Complications
Chronic kidney disease is a well-known complication of type 2 diabetes mellitus (T2DM) in adults. Nephropathy results from hypertension and abnormal glucose homeostasis. Risk in children and adolescents is not known, although studies have indicated that there is evidence of early renal disease appearing at or soon after diagnosis in young people with T2DM and it appears to be more prevalent than in those with type 1 diabetes.[115][116] A UK audit found that 21% of children and young people with T2DM had moderately increased albuminuria (previously known as microalbuminuria) or severely increased albuminuria (previously known as macroalbuminuria).[26] Another study showed that the prevalence of moderately increased albuminuria in adolescents with T2DM increased over time, regardless of which diabetes treatment was used.[112] The risk for moderately increased albuminuria was related to glycaemic control.
Assessment of renal function with a test for urine albumin-to-creatinine ratio and estimated glomerular filtration rate (eGFR) should be performed at diagnosis and annually thereafter.[1] An raised urine albumin-to-creatinine ratio (>3 mg/mmol [>30 mg/g]) creatinine should be confirmed on two of three samples.[1]
In youth with diabetes and hypertension, either an ACE inhibitor or an angiotensin-II receptor antagonist is recommended for those with moderately increased urinary albumin-to-creatinine ratio 3-29 mg/mmol (30-299 mg/g) creatinine and should be considered for those with urinary albumin-to-creatinine ratio >30 mg/mmol (>300 mg/g) creatinine and/or estimated GFR <60 mL/min/1.73 m².[1] Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counselling, and ACE inhibitors and angiotensin-II receptor antagonists should be avoided in individuals of childbearing age who are not using reliable contraception.[1] Referral to a nephrologist is warranted if there is uncertain aetiology, in the presence of worsening albumin-to-creatinine ratio, or if there is a decrease in eGFR.[1]
Evaluation of youth with type 2 diabetes for MASLD (formerly called non-alcoholic fatty liver disease) by measuring aspartate transaminase and alanine aminotransferase levels should be done at diagnosis and annually thereafter. Referral to gastroenterology should be considered for persistently raised or worsening transaminases.[1]
Retinopathy is a long-term complication of type 2 diabetes mellitus in adults. Risk in children and adolescents is increased in some races or ethnic groups, higher haemoglobin A1c (HbA1c), increased insulin resistance, hypertension, and hyperlipidaemia.[114]
Causes include hypertension and poor glucose control.
Dilated fundoscopy should be performed at diagnosis and annually thereafter in most patients.[1] Examination every 2 years may be appropriate if glycaemic targets are met and the previous eye exam is normal.[1]
Cardiovascular disease is the major cause of morbidity and mortality in diabetes. To reduce cardiovascular risk, blood pressure, lipids, glucose, and smoking history (including vaping and electronic cigarettes) should be monitored and aggressively addressed.[1][111] Life expectancy and excess risk of cardiovascular disease and death are higher for those youngest at diagnosis.[26] A UK audit found that 46% of children and young people with type 2 diabetes mellitus (T2DM) had blood pressure in the hypertensive range.[26] Another study showed the prevalence of hypertension in adolescents with T2DM to increase over time regardless of which diabetes treatment is used.[112] The study found the greatest risk for hypertension to be male sex and a higher body mass index.
Blood pressure should be measured at diagnosis and every follow-up visit, and compared with age- and height-appropriate standards.[1] Ambulatory blood pressure monitoring should be strongly considered if blood pressure is high (blood pressure ≥90th percentile for age, sex, and height or, in adolescents ages ≥13 years, ≥120/80 mmHg) on three separate measurements. After excluding secondary hypertension, treatment of 'raised blood pressure' (defined by the American Diabetes Association [ADA] as blood pressure 90th to <95th percentile for age, sex, and height or, in adolescents aged ≥13 years, 120-129/<80 mmHg) is lifestyle modification focused on healthy nutrition, physical activity, sleep, and, if appropriate, weight management. If clinical hypertension (defined by the ADA as blood pressure consistently ≥95th percentile for age, sex, and height or, in adolescents aged ≥13 years, ≥130/80 mmHg) is confirmed, ACE inhibitors or angiotensin receptor blockers should be started in addition to lifestyle modification.[26] Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counselling, and ACE inhibitors and angiotensin-II receptor antagonists should be avoided in individuals of childbearing age who are not using reliable contraception.[1]
Cardiovascular disease is the major cause of morbidity and mortality in diabetes. To reduce cardiovascular risk, blood pressure, lipids, glucose, and smoking (including vaping and electronic cigarettes) should be monitored and aggressively addressed.[111] A UK audit found that 29% of children and young people with type 2 diabetes mellitus (T2DM) had a total blood cholesterol of 5 mmol/mol [193 mg/dL] or higher.[26] Another study found that dyslipidaemia and raised cardiovascular inflammatory markers are common in children and adolescents with T2DM and worsen over time.[113] The study found that diabetes treatment does not control this worsening risk.[114]
The American Diabetes Association advises that optimal goals are low-density lipoprotein (LDL) cholesterol <2.6 mmol/L (<100 mg/dL), high-density lipoprotein (HDL) cholesterol >0.91 mmol/L (>35 mg/dL), and triglycerides <1.7 mmol/L (<150 mg/dL).[1] If lipids are abnormal, initial therapy should consist of optimising glycaemia and medical nutritional therapy to limit the amount of calories from fat to 25% to 30% and saturated fat to <7%, limit cholesterol to <200 mg/day, avoid trans fats, and aim for approximately 10% of calories from monounsaturated fats.[1] For raised triglycerides, medical nutritional therapy should also focus on decreasing carbohydrate intake and increasing dietary omega-3 fatty acids.[1]
