IDF - working for people with diabetes around the world© IDF (Europe) 1998

A Desktop Guide to
Type 1 (Insulin-dependent) Diabetes

Sections 15-18: Kidney, eye, foot, and nerve damage

15 Kidney damage
16 Eye damage
17 Foot problems
18 Nerve damage

TYPE 1 DIABETES - 15 - KIDNEY DAMAGE
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15 KIDNEY DAMAGE

15.1 Detection and surveillance

Detection and surveillance of kidney problems and blood pressure
are a routine part of Annual Review
Check for proteinuria yearly using reagent strips

Measure urinary albumin excretion yearly ( if not proteinuric ) using :

If ratio >2.5 mg/mmol ( >30 mg/g ) in men or >3.5 mg/mmol ( >40 mg/g ) in women

Or concentration >20 mg/l :
    • Repeat to confirm
    • Monitor progression of kidney damage by more frequent measurement

Check for infection and consider other renal disease if proteinuria positive

Measure serum creatinine yearly ( more often if abnormal )

Measure blood pressure yearly for surveillance purposes ( sitting, 1st/5th sounds, 5 min rest )

15.2 Blood pressure management if raised albumin excretion rate

Treat aggressively with a target of <130/80 mmHg or lower if easily attained

15.3 Other management

Maintain good blood glucose control and tight arterial risk factor control

Treat urinary infections aggressively; consider papillary necrosis if recurrent

Arrange early evaluation by a nephrologist ( at creatinine <200-300 µmol/l ( <2.5-3.5 mg/dl ) )

No patient should be excluded from renal replacement
programmes solely on the basis of having diabetes
( Top of 'Kidney problems' )
TYPE 1 DIABETES - 15 - KIDNEY DAMAGE
TYPE 1 DIABETES - 16 - EYE DAMAGE
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16 EYE DAMAGE

16.1 Detection and surveillance

Detection and surveillance of eye problems are a routine part of Annual Review
Organize a recall system to ensure it occurs regularly for every individual

Measure or assess yearly :

Reassess after shorter interval ( 3-6 mo ) if :

16.2 Eye disease management

Refer to ophthalmologist if :

Review and intensify management of :

Attend to the psychological and social aspects of visual impairment where it develops

The primary management of diabetic eye disease is by careful attention
to blood glucose control targets from the time of diagnosis
( Top of 'Eye damage' )
TYPE 1 DIABETES - 16 - EYE DAMAGE
TYPE 1 DIABETES - 17 - FOOT PROBLEMS
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17 FOOT PROBLEMS

17.1 Detection and surveillance

Detection and surveillance of foot problems are a routine part of Annual Review
Organize a recall system to ensure it occurs regularly for every individual

Examine yearly :

Assess yearly :

Categorize as :

1. foot ulcer : active foot ulceration, OR
2. high risk : neuropathy or vascular disease or previous ulcer, OR
3. at risk : defkrmity or self-care problem or simple skin problem, OR
4. low current risk

Monitor related factors ( blood glucose control, claudication, drug therapy, smoking )

17.2 Foot management - preventative

High risk foot

Involve a specialist in diabetes foot care

Provide :

    • regular foot assessment
    • local preventative attention to callus
    • relief of pressure using foam spacers, bespoke shoes, shoe inserts
    • regular foot care education - the commandments of foot care
    • vascular surgical referral if symptoms or critical arterial supply
At risk foot
Provide :
    • routine foot care according to need
    • advice on appropriate footwear
    • foot care education at routine visits
    • advice to carers

17.3 Foot management - advanced disease

Established foot ulceration / infection

Involve your local diabetes foot team without delay

Use local measures including :
  • debridement and trimming of callus
  • dressings to absorb exudate
  • foot casts to relieve pressure
  • surgical drainage

Use systemic and proximal measures including :

Reserve amputation for :

Foot ulceration is usually preventable
Amputation, even if foot ulceration occurs, is nearly always preventable
( Top of 'Foot problems' )
TYPE 1 DIABETES - 17 - FOOT PROBLEMS
TYPE 1 DIABETES - 18 - NERVE DAMAGE
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18 NERVE DAMAGE

For Foot problems see above

18.1 Detection and surveillance

Detection and surveillance of nerve damage are a routine part of Annual Review
Enquire yearly for :

Enquire for other manifestations of autonomic neuropathy if :

18.2 Management of painful neuropathy

Counsel for the depressing and disabling nature of the condition

Consider initially :

Consider therapeutic trials of :

18.3 Management of autonomic neuropathy

Erectile impotence

Gastroparesis

Diabetic nocturnal diarrhoea

Gustatory sweating

( Top of 'Nerve damage' )
TYPE 1 DIABETES - 18 - NERVE DAMAGE
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