By Seth H. Fritcher, MD
Hyperglycemia, its metabolic sequela and the ultimate development of diabetes mellitus constitute markers on a spectrum of disease resulting from abnormal glucose disposal.
The epidemiology of this disorder is overwhelming. As of 2005, 20.8 million people—seven percent of the population of the United States—have diabetes, of which only 14.6 million people were diagnosed. Diabetes was the sixth leading cause of death listed on U.S. death certificates in 2002. This ranking is based on the 73,249 death certificates in which diabetes was listed as the underlying cause of death. According
to death certificate reports, diabetes contributed to a total of 224,092 deaths.
Diabetes is likely to be underreported as a cause of death. Studies have found that only about 35 to 40 percent of decedents with diabetes have diabetes listed anywhere on the death certificate, and only about 10 to15 percent had it listed as the underlying cause of death.
Overall, the risk for death among people with diabetes is about twice that of people without diabetes of similar age. Diabetes confers a twofold to fourfold rise in the rate of heart disease-related deaths among adults and accounted for more than 60 percent of nontraumatic lower extremity amputations.
In 2002, about 82,000 nontraumatic lower-limb amputations were performed in people with diabetes. Finally, diabetes is the leading cause of treated end-stage renal disease, accounting for more than 44 percent of new cases on a yearly basis. The estimated direct and indirect monetary cost of diabetes in the U.S. as of 2002 was in excess of $132 billion.
As previously mentioned, diabetes is one of the leading causes of end-stage renal disease and is the responsible etiology for more than half of the renal failure for patients in our own access practice. The management of hemodialysis access is inseparable from the management of diabetes mellitus. The access options and the maturation rate for brachial artery-based autogenous accesses are comparable for diabetics. However, they frequently have arterial occlusive disease distal to the brachial artery which likely accounts for the lower success rate for radial artery-based accesses among diabetics. Even in the absence of identifiable hemodynamically significant stenosis, the radial artery may not be able to dilate sufficiently to accommodate the additional blood flow necessary for effective dialysis. Admittedly, we would proceed with a radial artery-based access in a diabetic if the choice was supported by the pre-operative imaging, but we would accept a lower success rate than that associated with the non-diabetics.
Although the global effects that diabetes can inflict upon its patient population cannot be overlooked, the vascular surgeon is all too keenly aware of the manifestations. Therefore, the vascular surgeon needs to be aware of these conditions and medical treatment options to supplement surgical treatment.
Diet and exercise are important first-line efforts, but medications are often required. Prevention of hypoglycemia, insulin overactivity, or both may significantly diminish the incidence of peripheral vascular disease.
Dr. Fritcher is a vascular surgeon affiliated with Peripheral Vascular Associates. He maintains an office at Medical Center Tower I with colleague Mellick T. Sykes, MD.
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