renal function in diabetic disease models: The tubular system in the pathophysiology of the diabetic kidney. Annual Review of Physiology, 74(1), 351-375.

Wang, Y., Deb, D. K., Zhang, Z., Sun, T., Liu, W., Yoon, D.,… Li, Y. C. (2012). Vitamin D receptor signaling in podocytes protects against diabetic nephropathy. Journal of American Society of Nephrology, 23(12), 1977-1986.

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