ABSTRACT

Background & Objectives:

Diabetes mellitus has become a leading cause of premature death, disability and high health care
costs
India will have the largest number of diabetic subjects in the world by 2025 and one out of 5
diabetic subjects in the world will be an Indian.
Diabetic neuropathy is common complication of diabetes mellitus. The objective of the study is

To study the peripheral neuropathy in type 2 DM > 5yrs duration.

To study the pattern of peripheral nerve involvement in these cases.
Correlate the level of HbAlc with peripheral neuropathy.
Correlate with various factors Causing peripheral neuropathy

Methods:
The study includes all type 2 diabetics from OPD's and IPD s in the department of medicine
AIMS and AH &RC,BG NAGARA in the period Between DEC 2014 to JUNE2016

Results:
In the study group, mean age of study population is 58.27 11.52. The mean HbA1C level in
this study is 8.611.66. In this study, mean FBS is 161.7445.17 and mean PPBS is

240.7083.80. In a total of 50 study population, 36 patients had nerve conduction study positive
and 14 patients had normal nerve conduction study and with symptoms of peripheral neuropathy.
Conclusion:
Peripheral neuropathy is most common micro vascular complication of type 2 diabetes
mellitus. Severe forms of diabetic complications where noted in uncontrolled blood sugars and
high HbA1c.There is strong relation between peripheral neuropathy with uncontrolled blood
sugars and duration of diabetes

Key words: Diabetes Mellitus, Peripheral Neuropathy, HbA1C, Blood sugar levels, Nerve
Conduction Study.
TABLE OF CONTENTS

1. Introduction
2. Objectives
3. Review of Literature
4. Materials and methods
5. Results
6. Discussion
7. Conclusion
8. Summary
9. Bibliography
10. Annexures

LIST OF TABLES

SL.NO.

TABLES

1.

SEX DISTRIBUTION IN PERIPHERAL NEUROPATHY

AGE AND SEX DISTRIBUTION IN PERIPHERAL

NEUROPATHY

DIABETIC NEUROPATHY IN RELATION TO

DURATION OF DIABETIS

BLOOD SUGAR LEVELS IN DIABETIC NEUROPATHY

PATIENTS
CLINICAL MANIFESTATIONS OF DIABETIC
NEUROPATHY

5
6

REFLEX LOSS IN NEUROPATHY

TYPES OF DIABETIC NEUROPATHY OBSERVED

HbA1C LEVELS

COMPLICATIONS IN PATIENTS WITH DIABETIC

NEUROPATHY

10

OTHER COMPLICATIONS IN PATIENTS WITH

DIABETIC NEUROPATHY

11

PERIPHERAL NEUROPATHY IN RELATION TO

TREATMENT OF DIABETIS

12

NERVE CONDUCTION STUDY AND PERIPHERAL

NEUROPATHY

LIST OF FIGURES

PAGE NO.

SL.NO.

FIGURES

PATHWAYS OF GLUCOSE METABOLISM

INVOLVED
IN
DEVELOPMENT
OF
COMPLICATIONS
REACTIVE OXYGEN INTERMEDIATE PATHWAY

POLYOL PATHWAY

AGE AND SEX DISTRIBUTION OF PERIPHERAL

NEUROPATHY
CLINICAL MANIFESTATIONS OF DIABETIC
NEUROPATHY
CLINICAL
PRESENTATION
OF
DIABETIC
NEUROPATHY

5
6

LIST OF ABBREVIATIONS

PAGE
NO.

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

A.N.
ALA
B.D.R
BMI
CN
CVS
D.N
DAN
DCCT
DSMN
DSN
DSPN
DSSN
ED
FBS
GLA
GlycoHb
HTN
IDDM
NIDDM
OHA
P.A
P.D.R
P.MN
PPBS
r-NGF

Autonomic Neuropathy
Alpha Lipoic Acid
Background Retinopathy
Body Mass Index
Cranial Nerve
Cardio Vascular System
Diabetic Neuropathy
Distal Autonomic Neuropathy
Diabetic Control and Complication Trial
Distal Sensory Motor Neuropathy
Distal Sensory Neuropathy
Distal Symmetrical Peripheral Neuropathy
Distal Symmetrical Sensory Neuropathy
Erectile Dysfunction
Fasting Blood Sugar
Gamma Linolenic Acid
Glycosylated Hemoglobin
Hypertension
Insulin Dependant Diabets Melilitus
Non Insulin Dependant Diabetis Mellitus
Oral Hypo Glycemic Agents
Perabdomen
Proliferative Diabetic Retinopathy
Proximal Neuropathy
Post Prandial Blood Sugar
Recombinant Nerve Growth Factor

INTRODUCTION
Diabetes mellitus is a syndrome characterised by chronic hyperglycemia and disturbances of
carbohydrate,fat and protein metabolism associated with absolute or relative deficiency in insulin
secretion and/or insulin action, which is modulated by genetic, HLA and environmental factors
resulting in micro and macroangiopathy.
It often runs in families.

It is associated with decrease in insulin production or utilisation, resulting in body's inability to

utilize nutrients appropriately.
Various genetic and environmental factors influence the aetiology and prognosis of diabetes.
Important differences in the types and frequency of Diabetes mellitus and its complications have
been reported between countries as well as ethnic and cultural groups.
Diabetes mellitus was formerly considered a disease of affluent. It has now become apparent
that increase in Diabetes mellitus is due to demographic changes, cultural transition and
population ageing, urbanization, increased consumption of refined foods, westernization,
sedentary habits and over nutrition.1, 2
Diabetes mellitus has become a leading cause of premature death, disability and high health care
costs.
Indians are genetically more susceptible to Diabetes mellitus compared to other races.
Indians settled abroad also show increased prevalence to Diabetes mellitus indicating that
environmental factors also play a role in incidence of diabetes.
India will have the largest number of diabetic subjects in the world by 2025 and one out of 5
diabetic subject in the world will be an Indian.
The rapid increase in population, increased longevity and high ethnic susceptibility to diabetes,
coupled with rapid urbanization and changes from traditional lifestyles will most likely trigger a
Diabetes mellitus epidemic
Diabetic neuropathy is common complication of diabetes mellitus.
It is Generally Considered to be related to duration and severity of hyperglycemia, Usually more
than 50% of Patients With the duration of diabetes of 25yrs or more are affected, making it as the
most common disease of Nervous system. This has-been stressed by various studies.
It is well Known that Diabetes mellitus is rising in an epidemic proportion in Indian
subcontinent, prevalence of Diabetic Neuropathy in type -2 DM of this Country was reported to
be 17 to 19% and that of Automatic Neuropathy of 35% of peripheral neuropathy cases.
Nerve conduction study shows abnormal conduction, predominantly of demyelinating type of
neuropathy.
Conduction velocity decreases slowly as duration of diabetes increases and directly related to
blood sugar levels, conduction velocity Improves with HbAlc levels returning to normal.
Strong relationship exists between duration of diabetes, level of hyperglycemia, to Incidence of
neuropathy.

Strict maintenance of glycemic state is most essential to prevent or slow the progression of
diabetic neuropathy in a patient of peripheral neuropathy, if autonomic system is also involved, it
Usually correlates with somatic neuropathy.
However it has been recognized that some patients with excellent glucose control were also
developed diabetic neuropathy,
Hence further studies are required to determine the possible risk factors.

AIMS AND OBIECTIVES

To study the peripheral neuropathy in type 2 DM > 5yrs duration.

To study the pattern of peripheral nerve involvement in these cases.
Correlate the level of HbAlc with peripheral neuropathy.
Correlate with various factors Causing peripheral neuropathy

REVIEW OF LITERATURE

Historical Review

Diabetes mellitus
Aretaus (AD 30-90 of Cappadocia in Secondary century coined the term "Diabetes"
derived from Greek word dia (through) and Bianeon (to go) meaning a Siphon. Because
fluid does not remain in body but uses man's body as a ladder where by to leave it as
patient was a Siphon "Which described the disease as melting down of flesh into the urine,thirst
unquenchable, kidneys never stop making water 4.5.6"

During 5th & 6th century BC, sweet taste of urine in polyuric patient was described in Sanskrit
(Indian) literature by Sushruta, Charaka. Vagbhata and the disease was named "Madhumeha"
They described that the urine of these Patients tasted like honey (madhu), sticky to touch and
ants were strongly attracted to it.

They differentiated two forms of the disease. One affecting thin people who do not survive long
and the other affecting older and obese. They also described relation of diabetes mellitus to
hereditary obesity sedentary life and diet.7

This description was parallel to the subdivision of Diabetes mellitus into the type l and type 2
Diabetes mellitus. Indian literature gets credit for the term Honey urine Referring to the clear
colorless nature of Diabetic Urine.
Diabetes Neuropathy is one of the commonest causes of Peripheral Neuropathy.
It accounts for hospitalization more frequently than complications of the Diabetes mellitus and is
the most frequent cause of non traumatic amputation diabetic autonomic neuropathy accounts for
silent myocardial infarction and Shortens the life span resulting in death in 25-50% of Patients
Within 5-10yrs of Autonomic diabetic Neuropathy.8

The diagnosis of subclinical Diabetic neuropathy requires Electro diagnostic testing and
quantitative sensory and autonomic testing.

Diabetic neuropathy has-been defined by the consensus conference of San Antonio as peripheral
neuropathy .Either clinically evident or sub clinically That occurs in the setting of diabetes
mellitus without other causes.31

The presence combination of the triad of neuropathy, retinopathy and nephropathy in the course
of the lifelong disease Regarded this "Triopathy" as consequences rather than complication,32
Diabetic neuropathy is one of the MOST common long term complication of diabetes mellitus
and is clinically present in 30- 50% of all diabetes Patients.33,34

The primary pathological role of Hyperglycemia in diabetic complications is well established,

With the increase increasing knowledge maintenance of euglycemia Greatly reduce, if not
Prevents the risk of diabetic complications and at times Helps even in regression of Such
complications, monitoring the Control of diabetes is essential for the successful management of
the diabetes.

