Diabetes mellitus Typ 2 bei Kindern

Recent reports indicate an increasing prevalence of type 2 diabetes mellitus (TD2M) in children and adolescents in Germany, possibly due to the increasing prevalence of obesity. Manifestation of T2DM is usually at mid- to late puberty, with few symptoms. Most children and adolescents with T2DM are extremely obese, have relatives with T2DM, and show other clinical features of the insulin resistance syndrome such as hypertension, dyslipidemia, or acanthosis nigricans. Hispanics, African-Americans, Asians, and Indians suffer more frequently from T2DM compared with Caucasians. Primary therapy is weight reduction, which is difficult to achieve in everyday life. Metformin is regarded as the drug of choice, and insulin therapy is necessary in severe cases. Treatment of T2DM comorbidities is important but seldom practiced.     

Nephropathie bei Diabetes mellitus Typ 2

Zum Thema Die renalen Komplikationen bei Patienten mit Typ-2-Diabetes wurden lange Zeit untersch?tzt. Die steigende Zahl dialysepflichtiger Typ-2-Diabetiker zeigt jedoch die Bedeutung einer rechtzeitigen Diagnose, besseren Pr?vention und konsequenten Therapie der diabetischen Nephropathie. Dadurch kann nicht nur die Dialysepflichtigkeit verhindert bzw. verz?gert werden, sondern auch das hohe kardiovaskul?re Risiko des Patienten mit Typ-2-Diabetes gesenkt werden. Die vorliegende übersicht beschreibt zun?chst die Stadien der diabetischen Nephropathie und m?gliche Probleme bei der Diagnosestellung beim Typ-2-Diabetes. Anschlie?end werden die derzeit etablierten Ans?tze zur Pr?vention und Therapie der Nephropathie beim Typ-2-Diabetes mellitus zusammengefasst.     

Registerstudien bei Diabetes mellitus Typ?2

Diabetes type 2 is a chronic disease with an increasing socioeconomic impact. Healthcare for diabetes type 2 and related complications is often not in accordance with current guideline recommendations. Registries can be used to collect data on the epidemiological situation as well as to improve screening, diagnosis and treatment. Using registries treatment of diabetic patients can be improved on an individual and on a societal level. Given the perspective of the statutory health insurance it is of major importance to collect valid data to evaluate epidemiological and health economic questions. To perform an evaluation based on registry data, different study designs, such as cohort studies, case control studies and surveys are available. Methods of diabetes registries depend on the preferred study design but also on financial aspects, structural resources and personnel.     

Antikoagulation bei Diabetes mellitus

Patients with diabetes mellitus have an increased cardiovascular risk (annual risk of coronary heart disease >1.5%), and in the case of a cardiovascular event, their prognosis is worse than that of nondiabetic patients. Medication with 100 mg aspirin is indicated following a cardiovascular event (stroke, myocardial infarction) for secondary prevention, as it reduces mortality, and because of diabetics’ high risk, this dose is also recommended for primary prevention. Following coronary stent implantation, dual antiplatelet therapy with 100 mg aspirin and 75 mg clopidogrel should be initiated. Dual antiplatelet therapy should be given for 4 weeks if a bare metal stent was used and should be prolonged to a minimum of 6 months (even better, 12 months) following implantation of a drug-eluting stent. Oral anticoagulation does not differ in diabetics and nondiabetics if proliferative diabetic retinopathy can be ruled out.     

Koronarchirurgie bei Diabetes mellitus

Patients with coronary artery disease (CAD) and diabetes mellitus have an increased risk of mortality when undergoing either interventional or surgical revascularization. However, the rate of necessary reinterventions is significantly lower after surgical revascularization than after percutaneous transluminal coronary angioplasty (PTCA). As yet, no results of long-term follow-up after stent implantation are available. The risk for a patient with diabetes mellitus and CAD of dying of myocardial infarction after a bypass operation is significantly lower than after PTCA. Bypass operation with sternotomy in patients with diabetes mellitus carries, however, an increased risk of postoperative mediastinitis, especially when both internal thoracic arteries are used for "totally arterial" revascularization. For this reason the internal thoracic artery should be used only unilaterally in surgical revascularization in these patients. Preoperative and postoperative stabilization of the blood sugar level is very important. Sclerosis of the vessels in close proximity to the heart (ascending aorta, carotid arteries) must be clarified preoperatively. The operation should be carried out particularly carefully, with the wound area kept as small as possible. Reexploration should definitely be avoided. If these guidelines are followed, surgical revascularization in patients with CAD and diabetes mellitus can achieve very good results.     

Thrombozytenfunktion bei Diabetes mellitus

More than 75% of patients with diabetes mellitus die because of vascular complications, mainly due to myocardial infarction and stroke. In addition, more than two-thirds of patients with myocardial infarction present with impaired glucose metabolism (impaired glucose tolerance or diabetes mellitus). The incidence of diabetes mellitus, as well as the number of degenerative vascular complications, especially coronary artery disease (CAD) and stroke, is increasing. Besides macrovascular events, persisting hyperglycemia has a significant influence on platelets. Platelets take part in cardiovascular events; platelets of patients with diabetes mellitus are larger and hyperactive. Size, shape and functionality of platelets are influenced by the surrounding environment which, in the case of diabetes mellitus, is procoagulatory. Furthermore, diabetes mellitus is associated with increased leucocyte-platelet interaction with the consequence of higher formation of leukocyte-platelet aggregates.     