If LDL cholesterol remains >3.4 mmol/L (>130 mg/dL) after 6 months of dietary intervention, initiate therapy with statin, with a goal of LDL <2.6 mmol/L (<100 mg/dL).[1] Due to the potential teratogenic effects, individuals of childbearing age should receive reproductive counselling, and statins should be avoided in individuals of childbearing age who are not using reliable contraception.[1]
If triglycerides are >4.7 mmol/L (>400 mg/dL) fasting or >11.6 mmol/L (>1000 mg/dL) non-fasting, optimise glycaemia and begin fibrate therapy, with a goal of <4.7 mmol/L (<400 mg/dL) fasting to reduce risk for pancreatitis.[1]
SDB encompasses a range of breathing abnormalities that occur during sleep. These include obstructive sleep apnoea, central sleep apnoea, and periodic breathing. SDB is commonly found in patients with type 2 diabetes mellitus; research demonstrates that the likelihood is independent of obesity.[119]
Symptoms of sleep apnoea should be screened for at every follow-up visit.[1] Referral to a sleep specialist for evaluation and a polysomnogram may be indicated in the presence of symptoms.[1]
In a 2022/2023 UK audit, 41% of children and young people with type 2 diabetes mellitus (T2DM) were assessed as requiring additional psychological support outside of multidisciplinary team clinics.[26] Furthermore, in one registry-based study, 40% of hospitalizations occurring in young individuals with T2DM were related to mental health conditions.[120]
A lack of peer support, educational tools, and resources for this group have been highlighted as possible contributing factors, with most such resources focused on type 1 diabetes or T2DM in older adults.[26] In clinic chats with children and young people with T2DM, stigma emerged as a key theme, as well as difficulty explaining the condition or following lifestyle advice when faced with the practicalities of daily life, linked to expectations for socializing with peers and family.[26]
The American Diabetes Association (ADA) recommends using age-appropriate standardised and validated tools to screen for diabetes distress, depressive symptoms, and behavioural health concerns in youth with T2DM, with attention to symptoms of depression and disordered eating, and referral to a qualified behavioural health professional when indicated.[1]
Hypoglycaemia occurs with blood glucose levels <3.9 mmol/L (<70 mg/dL).[1] It is uncommon in children with type 2 diabetes mellitys (T2DM), but it should be considered in patients on insulin. Patients need to be taught how to promptly identify the signs and symptoms (e.g., shakiness, irritability, hunger, sweating, tachycardia, mood changes, confusion, dizziness).[1]
Treatment of hypoglycaemia should increase blood glucose level by approximately 3-4 mmol/L (54-72 mg/dL). This can be accomplished by administering approximately 0.3 g/kg fast-acting carbohydrate orally, which equates to 9 g of glucose for a 30 kg child and 15 g for children >50 kg.[110] Pure glucose (i.e. glucose tablets) is preferred. If this is unavailable, the patient should ingest any form of carbohydrate-containing food containing glucose.[1] Fifteen minutes after treatment, the patient or carer should re-check the blood glucose, and if there is continued hypoglycaemia, they should repeat the treatment. Once the blood glucose pattern is trending up, the patient should eat a meal or a snack, to prevent recurrence of hypoglycaemia.[1]
Insulin-treated patients need to monitor blood glucose more frequently (before meals and before bedtime) than patients on oral drugs. The American Diabetes Association recommends that continuous glucose monitoring should be offered to children and adolescents with T2DM who are on multiple daily injections, or insulin pumps, and who are capable of using the device safely (either by themself or with a carer).[1] The Endocrine Society recommends using continuous glucose monitoring for patients with type 2 diabetes who take insulin and are at risk of hypoglycaemia.[94] Structured education should be offered to all diabetes patients at risk of hypoglycaemia (e.g., those receiving insulin).[94] Hypoglycaemia unawareness, or one or more episode(s) of level 3 hypoglycaemia, should trigger hypoglycaemic avoidance education and re-evaluation and adjustment of the treatment plan to decrease hypoglycaemia.[1]
Glucagon should be prescribed for all patients taking insulin or at high risk for hypoglycaemia, and used on an as needed basis.[1] Carers, school personnel, or family members providing support to children should know where it is and be advised when and how to administer it.[110]
Patients with diabetes are more prone to infections, particularly of the skin and urinary tract. Hyperglycaemia compromises the body's defence against bacterial infections, and normalisation of blood glucose reduces this risk.
A chronic inflammatory gum disease that destroys the supporting tissues of the teeth (the periodontium).[102] Current evidence on diabetes and periodontal disease is of variable quality.[117] A meta-analysis of 23 cross-sectional or cohort studies reported between 1970 and 2003 found greater severity but the same extent of periodontal disease in people with diabetes compared with those without diabetes.[118]
Education of people with diabetes should include explanation of the implications of diabetes, particularly poorly controlled diabetes, for oral health, especially gum disease. Patients with diabetes should follow local recommendations for day-to-day dental care for the general population, and (where access permits) attend a dental professional regularly for oral health check-ups.[102]
Polycystic ovary syndrome is associated with insulin resistance. Female adolescents with type 2 diabetes mellitus (T2DM) should be evaluated for polycystic ovary syndrome symptoms at diagnosis and at subsequent reviews, with laboratory studies where indicated.[1] Metformin, in addition to lifestyle modification, is likely to improve the menstrual cyclicity and hyperandrogenism in female individuals with T2DM.[1]
Occurs with insulinopenia.
Hydration, intravenous insulin therapy, and correction of electrolyte abnormalities are important for successful treatment.
Occurs with dehydration.
Hydration, intravenous insulin therapy, and correction of electrolyte abnormalities are important.
High risk of mortality in children.[109]
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