The Responsibility of the patient and his physician in close monitoring control of diabetes and
Tailoring the various components in Their management Have Assumed greater significance.35

The present study has-been undertaken to monitor the levels of blood sugar and HbA1C, in
diabetic neuropathy.

The study of diabetic neuropathy has been Undertaken for the many reasons. The diabetes is a
frequent cause of peripheral neuropathy. Affects almost every part of nervous system and
produces various, type of neuropathy.

It has significant morbidity and mortality.

Its incidence Increases, when the control of diabetes is poor.

OTHER STUDIES

Study done by sumner. CJ et al. out of 73 diabetic patient They Studied, found Prevalence
of Neuropathy in 56%, and Patients With impaired glucose tolerance HAD
Predominantly small fiber neuropathy Compared to other Diabetic Patients Who Had
more Involvement of large fiber, and nerve conduction study velocity is Gradually
diminished in diabetic neuropathy with Estimated loss of about 0.5M / S year.16

 Study done by S.Ashok et . Prevalence of diabetic neuropathy was 19.1% out of 1000
consecutive diabetic Patients Who Have visited there diabetic center They found
Prevalence of neuropathy Increases with Age of a patient and duration of diabetes. They
Also found age and duration, the major risk factor for neuropathy.17

Study done by Vishwanathan et al they studied 1319 type 2 diabetic Patients selected in
four different centers in India and found Prevalence of Diabetic Neuropathy in 15% of
Patients, mean age of development is 53 11 year, more in males than females ratio is
2:1, duration of diabetes in these study is 6.2 5.3 years, diabetic neuropathy patients
had mean PPBS of 278 91 mg%, hypertension in 34% subjects, mean systolic BP is
132 32 mmHg and Diastolic 85.1 11,5 mmHg, BMI of 25.41 2.99 kg/met2 in patient
with diabetic neuropathy, average cholesterol level is 194 48 and the incidence of
Neuropathy increased from 7.5% on diagnosis to 50% at 25years of follow up.21

Study done by Mitrabasu et.al found that out of 82 diabetic patients studied 42 patient
had peripheral neuropathy and 8 patients had autonomic dysfunction that shows 54.0%,
and Autonomic Involvement in 10.8%, average age of development of peripheral
neuropathy in these patients is 50.176.9 years. They also observed that age and duration
of diabetes play an important role in diabetic neuropathy and significantly associated with
higher age, male patients are predominant in developing diabetic neuropathy 75.8% than
females 24.2%, average years need to developing Diabetic Neuropathy is 6.737.21
fasting and post prandial Glucose levels and were associated with 2 times risk of
Developing peripheral Neuropathy. The mean fasting Glucose in there study is 149
48mg%, mean HbAIc for development of the diabetic neuropathy is 7.91.38, body mass
index,.hyper cholesterol and triglyceridemia levels were associated and higher incidence
of Diabetic neuropathy, systolic BP average in these study is 134 16mmhg. higher the
BMI higher the incidence of diabetic Neuropathy they found average BMI of 25.4 4,6
kg/met2 and average triglyceride levels of 133 44.20

Study done by Ch. Manes et al found That prevalence of diabetic Neuropathy is33.5%,
Among 821 diabetic Patients. they Studied found 275 patients HAD peripheral
neuropathy and it is more common in age group of 61.61 5.5years, there is no
significant difference Between male and female, in males 35.2% and females 32.6%, out
of 275 Patients theyStudied the average duration of diabetes is 10.68 07.8years to
Develop peripheral neuropathy, mean fasting glucose is 19550 mg%, 19

 Study done by Kjerosti morkid et al out of 294 diabetic Patients They found the
prevalence of diabetic Neuropathy in 19.7%, and it Increases With Age 11.1% in 23-40
years age group. 32.3% in 60-80 years age group, prevalence is more in females (52.7%)
155 than males (47.3%), mean duration of diabetes to Develop neuropathy is 9-1 l years,
mean HbAlc of 8.752.20, hypertension was not significantly related to neuropathy,mean
BMI in neuropathy Patients is 24.43 3.35 kg /met2,,mean cholesterol level were 19031.
They found prevalence of Diabetic neuropathy is 13.7% in oral hypoglycemic agents
(CHA) Treated group and 29.2 in Insulin Treated group ,found more in insulin Treated
group.19

Study done by Arindam dutt and et al 'They Studied 100 diabetic Patients found That
neuropathy is more in the age group of 50. 44 10.35 years, found That 28% are male
31% are female, showing diabetic neuropathy effects females more than males, fasting
and post prandial Blood Glucose levels are higher in Neuropathic Patients Compared to
non neuropathic group. mean FBS 220 68mg%,. mean post prandial Blood sugar of
(33484 mg%), 18% of males and 12.82% of female Who Had Diabetic neuropathy Were
suffering from Hypertension. Both systolic and diastolic Blood pressure are higher in
Diabetic neuropathic Patients Compared to non- neuropathic group.
systolic12919.9mmHg and diastolie 82.2 9.32mmHg, nerve conduction study was
abnormal in 27% of patient, out of 27%, 15% of Patients HAD reduced nerve conduction
velocity, 23% of patient HAD BMI of 25 kg /met2

According to them there is significant different in BMI of neuropathic and non

neuropathic groups 22.53 kg / met2 and 22.95 3.15 kg / met2, 32% of Patients HAD
Neuropathy symptoms. Tingling was The most common symptoms (43.75%) followed by
Tingling and Numbness (21.87%), Tingling and Burning feet in 12.5%, Burning feet
alone (12.5%) weakness of limbs (6.25%) combination of Tingling, Numbness and
Burning feet (3.13%), Impaired vibration is common in 21 Patients followed by Loss of
joint and position sense With absent Ankle jerk (3.3%) Loss of vibration pain and touch
(3.3%), Loss of vibration, pain and touch sensation in ( 3.5%).23
Study done by sase et al found mean age of development of diabetic neuropathy is 50
years, Among Diabetic Patients Who Had peripheral neuropathy, 62% are male and 38%
female, showing, males predominant than females They found 76% of diabetic

neuropathic Patients HAD predominantly Demyelinating plus Axonal type of

neuropathy. They found 72% of Patients HAD Bilateral symmetrical mixed (sensory and
motor). symptoms predominant distal Involvement in 94% and 16% patient presented
with pure sensory symptoms, 12% had Pure motor symptoms.21
Study done by ozgur Boyrai et al found mean age of Development of Peripheral
Neuropathy in Diabetic patient was 579.9 year, but obese Patients mean age of 61,39
years, mean duration of diabetes to Develop peripheral neuropathy was 9.1 8.5 years
and 10.17.4 years in obese Patients, mean HbAlc is 6.9 1.7 in normal diabetic and in
obese patient 7.91.4, mean BMI to Develop neuropathy in diabetic patient is 25.5 2.4
kg / met2 and in obese diabetics it is 27.9 1.4 kg/met2,24

Study done by Rathmann w et al diabetic autonomic neuropathy accounts for silent

myocardial infarction and Shortens the life-span, RESULTING in death in 25-50% of
Patients with in 5 to 10 years of autonomic neuropathy.26

Study done by DCCT Diabetic control and complication trial, study Showed significant
Reduction in the development and progression of clinical neuropathy (64%). Motor
conduction velocity (44%) and Autonomic Dysfunctions (53%) in type-2 Diabetic With
optimal Glycemic control.1
Study done by UK Prospective Diabetes Study, Control of Blood Glucose was
Associated With improvement in vibration perception and reduction of odds ratio for the
development of Autonomic Neuropathy.27

Study done by Sultan et al found That mean fbs for development of peripheral
neuropathy in a diabetic Patients for 5-10 year duration is 18o30 mg%, for > 10 years
duration is 15030mg%, mean BMI of 25.41 2.99 kg / met2 Where as Patients Who are
diabetic for >10years HAD mean BMI of 23.21 2 97kg/ met2.28

Study done by Jyothi m et al. out of 65 Patients Studied They found That mean FBs in
neuropathy patient is 20668mg%, mean HbAlc is 7.74 1.48.29

 Study done by Patel.H.s et al out of 838 diabetic They found 32.2% Patients of them had
a hypertension Among Diabetic neuropathy.30

Study done by Arezzo JC et al found They found maximum defect will be at sural nerve
They Also found 1% fall in HbAlc Improves the conduction velocity by about 1.3M/s.
found That motor nerves are Predominantly Involved early in Diabetic Neuropathy than
sensory.37

Study by Ewing et al They found out of 73 Patients They Studied 62 males and 11
females, out of 62 males 30 HAD erectile dysfunction followed by postural hypotension,
intermittent diarrhea, hypoglycemic unawareness and gustatory sweating, They found
autonomic function testing using a simple cardiovascular reflex Gives a good guide to
the diagnosis of autonomic neuropathy.92

DIABETIC COMPLICATIONS MICROVASCULAR

Microvascular complications in diabetes Comprise of retinopathy. nephropathy and neuropathy,
since retinopathy, neuropathy and nephropathy Develop in parallel With microvascular
pathology;

These complications cannot be entirely explained as being secondary to be microvascular

pathology.

Many of the Mechanisms: such as oxidative stress, glycosylation and activation of protein
kinase C (PKC) Have Been demonstrated in all tissues affected by microvascular complications.
Basement membrane is essential for maintaining tissue architecture, to modify cellular
proliferation and providing filtration barrier.

A classic morphologic finding in diabetic microangiopathy is thickening of the basement

membrane.75 leading to microvascular complications like retinopathy, nephropathy and
neuropathy.

A reduction in endothelial NO production in diabetes mellitus presumably due to Decreased

blood flow to nerves can cause abnormalities of basal vascular tone. NO is an Important
mediator of endothelium dependent vasodilation'76.

Pathogenesis of microvascular complications is multifactorial and Considered to be both

hyperglycemic induced pathologic Changes intrinsic to neurons.77 and ischemia induced neuronal
damage by Decreased neurovascular blood flow .78

"MOLECULAR BASIS (PATHOGENESIS) OF DIABETIC COMPLICATIONS

Various theories Have Been put forward, some accepted theories are:

Aldose reductase (polyol pathway) theory

Hyperglycemia causes an Increased flux through the enzyme aldose reductase Which gets
activated and use nicotinamide adenine dinucleotide phosphate hydrogenase (NADPH) to reduce
glucose to sorbitol.