Albuminurie bei Diabetes mellitus

Diabetic nephropathy requires intensive treatment as it is the main reason for the morbidity and mortality resulting from diabetes mellitus. Patients with diabetic nephropathy have a significantly higher mortality rate due to cardiovascular events such as myocardial infarct or stroke. Microalbuminuria is the earliest clinical sign of diabetic renal disease and is also a marker for increased cardiovascular morbidity and mortality. Thus, its early detection allows not only for effective secondary prevention of the progression of diabetic nephropathy, but is also an indication for the implementation of an individually-tailored cardiovascular risk reduction management program. People with diabetes mellitus are high risk patients who need intensive monitoring and intensive supportive therapy.     

Nierenbiopsiebefunde bei Diabetes mellitus

Diabetic nephropathy is the most common cause of terminal kidney failure. The focal point is glomerulosclerosis which forms the morphological equivalent of proteinuria. Pathogenically, increased glomerular matrix formation and hyperglycaemia are closely connected. Qualitatively similar diabetic and hypertensive preglomerular vascular damage exacerbate the glomerulosclerosis. Angiotensin II is a further causal factor of glomerular sclerosis, independently of its hypertensive effect. Normalisation of blood sugar levels and blood pressure, blocking of angiotensin II and the recognition of additional kidney diseases, form a scientifically sound strategy for the control of diabetic nephropathy.     

KHK-Diagnostik bei Diabetes mellitus

Diabetes mellitus is an independent risk factor in the development of cardiovascular disease and coronary heart disease is the major determinant of morbidity and mortality in diabetic patients. Early diagnosis of coronary heart disease is therefore a major task in diabetic subjects to allow aggressive treatment to inhibit disease progression. This review gives an introduction to epidemiological aspects of coronary heart disease in diabetes mellitus patients and focuses on the clinical indications for intensive cardiac evaluation in such patients; the specific roles of the different diagnostic tools available are also discussed.     

Nephropathie bei Diabetes mellitus

Nephropathy in diabetics is the number two complication of this disease with a prevalence of 20%–50% in the German outpatient population. Compared to type 1 diabetes with the typical glomerular diabetic lesions, nephropathy in type 2 diabetes is heterogeneous and frequently the result of hypertensive/vascular or immunological disease. Glomerular filtration rate (formula clearance) and albuminuria/proteinuria are reliable prognostic factors, both associated with cardiovascular morbidity and mortality. Baseline therapy to ameliorate renal failure includes control of the risk factors hyperglycemia, hypertension, and hyperlipidemia together with lifestyle changes. The therapeutic focus in advanced disease stages includes secondary consequences of renal failure (bone disease, acid-base and electrolyte disturbances, anemia, malnutrition). Timely preparation for renal replacement therapy is mandatory. Diabetic patients of all ages benefit from renal transplantation; combined pancreas-kidney transplantation is an option for younger type 1 diabetics. The diabetic patient benefits most from a multidisciplinary and multiprofessional therapy approach with individual therapeutic goals provided by the general practitioner, diabetologist, cardiologist, and nephrologist. Therapeutic targets in advanced kidney disease are based on limited evidence.     

Nierenersatztherapie bei Diabetes mellitus

Diabetes patients with advanced renal failure profit from a structured care combining early referral to a nephrologist with different options of renal replacement therapy. Kidney transplantation (preemptively) is currently only available in exceptional cases. Decision-making for dialysis includes patient preferences, medical and social aspects. Peritoneal dialysis (PD) is an option in cases with limited life expectancy, initial treatment before hemodialysis (HD) and as a bridging to transplantation. Integrated care includes a timely switch from PD to HD while using the initial advantages of PD (improved survival of initial treatment period, better quality of life and prolonged residual renal function). Supportive care to avoid disease-specific complications, such as amputation, infection, cardiac infarction, stroke and depression, is a cornerstone in the improvement of survival for diabetic patients undergoing renal replacement therapy.     

Krankheitskostenstudien bei Diabetes mellitus

Healthcare cost studies make the economic dimension of diseases transparent. Supplementary to clinical and epidemiologic studies they have the capability to show starting points for a more efficient treatment of affected patients. There are different approaches. Usually the studies focus on the perspective of the payers and the economy, on direct (medical) costs and productivity losses as indirect costs. A patient with diabetes causes diabetes-related costs and costs not related to diabetes. The former can be split into the costs of the basic disease and the costs of complications. Whereas the mean per capita costs of a patient with diabetes clearly increase with age, this trend cannot be found regarding the diabetes-related costs. The costs of complications clearly dominate the costs of the basic disease. Depending on the point of view the economically most important diabetes sequelae are nephrologic and cardiovascular injuries.