This is then oxidized to fructose via sorbitol dehydrogenase. The decline in NADPH Caused by
Increased Aldose reductase flux decreases the generation of nitric oxide in endothelial cells.79
and cellular redox balance. Increased NADH /NAD ratio that May alter enzyme activity Also
Contribute to the complications.80 by Increased sorbitol accumulation Which is neurotoxic to
nerves.81

Advanced glycation end product theory:

During the normal course of aging, proteins become irreversibly modified by sugar in a process
Known as Mailard reaction, leading to tissue "browning.hyperglycemia in diabetes accelerates
this process by covalent modification and cross linking proteins82.

The products of the nonenzymatic glycation of proteins are varied in chemical structure and as a
group, Have Been termed AGEs. Formation of AGE May damage cells by impairing function of
a wide range of proteins.83 including modifications of extracellular structural proteins: such as
collagen.84 and intracellular proteins.85,86 AGEs can Also cellular alter function by binding to
receptors called RAGE, a trans-membrane receptor.

This initiates a cascade of cellular signaling events, Such as activation of mitogen activated
protein (MAP) kinase Which can Lead to cellular dysfunction.87

Reactive oxygen intermediate theory:

The metabolism of glucose through glycolytic pathway and the tricarboxylic acid cycle produces
t Reducing equivalents that are used to drive ATP synthesis via oxidative phosphorylation in the
mitochondria.

Byproducts of mitochondrial oxidative phosphorylation include free radical: such as superoxide

anion and Their generation is Increased by high glucose levels.88 Glucose autoxidation Also
Creates free radicals that can damage cellular proteins.89 as well as mitochondrial DNA.90

Increased oxidant stress reduces nitric oxide levels damages cellular proteins and Promotes
leucocyte adhesion to the endothelium while inhibiting it barrier functions.

Protein kinase theory:

Protein kinase C and Diacylglycerol are critical intracellular signaling molecules that can
regulate many vascular functions Including permeability, vasodilator release, endothelial
activation and growth factor signaling.

Hyperglycemia causes pathological activation of PKC in diabetes increase increasing glycolytic

pathway leading to elevation in the levels of intracellular glyceraldehydes-3-phosphate, which in
turn stimulate increased Denovo synthesis of DAG through glyceraldehydes-3-phosphate. these
chronically elevated levels of DAG activates PKc.

In Addition DAG-PKC can Indirectly be activated by reactive oxygen intermediates and

advanced glycation end products altering gene expression leading to cellular dysfunction and
damage.

FIG 1

FIG 2

FIG 3

INVESTIGATIONS FOR DIABETES MELLITUS

Blood glucose levels

Glucose is essentially used as a screening parameter. Values are highly diet dependent and drug
intake influences the results. Glucose can be Estimated chemical and enzymatically if the fasting
plasma glucose > 7.0 m (126 mg %) or the post prandial plasma glucose >11.1Immol l / L(200)
mg Then it is Considered to be a case of diabetes.

Glucose tolerance test ( GTT)9

The WHO criteria for interpretation of glucose tolerance tests after oral dextrose 75g is
Normal: Fasting plasma glucose is <6.4 mmol and 2hr plasma glucose <7,8mmol / L
Diabetes: Fasting plasma glucose 7.8 mmol / or 2hr plasma glucose >11.1mmol / L.
impaired glucose tolerance (IGT): any other condition

A glucose tolerance test in medical practice is the administration of glucose to determine how
quickly it is cleared from the blood.

The test is usually used to test for diabetes, insulin resistance and sometimes reactive
hypoglycemia.

The glucose is most often given orally so the common test is technically an oral glucose
tolerance test.(OGTT).

Glycosylated hemoglobin:

Of all the glycosylated form of hemoglobin, HbAle The most viable. More than 80% of the
glycosylated form is HbA1c. Hence its measurement is taken to be the perfect parameter
Understand the long term diabetic Control.

This is the Most Important tool for monitoring diabetes.This test Refers to the hemoglobin
component FORMED by interaction with glucose.

Since life span of RBCs is approx 120, a single HbAlc determination can give information about
glycemic control in the preceding 8- 12weeks. It is estimated by HPLC method, which is
considered to be the gold standard.

The advantage is this test does not require any dietary preparations and has low sensitivity and
high specificity Compared to oral glucose tolerance test

Microalbuminuria

Microalbuminuria is the first warning signal to an impending Nephropathy. if attention is not

paid to keep diabetes under control. Microalbuminuria is present in 25% of Patients with Type 2
DM and 36% with type 1 DM.

Summary of recommendations for adults with Diabetes mellitus

(ADA Guidelines, 2016)10,11
Glycemic control criteria for the diagnosis of diabetes

FPG >126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*
OR
2-h PG>200 mg/dL (11.1mmol/L) during an OGTT. The test should be performed as described
by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved
in water.*
OR
A1C >6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that is
NGSP certified and standardized to the DCCT assay.*
OR
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma
glucose >200 mg/dL (11.1 mmol/L).
*In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing.

CHRONIC COMPLICATIONS oF DM
"Microvascular:

Eye disease
-Retinopathy (no proliferative proliferative)
-Macular edema
Neuropathy:
- Sensory and motor (mono- and polyneuropathy)
- Autonomic
Nephropathy
Macrovascular:
- Coronary heart disease
- Peripheral arterial disease
- Cerebrovascular disease
Others
- Gastrointestinal (gastroparesis, diarrhoea)
- Genitourinary ( uropathy/ sexual dysfunction)
- Dermatologic
- Infectious
- Cataract
-Periodontal disease
-glaucoma
-Hearing loss

EVALUATION OF DIABETIC Peripheral Neuropathy

The diagnosis of Diabetes Mellitus can be made on clinical examination but subsequently it
need to be confirmed by investigations (non-invasive/ invasive), The diagnosis of Diabetes
Mellitus in time is very important. Because effective intervention will only be possible only
during the subclinical or early phase of dysfunction.

There are 3 Approaches for the diagnosis of Diabetic Neuropathy.

- Clinical examination
- Nerve biopsy
- Nerve conduction study

CLINICAL EXAMINATION

Sensory examination

Vibration perception threshold (VPT) With 128 hz tuning fork.

Light touch sensation thresholds microfilament 10gm.
Thermal thresholds
Tests for autonomic dysfunction
Testing for tendon reflexes

NERVE TESTS
Skin punch biopsy

Quantitative sensory testing

Nerve conduction study

Clinical feature of diabetic Neuropathy

Distal symmetrical sensory motor polyneuropathy

Most common type of DN Involves Both small and large fibers and have insidious onset. The
most distal part of the extremities is first affected resulting in a stocking pattern of sensory loss.
As the sensory symptoms advance above the knees, the distal aspect of trunk is affected. It is
predominantly sensory neuropathy.

Autonomic neuropathy
ls sensory and often overlooked component of diabetic Neuropathy Any organ of the body
Which is supplied by autonomic nerves are Affect, it follows. "All or None phenomenon 12
symptoms range from minor to severe among autonomic neuropathic symptoms. , gustatory
sweating is common most followed by hypotension and diarrhea.

Proximal neuropathy
Typically Affects the elderly males >50 yrs suffering from type2 DM May be symmetrical or
asymmetrical With or Without sensory loss.13patient complaints of difficulty in squatting
position , climbing, marked weight loss. diabetic amyotrophic mainly nerve root involvement
due to occlusion of the vasa nervosum and infarction. mainly affected are anterior and lateral
adductor compartments of thigh , knee jerk absent, ankle jerk +.

FOCAL NEUROPATHIES
CRANIAL NEUROPATHY:3 rd,4th and 6th cranial nerves commonly involved .

TRUNCAL NUROPATHY:Most commonly affected groups are 5th and 6th decade of life. with
variable duration of diabetes, patients present with pain and dysasthesia in the lower ant chest or
upper abdomen with nocturnal intensification causing abdomen muscle weakness.

ENTRAPMENT NEUROPATHY
called pressure palsy
medial nerve most commonly involved
occasionally ulner or lat cutaneous nerve of thigh.

CRITERIAS TO DIAGNOSE DIABETIC PERIPHERAL NEUROPATHY

presence of 1 or > symptoms
Absence of two or more reflexes 9of ankle or knee tendon
abnormal autonomic functions (postural hypotension with a fall in systolic bp of 20mm hg or
more)
Vibration perception threshold that was abnormal

DIABETIC NEUROPATHY AND GLYCEMIC CONTROL

The relation between hyperglycemia and development of severity of neuropathy has-been shown
in retrospective studies.
A classic study of 440 diabetic Patients who Were Followed up over 25y Showed Increase in
detectable DN from 12% at time of diagnosis to About 50% after 25y And Those With Diabetic
Control poorest had a highest prevalence in DCCT trial 1
The prevalence rate for clinical or electrophysiological evidence of Neuropathy was reduced by
50% in Those Treated by Intensive therapy during 5yrs.

NERVE CONDUCTION STUDY

This is the test commonly used to Evaluate the function Especially the Ability of electrical
conduction of the Motor and sensory nerves of the Human body.
Nerve conduction studies are used mainly for the evaluation of paresthesis (tingling, numbness.
Burning) weakness of the arms and legs.

COMMON DISORDER WHERE NERVE CONDUCTION STUDY IS USED

Peripheral neuropathy
Carpel tunnel syndrome
Ulnar neuropathy
GB syndrome
Facio muscular humeral scapula dystrophy
Spinal disc hemiation
cubboital tunnel syndrome

NERVE CONDUCTION STUDY CONSIST OF FOLLOWING COMPONENTS:

Motor nerve conduction study
Sensory nerve conduction study
F wave reflex
H reflex study

Motor nerve conduction study

Performed by electrical stimulation of peripheral nerve and recording from muscle supplied by
this nerve.The Time It Takes for the electrical impulse to travel from the stimulation to recording
site is measured.

This value is the latency and is Measured in seconds (ms), The size of response is called
Amplitude. Motor amplitude are Measured in m volt (mv)

Sensory nerve conduction study14

'Performed by electrical stimulation of peripheral nerve and recording from a purely sensory
portion of the nerve: such as on a finger. The recording electrode is the more proximal of the two
like the motor studies.

Sensory latencies are on the scale of milliseconds. Sensory amplitude are much smaller than the
amplitude motor Usually in microvolt (ultraviolet) range. The sensory NCV is Calculated based
upon the latency and the distance b/w the stimulating and recording electrode.

F "study
'F wave study use supramaximal stimulation of motor nerve and recording of action potentials
from a muscle supplied by the nerve.

This is not reflex per se in that the Action potentials travel from the site of the stimulating
electrode in the limb to the spinal cords central home and back to the limb in the same nerve That
was stimulated.

The F wave latency can be used to derive the conduction velocity of nerve b/w the limb and
spine.

H reflex study

H reflex study uses stimtilation of a nerve and recording the reflex electrical discharge from a
muscle in the limb
This also evaluates conduction b / n the limb the spinal cord but in this case The afferent
impulses (Those going towards the spinal cord) are in sensory nerves while the efferent impulse
(Those coming. from the spinal cord) are in motor nerves.

Small pain fibers method

This method use an electrical stimulation With the neuro selective frequency to determine the
minimum voltage Causing conduction.

CONTRAINDICATION FOR NERVE CONDUCTION STUDY

Permanent pacemaker
Deep brain stimulator
Spinal cord stimulator

METHODOLOGY

STUDY GROUP

The study includes all type 2 diabetics from OPD's and IPD s in the department of medicine
AIMS and AH &RC,BG NAGARA in the period Between DEC 2014 to JUNE2016.

INCLUSION CRITERIA

Patients WHO full fill ADA criteria for diagnosis of diabetes

Diabetics of more than 5 years Were selected for further evaluation of neuropathic
symptoms/ signs
EXCLUSION CRITERIA

Nutrition deficiency
Alcoholism
Leukemia
Chronic renal failure
Infectious diseases
Occupational diseases
Type l Diabetes mellitus
Unilateral reflex loss
Toxic neuropathy
chronic liver disease
critically illness polyneuropathy
heriditarry neuropathy
autoimmune diseases
GB syndrome
Drug induced neuropathy
Malignancy

A detailed history was taken and examination done as per the proforma. With detailed emphesis
on peripheral nervous system Including cranial autonomic Involvement-for target organ
Involvement due to diabetes. All Patients in Addition to hematological and routine work up.

All Patients underwent nerve conduction studies for assessment of peripheral nerve Involvement
reading of ENMG was done with the help of neurologists.

INVESTIGATIONS
-FBS
- PPBS
- HbAlc
-CBC
-ESR
- Routine urine
- ECG
- RFT, LFT
- Autonomic function test
- NERVE CONDUCTION STUDY

Patients Where diagnosed based on the ADA criteria for diabetes10

symptoms of diabetes plus random blood glucose concentration of 11.1 mmol / L (200 mg / dl)
or
Fasting plasma glucose of 7.0 mmol / L(1 26 mg / dL)
or

Two-hour plasma glucose of 11.1 mmol / L (200 mg / dl) During an oral glucose tolerance
test.subjects who are alrady on treatment for diabetes.

RESULTS

In this study, 50 patients with diabetic neuropathy are studied and results were tabulated
as follows

TABLE 1.

Sex distribution peripheral neuropathy

Sex

Male

Female

Size

25

25

Peripheral neuropathy

25

25

In the present study of 50 patients with type 2 diabetes, 25 are males and 25 are females. We
have found that prevalence of peripheral neuropathy was same in both females and male.

Table 2. The age and sex distribution of neuropathy cases

Age group

Male

Female

Total

Percentage

35-45years

10

20

46-55years

10

20

56-65years

11

12

23

46

66-90years

14

Total

25

25

50

100

Figure 4

25

20

15
FEMALES
MALES

10

0
35-45

46-55

55-65

66-90

In this study, we had 50 patients with type 2 diabetes with neuropathy, they were in age
group between 35 to 90 years. Out of this, 10 patients were in age group 35-45
years(20%), 10 patients were in age group 46-55 years(20%), 23 patients were in age
group 56-65 years(46%) and 7 patients were above the age of 65 years(14%)
Mean age of all 50 patients is 58.27 11.52years. Diabetic neuropathy was found
common in the age group of 56 to 65 years that is 23 patients 46%, males 11 Patients
(22%) and females 12 patients (24%)

Table3 . Diabetic neuropathy in relation to duration of diabetes

Duration of DM

No of pts

Percentage

5 10 years

11 15 years

16

32

16 20 years

30

60

Duration of diabetes in these patients varied from 5 20 years. Mean duration of diabetes is 9.54
3.65 years
Increased duration of diabetes had significant relation to neuropathy.

Table 4 : Blood sugar levels in diabetic neuropathy patients

Blood sugar levels

No of cases

Percentage

Good control

14

FBS 120-140mg, PPBS

140-180mg
Fair control

17

34

FBS 140-180mg, PPBS

180-235mg
Poor control

26

52

FBS>180mg, PPBS
>235mg
Out of 50 diabetic neuropathy patients, 7 patients had good control (14%), 17 patients had fair
control(34%) and 26 patients had poor control(52%)

In this study, mean FBS value is 161.74 45.17

In this study, mean PPBS value is 240.70 83.80

Table 5: Clinical manifestations of diabetic neuropathy

Symptoms of
neuropathy
Sensory symptoms

No of patients

Percentage

36

72

Motor symptoms

11

22

Cranial nerve symptoms

Autonomic symptoms

Figure 5

CLINICAL MANIFESTATIONS OF DIABETIC NEUROPATHY

Sensory symptoms

2%4%

Motor symptoms

22%

Cranial nerve
symptoms
Autonomic symptoms
72%

Symptoms pertaining to the involvement of nervous system due to diabetes mellitus were further
analysed in 50 cases as follows.
Out of 50 diabetic patients, symptoms of neuropathy were present in 50 patients. The symptoms
with which patients presented are burning feet in 20 patients(40%), tingling sensation of limbs in
11 patients(22%), numbness of limbs in 5 patients (10%), weakness of limbs in 11
patients(22%), the commonest symptom was burning pain at night hours in 20 patients (40%).

Neurological examination

Higher Mental function: Evaluation was normal in all Patients

Cranial nerve examination: Third nerve palsy without papillary involvement seen in 1 Patient.
Motor System : 10 patients showed distal muscle weakness, only one patient had proximal
muscle weakness in both lower limbs.
However there was no significant wasting except in one case who showed moderate
wasting of thigh muscles.

Sensory system:
The following observation were made in 36 patients.
1. Impairment of temp, touch, and pain, sensation.

9 (25%)

2. Impairment of vibration sensation

9 (25%)

3. Impairment of joint/ position 'sensation

8 (22%)

4. Total vibratory sensory loss

5 (14%)

5. Total loss of temp, touch, and pain sensation

5 (14%)

Figure 6

CLINICAL PRESENTATION OF DIABETIC NEUROPATHY

Impairment of temp,
touch, and pain,
sensation

14%
25%

Impairment of vibration
sensation

14%

Impairment of joint/
position 'sensation

22%

Total vibratory sensory

loss

25%

Total loss of temp,

touch, and pain
sensation

Table 6. Reflexes loss in Neuropathy

Sluggish

Absent

Total

Ankle jerk

15

20

Knee jerk

10

13

Diminished or absence of reflexes were mainly found in patients with uncontrolled blood sugars
and higher values of HbA1c levels.

Gait:
Gait was normal in all patients except 5 patients who had sensory ataxia and all of these patients
showed romberg's test positive

Autonomic nervous system evaluation

2 patients showed objective evidence of autonomic neuropathy .
Dibetic gastroparesis was seen in 1 case
diabetic uropathy was found in 1 case

Types of neuropathy

Table 7. Types of Diabetic Neuropathy Observed

Patients were as follows

No of cases

Percentage

Distal symmetrical sensory

neuropathy

36

72

Distal symmetrical sensorimotor neuropathy

11

22

Autonomic neuropathy

Cranial neuropathy

Distal symmetrical sensory neuropathy was most commonest type found in 36 patients
(72%).

Table 8. Glycosylated hemoglobin

HbA1c Levels

No of Cases

Percentage

Good control(5.5-6.8%)

14

Fair control (6.8

7.6%)
Poor control (> 7.6%)

17

34

26

52

Mean HbA1c level is found to be 8.611.66 and 40 Patients (80%) had higher HbAlc values of
more than 7
and it is found that 26 patients (52%) had poor control.

Table 9. complications in patients with diabetic neuropathy

TOTAL NO. OF PTS

Percentage

DM with other microvascular

complications

33

66

No complications

17

34

Table 10. Other complications in patients with diabetic neuropathy

DM complications

Total no of pts.

Retinopathy

(Proliferative-5, Non proliferative-7)

12

33

Nephropathy
17
In this study, out of 50 patients with type 2 diabetes, 33 patients (66%) had complications
of diabetes in the form of retinopathy, nephropathy and peripheral vascular disorder
based on clinical and laboratory evidences. 12 out of 33 patients had retinopathy changes
(24%), nephropathy in 17 patients(34%).

Table 11. Peripheral neuropathy in relation to treatment of diabetis

Treatment

No of pts

OHA`S

39

INSULIN

OHA`S and INSULIN

11

In this study of 50 patients with type 2 diabetes with peripheral neuropathy, 39 patients
(78%) were on only OHAs and 11 patients (22%) were on both insulin and OHAs, none
of them were on only insulin.

To conclude among those with peripheral neuropathy, we have found that glycemic
control was poor, this could be due to the effect of hyperglycemia on peripheral nerves.

Nerve conduction study and peripheral neuropathy

Table 12:
Nerve
conduction
Study

Nerve
Conduction
Study - Positive

Nerve
Conduction
Study - Normal

No of patients with
peripheral neuropathy
Velocity
Reduced
Amplitude
Reduced

27
36
9

14

14

50

Total

Nerve conduction study was done for all patients with signs and symptoms of
neuropathy. Nerve conduction study was positive in 36 patients (72%), among them 30
patients (60%) had uncontrolled blood sugars and HbAlc levels, 6 patients( 12%) with
normal blood sugars and HbAlc. 14 patients (34%) who had symptoms of neuropathy
and uncontrolled blood sugars found normal nerve conduction study

Among positive nerve conduction study in 36 patients, Nerve conduction velocity

reduced in 27 patients it was less than 39m /s, and Reduced amplitude of nerve
conduction <1mv n 9 patients, mean HbAlc in patient with abnormal nerve conduction
study is 8.25.
In this study we have found that there is direct correlation with uncontrolled blood sugars
in type2 diabetes in development of peripheral neuropathy
General physical examination revealed 23 patients (46%) were obese with BMI >
23 , mean BMI of all 50 diabetic patients is 25.24 3.41kg/m2
12 patients (24%) had hypertension with diabetic neuropathy, mean systolic BP in
these patients is 140 15.5 mmHg and diastolic BP 85 11.5 mmHg.
Lipid profile in patients with peripheral neuropathy in this study showed
triglycerides at higher levels and mean triglyceride levels were 202.7 57.22 mg/dl,
mean total cholesterol levels were 208.09 43.24 mg/dl. Out of 50 patients, total no of
patients with abnormal cholesterol levels were 15(30%).

DISCUSSION

Among the endocrinal metabolic diseases diabetes occupies the major share. India has the
dubious distinction of being home to the largest number of people suffering from diabetes in any
country. The disease is responsible for significant mortality and morbidity due to the
complications.15

This study was conducted at AIMS, AH&RC during 2015 and 2016. Peripheral neuropathy was
studied in type 2 Diabetes Mellitus patients attending the OPD and IPD of AIMS Medical
College and Research Hospital.

A total of 50 type 2 diabetics were studied. All were confirmed diabetics who previously had
blood glucose levels of > 126 mg / dl or RBs of >199 on more than one occasion and were
receiving treatment such as Insulin, OHA's or physical exercise therapy.

Prevalence and spectrum of Peripheral Neuropathy in Type 2 diabetics

In this study of 50 patients with type 2 diabetes 25 were males and 25 females. We have found
40 patients (80%) withHBA1c abnormal levels, number of reports have also indicated higher
prevalence of peripheral neuropathy in higher HbAlc levels diabetic patients. Prevalence of
diabetic neuropathy varies wildly due to the different diagnostic criteria employed. In different
studies

Study done by Sumner. CJ et al16 ,out of 73 diabetic patients they have found prevalence of
Neuropathy in 56% of Patients.

Study done by S.Ashok et al17 Prevalence of diabetic neuropathy was 19.1% out of 1,000
consecutive diabetic patients who have visited there diabetic center.

Study done by Ch. manes et al18 they found incidence of that diabetic neuropathy was 33.5%,
among 821 diabetic patients they found 275 patients had peripheral neuropathy.

Study done by Kjerosti morkid et al19 , they studied 294 diabetic patients they found Prevalence
of Diabetic neuropathy in 19.7% patients.

Study done by Mitrabasu et al20 , found that out of 82 diabetic patients studied 42 patient had
peripheral neuropathy and 8 patients had autonomic dysfunction that shows 54.0% patients had
peripheral neuropathy and that Autonomic Involvement in 10.8%.

Study done by Vishwanathan et al21,3,they studied 1319 type 2 diabetic subject patients in
selected four different centers in India and found prevalence of Diabetic neuropathy in 15% of
patients .

In this study it was found prevalence of diabetic neuropathy is 52% in patient with uncontrolled
blood sugars which is similar to study done by sumner c J et al. mitrabasu et al

Age and diabetic neuropathy

In this study we found that patients were in age group of 35-90 years, maximum cases
are in age group of 56-65 years constituting 46%, mean age of diabetes was 58,2711.52 years.

Study done by S. Ashok et al17 they studied 1000 consecutive diabetic patients who have
visited there diabetic center they found prevalence of neuropathy Increases with Increases in Age
of a patient and duration of Diabetes.

Study done by Ch manes et al18 in there study they found Diabetic neuropathy is more
common in age group of 61.615.5 years, out of 821 diabetic patients 275 patients had diabetic
neuropathy which falls in above age group.

Study done by Kjerosti They morkid et al19 they studied 294 diabetic patients they
found prevalence of Diabetic neuropathy Increases With age 11.1% in 23- 40 years. 32.3% in age
group 60-80 years. age

Study done by Sase et al22 in there study they found mean age of development of
diabetic neuropathy is 50 years.

Study done by Mitrabasu et al20 found that out of 82 diabetic patients studied 42 patient
had peripheral neuropathy, Average age of development of peripheral neuropathy In these
patients is 50.17 is 6.9 years. They also observed hat age and duration of diabetes play an
Important role in diabetic neuropathy and significantly associated with higher age.

Vishwanathan et al3 they studied 1319 type 2 diabetic subject patients in selected four
different centers in India found mean age of development of diabetic neuropathy was 53 11
years.
Study done by Arindam dutt et al23 they studied 100 diabetic patients found that
neuropathy is more in the age group of 50.44 10.35 years

Study done by ozgur Boyraj et al24 average age of Development of peripheral

neuropathy in Diabetic patient was 57 9.9 year, but in there study they found average 61.3 9
years in development of neuropathy

In this study incidence of neuropathy is more in age group of 58.2711.52 years, similar
to other study by ozgur boyraj et al vishwanath et al, ch mane et al

Diabetic neuropathy and sex difference

In this study, it is found that 50% of males and 50% females equal distribution in sex
ratio study done by Ch manes et al18 in there study there is no significant different between male
and female in prevalence of Diabetic neuropathy in males 35.2%,female 32.6% .out of 275
Patients they studied.

Study done by Sase et al22 in their study they found among diabetic patients who had
peripheral neuropathy, 62% are male and 38% female, showing males predominant than females

Study done by Mitrabasu et al 20 found that out of 82 diabetic patients studied 42 patient
had peripheral neuropathy, and male patients are predominant in developing diabetic neuropathy
75.8% than females 24.2%.

Study done by the Kjerosti morkid et al19 they studied 294 diabetic patients they found
prevalence is more in female (52.7%) 155 than males (47.3%) 139

Study done by Vishwanathan et al3 they studied 1319 type 2 diabetic subject patients in
selected four different centers in India found diabetic neuropathy more in males than females
ratio was 2: 1.

Study done by Arindam dutt et al23 they studied 100 diabetic patients found That 28% are
male diabetics 31% are female, showing diabetic neuropathy effects females >males
In this study females are equal to males which is similsr to kjerosti mokrid et al, a study by
sase et al shows slight male predominant, and study by arindam dutt et al shows female
predominant.

Peripheral neuropathy and duration of diabetes

In this study found that average year of developing diabetic neuropathy is 9.54 3.65
years after detecting the diabetes, mean age of patient to develop peripheral neuropathy is 58.27
11.52y

Study done by Mitrabasu et al20 found that out of 82 diabetic patients studied 42 patients
had peripheral neuropathy, they found average years need to develop Diabetic Neuropathy
is6.737.21 years.

Study done by by Ch manes et al18 the average duration of diabetes is 10.687.8 years to
develop in to peripheral neuropathy they Studied 821 diabetic patients among which 275 had
diabetic neuropathy.

Study done by Kjerosti morkid et al19 they studied 294 diabetic patients they They found
average duration of diabetes to develop was 9-11 years.

Study done by s Ashok et al17 out of 1000 consecutive diabetic patients who have visited
their diabetic center they found age and duration the major risk factor for neuropathy.

Study done by Vishwanathan et al3 l they studied 1319 type 2 diabetic patients in selected
four different centers in India found duration of diabetes in these study is 6.255.3years to
develop diabetic neuropathy.

Study done by Pirarat et al25 the incidence of Neuropathy Increased from 7.5% on
diagnosis to 50% at 25 years of follow up.
Study done by Rathmann w et al diabetic autonomic neuropathy accounts for silent
myocardial infarction and shortens the life-span, resulting in death in 25-50% of patients with in
5 - 10 years of autonomic neuropathy.

Study done by ozgur Boyraj et al24 duration of diabetes et l to develop peripheral

neuropathy was 9.18.5 years and 10.17. 4 yeras in obese patients.

The average time of developing diabetic neuropathy being 9.54 6.5years in this study
is similar to the other studies by ch manes et al, kjerosti mokrid et al, Vishwanath et al, pirarat et
al ashok et al, Ozgur boyraj et al

Blood sugar and peripheral Neuropathy

In this study, it is found out of 50 patients mean fasting blood sugar is 161.74 45.17mg
%, mean post prandial blood sugar 240.70 83.80mg%, 26 patients 52% who have poor control
of blood sugars were more prone to develop neuropathy

Study done by Arindam dutt et al23 they studied 100 diabetic patients found that both
fasting and postprandial Blood Glucose levels are higher in Neuropathic patients compared to
non-Neuropathic group. Average FBS (22068 mg%), average post prandial blood sugar of (333
84 mg%).

Study done by Mitrabasu et al 20 found that out of 82 diabetic patients studied 42 patient
had peripheral neuropathy in theier study they found fasting and post prandial Glucose levels and
Were associated and 2 times risk of Developing Peripheral Neuropathy in diabetic patients. The
mean fasting Glucosein their study is 149 +/- 48 mg%

Study done by Vishwanathan et al3 'Profile of diabetic foot complication and Its associated
complications a multi center study from India they studied 1319 type 2 diabetic patients in
selected four different centers in India found diabetic neuropathy patients have mean PPBS IS
27891 mg%.
Study done by Ch manes et al18 they found mean fasting glucose was fo 19550mg% in
a patient who had developed Diabetic Neuropathy it was very significant finding. They studied
among 821 diabetic patients among which 275 had diabetic neuropathy.

Study done by Sultan and et al28 found that fasting Blood Glucose average for development
of peripheral neuropathy in a diabetic Patients for 5-10 year is 180 30mg%. for > 10 years
duration is 150 30mg%.

Study done by Jyothi.m Sarvant et al29 out of 65 patients they studied found that average
FBS in neuropathy patient is 20668.mg%.

The mean fasting and postprandial levels in present study was similar to the other studies
reported by Viswanath et al, mitrabasu et al, sultan at al and jyothi et al.

HbA1c and peripheral neuropathy

In this study, mean HbA1c level in neuropathy patient is 8.611.66.

Duration and level of hyperglycemia are known to be related to incidence of neuropathy

though relationship is well defined that reduction in HbA1c by 0.9% could reduce the incidence
of diabetic neuropathy by 60%.

Study done by Mitrabasu et al20 found that out of 82 diabetic patients 42 patients had
peripheral neuropathy, and they found mean glycosylated Hb% for development of the diabetic
neuropathy is 7.9 1.38

Study done by Jyothi. M sawant et al29 out of 65 patients they studied found average
HbA1c of 7.74 1.48 in a diabetic neuropathy patient.

Study done by the Kjerosti morkid et al19 they studied 294 diabetic patients they found mean
HbA1c of 8.752.20 for the development of peripheral neuropathy.
Study done by Ozgur boyraj et al24 average HbA1c to develop peripheral neuropathy
6.91.7 in normal diabetic and in Obese patient 7.91.4 .

The mean HbA1c level in this study was 8.61 1.66 and is similar to other studies by
mitrabasu et al, jyothi m sawant et al, kjerosti mokrid et al and Ozgur boyraj et al.

Blood pressure and Diabetic neuropathy

In this study, 24% of patient had hypertension with diabetic neuropathy Mean systolic BP
is 140 15.50 mmHg and diastolic BP is 85 11.5 mmHg.

Study done by Vishwanathan et al3 hypertension was found in 34% subjects who also had
diabetic peripheral neuropathy.

Study done by Patel.H. S et al30 they S studied 838 diabetic patients they found 32.2% of
patients had a hypertension with Diabetic neuropathy.

Study done by the Kjerosti morkid et al19 they studied 294 diabetic patients they found
hypertension not related to neuropathy.

Study done by Mitrabasu et al20 found that out of 82 diabetic patients studied 42 patient had
peripheral neuropathy in their study Body mass index, hypercholesterol and hyper
triglyceridemia levels were associated and higher incident of Diabetic neuropathy systolic BP
average in their study is 134 16.0 mmHg in peripheral neuropathy patients.

Study done by Vishwanathan et al3 they studied 1319 type 2 diabetic patients in selected
four different centers in India found that mean systolic BP of 132 32 mmHg and Diastolic BP
of 8511.5 mmHg in a patient of diabetic neuropathy.

Study done by Arindam dutt and et al23 they studied 100 diabetic patients found that 18%
of males and 12.82% of female patients who had Diabetic neuropathy were suffering from
Hypertension. Both systolic and Diastolic Blood pressure is higher in Diabetic neuropathy
patients compared to non-neuropathic group. Systolic 12919.9mmHg and diastolic of
82.29.32 mmHg.

In our study result were similar to Vishwanathan et al, and arindam Dutt et al.

Nerve conduction study and peripheral neuropathy

In our study 36 patient 72% had abnormal nerve conduction study and 14 patients(34%)
had normal nerve conduction study.

Study done by Sase et al22 in their study found 76% of diabetic neuropathy patients had
predominantly demyelinating plus axonal type of neuropathy

Study done by Sumner C J. et al16 patients with impaired glucose tolerance had
predominantly small fiber neuropathy compared to other patients and in Diabetes Patient more
involvement of large fiber, According to nerve conduction study, velocity is gradually reduced in
diabetic neuropathy with estimated loss of about 0.5M / S / year.

Study done by Arezzo J C. et al37 they found maximum defect will be at sural nerve they
also found 1% fall in HbA1c mproves the conduction velocity by about 1.3M / S .

Study done by Arindam Dutt et al23 they studied 100 diabetic patients and found the nerve
conduction study was abnormal in 27% of patient of diabetic neuropathy out of 27%, 15% of
patients had reduced nerve conduction velocity.

Result of nerve conduction study was done at this center was in conformation with the
results of study done by sase et al and arindam et al.

BMI and Diabetic Peripheral Neuropathy

In this study, it is found that average BMI is 25.143.41 kg / m2. Study revealed that 23
patients(46%) were obese with BMI>23.

Study done by Mitrabasu. et al20 found that of of 82 diabetic patients studied 42 patients
had peripheral neuropathy, and also they found that higher the BMI higher the incidence of
Diabetic Neuropathy, they found mean BMI of 25.4 4.6 kg / met2 in neuropathy patients.

Study done by Kjerosti morkid et al19 they studied 294 diabetic patients they found mean
BMI of 24.43 3.35 kg / met2 in neuropathy patients.

Study done by Ch manes et al18 in their study Body weight not positively correlated with
Neuropathy, in their study of 821 diabetic patients 275 had diabetic neuropathy.

Study done by Sultan. et al28 found that patients who are 5-10 years to develop Neuropathy
had mean BMI of 25.412.99kg/met2 where as patient who are diabetic for >10 years had
average BMI of 23.21 2.97 kg / met2

Study done by Vishwanathan et al21 they studied 1319 type 2 diabetic subject patients in
selected four different centers in India found BMI of 25.41 2.99 kg / met2 in a diabetic
neuropathy patient .

Study done by Arindam dutt et al23 they studied 100 diabetic patients found that 23% of
patient with diabetic neuropathy had BMI of 25 g / met2, according to them there is significant
difference in BMI of neuropathic and non neuropathic groups 22.5 3 kg /met2 and 22.953.15
kg / met2.

Study done by Ozgur boyraj et al24 BMI to develop neuropathy in diabetic patient is 25.5
2.4 kg / met2 in obese diabetics it is 27.9 1.4.kg/met2.
Result in this study is 25.24 3.41kg / met2 'which is similar to mitrabasu et al, sultan et al
and vishwanathan et al.

Cholesterol Levels and Diabetic Neuropathy

In this study we found mean cholesterol levels of 208.08 43.24 in diabetic neuropathy
patients, mean triglycerides levels 202.70 57.22, and 30% of patients who had diabetic
neuropathy also had deranged cholesterol levels.

Deranged Triglyceride level was found to be risk factor for development of Diabetic
neuropathy.

Study by Mitrabasu et al20 found that 82 diabetic patients studied 42 patients had peripheral
neuropathy and found mean triglyceride levels are 133 44, In neuropathy patients.

Study done by Kjerosti morkid et al19 they studied 294 diabetic patients they found average
cholesterol level of 19031 in Diabetic Neuropathy Patients.

Study done by Vishwanathan et al21 they studied 1319 type 2 diabetic subject patients in
selected four different centers in India found average cholesterol level of 19448 in a patient
with Diabetic Neuropathy.

Mean cholesterol level found in this study was similar to that of Vishwanathan et al and
kjerosti mokrid et al.

Clinical symptoms and diabetic neuropathy

In our study out of 50 diabetic patients, symptoms of neuropathy were present in 50
patients,. the symptoms with which the patients with neuropathy presented are Burning feet in 20
Patients 40%, Tingling sensation of limbs in 11 Patients 22%, numbness of limbs in 5 Patients
10%, weakness of limbs in 11 patients 22%, the commonest symptoms was burning pain at night
hours in 20patients 40%, mean duration of diabetes in these patients is 9.54 3.65 years.

Study done by Sase. et al in their study they found 72% of patients had Bi-lateral
Symmetrical mixed (sensory and motor) symptoms Predominant distal Involvement in 94% and
16% patient presented and pure sensory symptoms., 12% had pure motor symptoms.

Study done by Sultan et al28 found that motor nerves is predominantly Involved in early
Diabetic Neuropathy than sensory.

Study done by V.Bamal38 distal symmetrical Neuropathy is the commonest form of the
peripheral neuropathy in diabetic patients constitute 75%.

Study done by Arindam dutt et al23 they studied 100 diabetic patients found that 32% of
patients had Neuropathy symptoms, Tingling was the most common symptom (43.75%)
followed by Tingling and Numbness (21.87%), Tingling and Burning feet in (12.5% ), Buming
feet alone (12.5%), weakness of limbs (6.25%) combination of tingling, Numbness and Burning
feet (3.13%)

Impaired vibration is severe, most common Abnormality in 21 patients followed by Loss of

and position sense with absent Ankle jerk (3.3%) Loss of vibration pain and touch (3.3%). Loss
of vibration, pain and touch sensation in (3.5%).

In this study results are similar to sase et al, sultan et al and arindam dutt et al.

Mode of treatment and diabetic neuropathy

In this study we found that 78% of patients were on only OHAs and 22% of patients are on
both OHA and insulin therapy

Study done by the Kjerosti morkid et al19 they studied 294 diabetic patients found
prevalence of Diabetic neuropathy in 13.7% who are on oral hypoglycemic agents (OHA) and
29.2% in insulin treated group , found prevalence more in Insulin treated group.

In this study, among those with peripheral neuropathy we found that glycemic control was
poor.

CONCLUSION

 Peripheral neuropathy is most common micro vascular complication of type 2 diabetes

mellitus.
Elderly patients had higher incidence 23 (46%) of peripheral neuropathy because of
associated factors like degeneration of nerves and other co morbid conditions.
No sexual predilection to affection Peripheral neuropathy..
26 patient with peripheral neuropathy had poor glycemic control even with treatment.
12 patients (24%) had hypertension, 23 patients (46%) had higher BMI, 15 patients 30%
had abnormal cholesterol levels and age group 56-65 years all this contributes to
development of diabetic neuropathy
Severe forms of diabetic complications where noted in uncontrolled blood sugars and
high HbA1c. Hence, patients with diabetes must undergo frequent monitoring of blood
sugars and Hba1c to rule out complications of long term.
There is strong relation between peripheral neuropathy with uncontrolled blood sugars
and duration of diabetes.
Burning pain and numbness are most common symptoms of peripheral neuropathy in
diabetes.
One must have strong suspicion of complications in patients with uncontrolled blood
sugar levels and must be evaluated for peripheral neuropathy especially in aged diabetics
with history of diabetes more than 10 years having a poor glycemic control.
Longstanding diabetes and poor glycemic control are particularly associated with an
increased risk of neuropathy in diabetes mellitus. Estimation of glycosylated hemoglobin
is a simple, rapid, and objective procedure to assess diabetic control of previous 3
months .It serves both as a screening test for uncontrolled diabetes and as an indicator of
the efficacy of various therapeutic regimens. It also provides a conceptual frame work for
the pathogenesis of the long term complications of diabetes. Its estimation gives a
relatively precise reflection of the state of diabetic control.
7 Patients (14%) of patients with diabetic neuropathy had good glycemic control.
This study suggests that not only poor glycemic control other risk factors also are
important in development of diabetic peripheral neuropathy.

SUMMARY
50 patients of diabetic neuropathy studied clinically and nerve conduction study.
Symptoms of sensory system involvement were the most common, seen in 36 (72%)
patients, followed by motor symptoms seen in 11 (22%) cases. Autonomic symptoms 2
(4%) cases and cranial nerve symptoms one case (2%).
Examination of the cranial nerve revealed Ill cranial nerve palsy in one patient.
Symmetrical sensory loss was confined to the lower limbs and upper limbs in all
patients.
Distal symmetric sensory neuropathy was the most common type of clinical neuropathy
found.
Blood sugar estimation revealed evidence of poor control on 26 Patients (52%).
Estimation of glycosylated hemoglobin showed poor control in 26 Patients (52%).
Patients With hypertension (24%), BMI (46%) and age (56-65) 46% were predisposed
to neuropathy.
The efficacy of glycosylated hemoglobin estimation in assessing diabetic control is not
influenced by Age, Sex, duration, or diabetes and a mode of therapy.
Longer the duration and poorer the control of diabetes, more are the chance of
development of the complications of diabetic neuropathy.
14% of patient with diabetic neuropathy had good glycemic control.
This study is done in rural patients, the incidence of neuropathy in type 2 diabetes and
its relation to glycemic control were found to be similar to that of urban patients reported
from other studies.

BIBILOGRAPHY

I.
II.
III.

IV.

DCCT Research Group. The effect of intensive diabetes therapy on the development
and progression of neuropathy. Ann Intern Med 1995 122 561-8 2.
Ramachandran A, Mohan V. M c millan, Donald E, snelatha CEvaluation of clinical
neuropathy in diabetes use and Limitations of biothesiometer
V vishwanath, N Thomas, N Tendon, A Asirvatham, Seena rajeshakar Profile of
diabetic foot complications and Its Associated complications-A centric study from
india.
On the term F. Henschen diabetes in the work of Aretaeus and Galen. Ist Med 1969;
13 (2): 190-93
Ahmed AM. History of Diabetes I Saudi Medical Journal. 2002; 23 (4): 373-76
6. E Kenyan, Nagy J. A History of Diabetes Mellitus or how a disease of the kidneys
evolved into a kidney disease. Adv Chronic Kidney Dis. 2005; 12 (2): 223-9
7. H. Anwar Ali Ahmad M. T, Chand N. Diabetes Mellitus from antiquity to present
scenario and contribution of Greco- Arab physicians. JISHIM. 200 46-50
8. v Mohan, sasthry ng, premalatha g n Autonomic dysfunction in insulin dependent
diabetes mellitus and pancreatic diabetes fibrocalculus in india south Diabet med
1996. 13: 1038-1043
9. WHO definition and diagnosis of diabetes mellitus and hyperglycemia intermittent
10. American Diabetes Association Diagnosis and Classification of Diabetes Mellitus
Diabetes Care. 2010 January 33: S62-S69
11. Harrioson's Principles of Internal Medicine, 17th edition
12. "Variable relationship Between peripheral somatic and autonomic neuropathy
syndrome With Different inpatients of peripheral neuropathy." Young. R.J. et al 1986:
35: 192
13. American Diabetic Association standards of medical care in diabetes. Diabetic
care 2005: 28 (suppl 1) s4-36
14. Sharma K, O Farronay Cross J., et al. Demyelinating neuropathy in diabetes
mellitus Arch Neurol 2002; 59: 758-65
15. Palanisamy Pasupathi i. ning for Thyroid Dysfunction in the Diabetic / NonDiabetic Population. Thyroid Science. 2008: 3 (8): CLSI-6
16. Summer CI, Sheth S. Griffin w, Comblath DR, Polydefkis M The spectrum of
neuropathy in diabetes and impaired glucose tolerance. Department of Neurology,
The Johns Hopkins University, Baltimore, MD, USA. Comment in: J Med Natl India.
2004 Jul-Aug; 17 (4): 206
17. s Ashok, M Ramu, R Deepa, v Mohan Prevalence of Neuropathy in Type 2
Diabetic Patients Attending a Diabetes Centre in South India Specia MV Diabetes
Centre and Madras Diabetes Research Foundation, Chennai. Received 27.12.2000
Accepted: 28.8.2001
18. Ch Manes, MD;. N. Papazoglou, MD; E. Sossidou; K. Soulis, MD: D. Milarakis:
A Prevalence of Diabetic Neuropathy and Foot Ulceration: Identification of Potential
Risk Factors A Population-Based Study Satsoglou; A. Sakallerou PUBLICATION
DATE 10 February 2002

19. kristogi mokrid et al: Risk factors and prevalence of diabetic peripheral
neuropathy: a study of Patients in type2 diabetic Patients in Bangladesh ijddc out JanMarch 2010
20. Mitrabasu et al Association of diabetic neuropathy With clinical and laboratory
parameters in adult Indian subject "the Indian practitioner 139-144 march 2011
21. Vishwanath et al Evaluation of clinical neuropathy in diabetes: use and
Limitations of bio is thisomete Sase
22. NS, Correia PWM Clinical Profile of Peripheral neuropathy A Study of 100
Patient Wanless Hospital, Miraj, Maharashtra Arindam
23. Dutt, St. Naorem, Th Premchand Singh, Kunjabashi Wangjam Prevalence of
Peripheral Neuropathy in Type 2 Diabetics Diagnosed Newly Mellitus Inter national
journal of diabetes in developing countries
24 ozgur Boyraj er rahm The effect of obesity on the assement of diabetic peripheral
neuropathy: a comparison of test version Micigan patient and physician assement
Michigan diabetic resesrch and clinical practice (2010): 256-260
25. Pirate j. Diabetes Mellitus and Its degenerative complications to prospective study
of 4400 and 1974 Patients Observed Between 1978 1168-1188 1973 .diabetic care al.
Mortality in Patients With diabetic cardiovascular autonomic neuropathy
26. Rathmann W et Diabetic. 1993 Med. 10: 820-4
27. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of
macrovascular and microvascular complications in type 2 diabetes. UKPD s38. BM
1998; 317: 703-13
28. Sultana s egum N et al Changes of electrophysiological nerves engine type 2
diabetes mellitus in
29. Jyoti Sawant M. Ph.D: Association of Poor Glycemic Control with Lipid
Peroxidation Increased Reduced Antioxidant vitamin And Status in diabetic
Neuropathy The Internet Journal of Endocrinology 2007 Volume 3 Number 2
30. HS Patel, BN Srivastava Distal polyneuropathy in non-insulin dependent
diabetes mellitus
31. American diabetes Association. "American Academy of Neurology consensus
statement. Report and Recommendations of the San Antonio conference on diabetic neuropathy
Diabetic Care in January 1988
32. KC 592-7. Samai, BB Tripathy." Diabetic neuropathy "Japi 1993.suppll 47
33. Dyck. Pt, et al. "the prevalence by staged, severity of various types of diabetic neuropathy
retinopathy, and nephropathy in a population based Cohort:" I've Rochester diabetic neuropathy
study Neurology 1993 43:.... 817-24
34. Young MJ et. a multicenter study on the prevalence of diabetic peripheral neuropathy of
"Kingdom Hospital ed in the cTinaal population. Diabetologia 1993 05/01/36

35. Sheshiah. V: "Monitoring the Control of diabetes" Diabetes mellitus. 1989: 104-110
36. J. Mcleod "Diseases of the nervous systems Davidson's Principles and Practice of Medicine
15th ed, 1987: 483-84
37. Arezzo JC et al Changes of electrophysiological nerves engine type 2 diabetes mellitus in
38 V.Bamal et al 2006) Diabetic neuropathy in older adults clinical geriatric medicine 2008aug
39. Nabar JD, M ustaffa BE, Morris Dv, Walport MJ Kurtz AB. With insulin deficient diabetes
contrasts other endocrine deficiencies. Diabetologia 1979; 16: 5-12 F. Henschen
40. On the term diabetes in the work of Aretaeus and Galen. Hist Med 1969; 13 (2): 190-2
41. Ahmed AM. History of Diabetes Mellitus. Saudi Medical Journal. 2002; 304): 373-76
42. Ali H, Anwar Ahmad M. T, Chand N. Diabetes Mellitus from antiquity to present scenario
and contribution of Greco- Arab physicians. J 2006: 5: 46-50
43. American Diabetes Association Diabetes Diagnosis and Classification of Diabetes Care M.
2010 January; 33: S62-S69
44. Chiovato L, Barbesino G, Pinchera A. Graves' disease. In: DeGroot L J, Jameson JL, Burger
H, eds. Endocrinology. 4th ed. Philadelphia: Saunders, 2001
45. Tripathy B. RSSDI Text book of Diabetes Mellitus. 2 Edition. 2008.
46. D Chowdhury, N Patel Approach to arease of Autonomic Neuropathy peripheral
48. "Diabetic Neuropathy in Older Adults" Clin Geriatr Med 2008 August 24 (3):. 407 v doi:
10.1016 / j.
49. cger.2008.03.011 V Bansal, J Kalita. U K Misra Postgrad Med J Diabetic neuropathy 2006;
82: 95-100. doi: 10.1136 pgmi 2005.036137
50. SK Bhadada, RK Sahay, VP Jyorsna, JK Agrawal Diabetic Neuropathy: Current Concepts
Neurology. Jan 2003 14:60 (1): 108-11 68
51. v Mohan, M Deepa, RM Anjana, H Lanthorn, R Deepa Incidence of Diabetes and prediabetes
in a selected South Indian Urban Population (19 cups)
52. SK Sachdeva, HK Efficacy and Safety of Madaan Pregabalin (300 mg) for Treatment or
Painful Diabetic Peripheral Neuropathy, Government Medical College Patiala Punjab Bhadada
53. SK, RK Sahay, I'P Jh na, JK Agraw Diabetic Neuropathy: Current Concepts Neurology,
2003 Jan 14:60 (1): 108-11

54. API textbook of internal medicine Boulton AJM

55. 12th edition, JD Diabetic neuropathies ward and pain Clinical endocrinal Metab 1986 16:
917-31
56. Thomas Jr coll pk metabolic neuropathy lond1973 physicians; 7: 154-60
57. Grazia et al Diagnostic criteria devigili for small fiber neuropathy: from symptoms of
neuropathology Brain 2008, 131 7): 1972-1925
58. Gregersen.G Motor nerve function and duration of diabetes The lancet 1964: 733
59. JW Engstrom, Martin JB. Disorders of the autonomic nervoussystem. In: Braunwald E Fauci
AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison's Principles of Internal
Medicine. 15th edition. New York: McGraw-H 2001: 24 16-20
60. Shaw JE, Zimmet PZ, Gries FA, Ziegler D Epidemiology of diabetic neuropathy. In Textbook
of Diabetic Neuropathy, Gries FA, Cameron NE, Low PA, Ziegler D, Eds Stuttgart, New York,
Thieme, 2003, p. 64-82
61. Ceriello A Bridge Between Hyperglycemia the non-enzymatic glycation and oxidative stress
in the pathogenesis of diabetic complications. Diabetes. Nutr. Metab. 1999; 12 (1) 42-46
62. Karnes Dyck PJ O'Brien JT Daubert P Serviee FJ Glinical and neurological criteria for the
diagnosis and staging of diabetic polyneuropathy. Brain 1985; 108: 861-80
63. V. Mohan et al (1985) terogeneity in clinical & biochemical profile of tropical diabetes
mellitus Diabetologna 28: 229-232
64. MMS Ahuja Practice of Diabetes Mellitus go India (1983) Ed M.M.S. Ahuja, Vikas
Publishing House Pvt. Ltd. 45-50
65. Bajaj M, Banerji MA. Type 2 diabetes in South Asians: a pathophysiological f the Asian
Indian epidemiologist C URR Diab Rep 2004: 4213-18
66. I've absence of aglycemic threshold for the development of long term complications: The
perspective of the diabetes Diabetes Control and Complications Trial 1996: 45:
67. 1289 American Diabetes Association "Tests of glycemia in diabetes Clinical Practice
Recommendations, 2003. 107-108
68. Stration IM .. et al "Association of macrovascular and microvascular glycemia with
complications of diabetes type-II" (UKPDs35):... Prospective study Br Med J. observation. 2000:
321: 405-1

69. J. Mcleod You diseases of the nervous systems Davidson's Principles and Practice of
medicine ": 15th ed 1987: 483-84
70. Malik RA,". Can diabetic neuropathy be preventer by angiotension converting enzyme
Inhibitors "? Ann Med 2000 32: 1-5.
71. Sheshaiah v: Rangarao Kv: "Glycosylation of protein: Relevance to diabetes mellitus Pl 1989
JA:.. 37 (6): 403-404
72. Baker, JR: et al." Serum Concentrations as a measure fructosamine of blood glucose
monitoring in IDDM Br Med J. 1985:.. 290: 352-5
73. Baker, JR Johnson, RN: DJ Scott. "Serum fructosamine concentration in Patients With
NIDDM, During Changes in management", Br Med J. 1984. 285.1484-86
74. Kenneth H. "Gabby glycosylated hemoglobin and diabetes mellitus
75. Cameron JS and Brandford G. The simplest assessment of selectivity in heavy proteinuria
Lancet Il 1966.242
76. Maack T, Johonson V, Kau S, J Figueiredo, Siguelin D. Renal filtration, transport and
metabolism of low molecular weight proteins A review Kidney 1979 16:.... 251-270
77 Christensen E, Brm has Megahin and eubilin synergistic endocytic receptors in renal proximal
tubule Am J. Physiol 2001; 280:.. 563-573
78. WG Guder, Ivandic M, Hofmann W. physiopathology of proteinuria and laboratory
diagnostic strategy based on single protein Clin Chem Lab Med patterns 1998.. 36,935,939
79. Jung K, Matte eimer H, Burchardt U. ry enzymes Berl York Springer Verlag London 1991
KM Ward
80. Renal function (microalbuminuria) Anal Chem 1995, 67:... 383 -391
81. JC Selby, Fitzsimmons sc, Newman JM, Katz PP, sepe s, Showstack J. The natural history
and epidemiology of diabeti nephropathy. Implications for prevention and control. JAMA 1990
263: 1954-1960
82. Viberti GC, Hill RD, Jarrett RJ, Argyropoulos A, Mahmud U, Keen H microalbuminuria as a
predictor of clinical nephropathy in insulin-dependent diabetes mellitus, Lancet 1982
83. Mogensen CE 430-1432. Microalbuminuria Predicts clinical proteinuria and early mortality
in maturity-onset diabetes. N Engl. J. Med 1984.310: 356-360.

84. Chavers BM, Bilous Rw, Ellis, Steffes MW, Mauer sM. Glomerular lesions and urinary
albumin excretion in type 1 diabetes without proteinuria over. N. Engl. J Med 320: 966-970
85. Alzaid AA. Microalbuminuria in Patients With NIDDM An overview. Diabetes Care 1996
19: 79-89
86. Mogensen CE. Christensen CK. Predicting insulin dependent diabetic nephropathy in
Patients. N. Engl J Med 1984 89-93
87. Grey M, Cameron ME. Lipman TH, et al. Diabetic nephropathy. Diabetes Care 1997 20:
S24-S27
88. Dakshinamurty Kv, Malati T, PV Rao, T. Gangadhar Microalbuminuria in Renal Diseases.
Trends Biochem Clin. Lab Medicine 2003: 256-265.
89. John J. Rao PS, AS Kanagasabapathy. Prevalance of diabetic nephropathy in non-insulin
dependent diabetes. Indian J Med Res 1991; 94: 24-29.
90. S. Bianchi Bigazzi R, Campese VM. Microalbuminuria in essential hypertension:
significance, pathophysiology and therapeutic implicaciones. AmJ.Kidney Dis 1999; 34: 973995.
91. Aron.L vinik et al, American Diabetic Association, diabetic care
92. DJ Ewing et the natural history of diabetic autonomic neuropathy QJM oxford journal (95108)

PROFORMA FOR Peripheral Neuropathy in Type 2 Diabetes Mellitus

Name:
Age:
Sex:
Address:
Occupation:

Income:
Diagnosis:
D.O.A.:
D.O.D:
I.P.No:
Diagnosis of DM type and duration :
Treatment - Diet / exercise / OHA'S / Insulin
Insulin: Type/Dose/Duration/Irregular or regular
Oral Hypogycemic agents: Type / dose duration regular or irregular.
Control of DM : Good /Fair/Uncontrolled .
General Symptoms:
Polyphagia/ Polyuria/ polydipsia/ Loss of Weight /Tiredness
C.N.S
a. Tingling and numbness (paraesthesia) of feet and hand /duration/ Pain in lower limbs/
Burning sensation in the feet or palm
b. Sensory loss/unsteadiness of gait/
c. Motor Weakness of limb
d. Symptoms suggestive of Cranial Nerve
, visual disturbances
Diplopia
Blurring of vision with headache
. Unilateral facial weakness

AUTONOMICSYMPTOMS
CVS
H / O Painless Myocardial infarction, Postural Giddiness ,gustatory sweating,Absence
of sweating

G.I.T (Gastric emptying abnormalities)

Dysphagia/ Diarrhoeal/ Constipation

Post prandial nausea, vomiting, early satiety,

Genito Urinary
bladder dysfunction
Sensation of incomplete emptying with straining
overflow incontinence / recurrent urinary tract infection

Sexual Dysfunction
Male: Impotence/ Retrograde ejaculation

Genitourinary
Female: Dysuria / Pruritis / Vulva/White discharge per vagina
Hypoglycemic unawareness
sweating disturbance / Blurring of vision / Palpitation

CVS
Chest Pain / Palpitation / Breathlessness/syncope/swelling of feet

R.S.cough with expectoration/ Breathlessness/ hemoptysis/ Chest Pain / Wheezing

G.I.T. dysphagia / Abdomen Pain/ Constipation / Diarrhoea/vomiting

Family history; Diabetes/ hypertension / IHD

Personal History
Diet: mixed/ veg
Sleep:
Bowel / Bladder movements
Smoking Duration No. of beedi; Cigarette perday
Alcohol in take; Type/ Duration/ frequency/frequency
Drug Addiction. Tobacco chewing

GENERAL PHYSICALEXAMINATION
Level of consciousness
Decubitus
State of Nutrition
Build
Trophic Changes
Skin Changes
Lymphadenopathy
Oral hygiene
Pedal edema
ENT
Eye
Gangrene / Ulcer
Peripheral felt pulses / not felt
Wt. Kgs

Height in cm
Waist circumference
BMI
PULSE: rate / rhythm / volume /charecter condition of vessel wall/ change of pulse to Valsalva
maneuver
B.P. Supine / standing / postural drop
Respiratory Rate :Rate/ Rhythm
Temp: Normal/increased/ Decreased

Systemic Examination:
A. Central Nervous System
Higher Mental Functions
Cranial nerves
Sensory System
Touch
Pain
Temparature
Joint Sensation
Position Sensation
Vibration Sensation
Cortical Sensation
Romberg's Sign

Motor System
a. Nutrition .wasting+/-, type

b. Tone
c. Power
d. Coordination
e. involuntary movement.
Reflexes
a. Superficial reflexes
b. Deep reflexes
Cerebellar System
Signs of meningeal Irritation
Examination of spine/skull

B. Cardiovascular system
. Inspection/ Palpation/ Percussion/ Auscultation/ Heart sounds ,added sounds. Murmurs
C.Respiratory system.
Inspection/ Palpation/ Percussion/ Auscultation: