DIABETIC NEPHROPATHY

END STAGE KIDNEY DAMAGE-DM-ESKD

Our body's metabolic and other wastes are excreted out by various means. But a major chunk especially the protein metabolic wastes such as Blood Urea Nitrogens and Creatinin which should be cleaned out 100% from our blood are excreted by kidneys. If kidneys are not functioning properly these deadly poisonous wastes will remain in our blood to produce a fatality.

Kidney damages are of two types such as Acute or reversible and Chronic or irreversible. Chronic Kidney Damages (CKD) and End-Stage Kidney Damages (ESKD) are the major causes of Diabetic mortality.

Chronic and improperly managed hyperglycemia is one of the major causes of nephropathy. Diabetic nephropathy is a leading cause of ESKD.

A nephron is one of the million basic units by which our two kidneys are composed and made of.

In brief, a nephron is composed of a capsule-like structure known as the Bowman's Capsule which forms the head as in the figure above. Inside the capsule, there is a meshwork of tiny blood vessels known as the Glamerulus through which the blood is filtered off.

The Bowman's Capsule descends downwards to a tubule known as the proximal convoluted tubule (PCT) through which the filtrate passes and subjected to various proportions of reabsorptions and secretions.

The proximal tubule further descends down to a small loop like a narrow U tube known as Loop of Henley which has no activities on the filtrate. The loop again ascends to form the distal convoluted tubule (DCT) in which again there are certain proportions of reabsorptions and secretions on the filtrate.

Finally, the filtrate after subjected to various reabsorptions and secretions to form the final shape to form the urine and will be guided to pass through the collecting duct followed by the ureter which leads to the urinary bladder.

These units are by God's Grace present in each kidney many and many and approximately one million nephrons are present in each kidney. More than a certain proportion of these units if they get damaged irreversibly by some diseases such as DM and Hypertension the result is the ESKD.

Diabetic nephropathy is a slowly progressing disease with no symptoms in the beginning but if unattended properly with longstanding mismanagement of DM the disease progresses to the final stage of ESKD. Fortunately, the progression is slow and may take hardly 10 to 15 years.

The nephropathy is caused by the damages in the glomerular filter barrier (GFB) a fine meshwork of small tiny blood vessels to carry blood. Diabetes mainly damages these tiny blood vessels by improper glucose metabolism and by forming toxic active oxidative products. It is classified as small blood vessel complications of diabetes.

Signs and Symptoms

During its early course, the nephropathy is mostly asymptomatic. As the disease progress slowly and the symptoms appear after 10 to 15 years when the progression attains ESKD.These ESKD symptoms are as follows:-

1.Tiredness

2.Headaches

3.General feelings of illness

4.Nausea and Vomiting

5.Frequent urine

6.Lack of hungry

7.Itchy skin

8.Leg swelling.

If anyone of the above symptoms are present please check for albuminuria, BUN, and creatinine.

Major Causes

1.Long-standing Diabetes Mellitus (especially type-1.)

2.Long-standing Hypertension

3.Heavy smoking

4.Family history of kidney problems

Mechanism

Diabetes causes an imbalance of glucose metabolism and damage blood vessels by producing toxic oxidative chemicals.

As we already knew the head of the nephrons is composed of a fine blood filtering meshwork made out of tiny blood vessels known as Glomerular Filter Barrier (GFB) which will allow only water and small molecules through the meshwork to be filtered off by leaving large protein molecules like albumin, and microalbumin, and lipids to stay in the blood itself.

As nephropathy progresses this glomeruli meshwork also progressively undergo damages and the filter processes become improper by tearing off the meshwork so that albumin and other large molecules also will be filtered off.

Diagnosis

1. Albumin and microalbumin tests in the urine may show their presence  (Normal value for albumin is <30mg/24 hrs;

The normal range for microalbumin is 30 -299 mg/24 hrs)

If clinically the total albumin presence exceeds 300mg/24 hrs then it is concluded that there is nephropathy.

People with DM are recommended to undergo the albumin test in the urine annually with an immediate beginning of test if diagnosed positively for type-2 diabetes because the onset of the disease is not well established in the beginning, and begin after five years in case of type-1 diabetes.

To test the kidney function the established glomerular filter rate (eGFR) should be measured by the 24-hour collection of urine.

The normal range is 90 - 120ml/min/1.73square meter 

Treatments

The aim of the treatment is to slow down the disease progression and to reduce the related complications

The drugs of choice are the hypertensive group of medicines the Angiotensin Converter Enzyme Inhibitors such as enalapril, captopril, and benazepril.

Angiotensin-II is a polypeptide that playing an important role in regulating total peripheral resistance(TPR) and altering kidney functions. 

Renin an enzyme secreted by the kidneys acts on a kind of plasma protein the angiotensinogen when blood enters into the glomeruli to form angiotensin-I. Another enzyme is known as angiotensin-converting enzyme acts on it and converting it into angiotensin-II. This is the active form of regulating kidney functions. It causes in distal tubule to increase the reabsorption of sodium with the exchange of potassium through a hormone known as vasopressin so that more concentrated urine formed.

ACE inhibitors prevent the formation of this substrate and alter the process by eliminating more sodium out and ease the blood pressure and protect the kidney to function normally.

To see the video of top delicious fruits can be taken safely by diabetics, please click 

To download the thorough illustrative article regarding diabetes please click 

   

 

DIABETIC NEUROPATHY

DIABETIC NERVE DAMAGES

We have already seen in our first post that what is diabetes mellitus (DM) and how it is developing and all other basics of its pathology and therapeutics.

Here we will see one of the DM's major complications the Diabetic Neuropathy which affects almost all parts of our body that are innervated.

Our entire body system needs energy for its daily activities. Our body gets its energy 100% from the burning of glucose a carbohydrate within each cell of all tissues including neuronal tissues of our body.

Glucose metabolism is basically regulated and maintained by a hormone known as insulin from the pancreatic beta islets of our body.

Lack of insulin impairs glucose metabolism and the cells would become depleted of energy, tired, and die. The tissues would be damaged and become ischemic.

These complications mostly happened in nerve tissues during DM and the result is Diabetic Neuropathy, the nerve damages of diabetes.

Normally the peripheral nerves are blood supplied by very small arteries known as vasa-nervorum. Diabetes damages and narrowing these arteries and thereby block the blood supply to the nerves.

Types of Conditions Associated With DN

1.Third nerve palsy

The third cranial nerve and its branches are supplied to our oculomotor system (Eye system)

Any damage to these third cranial nerves will affect the eye movements. The affected individual will feel difficult to move his eyes.

2.Mononeuropathy

In this condition, anyone nerve supply to the peripheral organ or part of our body is affected and that will result in loss of movement, sensation, and other functions of that nerve. The nerve is mostly supplied to outside the brain and spinal cord and hence it is known as peripheral neuropathy.

Mononeuropathy may affect any part of the peripheral organs or parts of the body leads to loss of sensations, weakness, paralysis, tingling, burning pain, and abnormal sensations.

3.Mononeuropathy multiplex 

In this condition as in mononeuropathy there instead of one nerve, there are two or three nerves are damaged.

4.Diabetic Amyotrophy

 Also known as lumbosacral-radiculoplexes-neuropathy, or femoral neuropathy. It is a polyneuropathy involved by many nerves supplied to the peripheral parts. This is the most common type among the other diabetic neuropathies which affects thighs, hips, buttocks, and legs. The symptoms are painful muscles, muscle wasting, and muscle weakness. It commonly occurs in type-2 DM patients.

The common symptoms start all of the sudden onsets with mild pain in the buttocks, hip, and thighs first on one side of the body followed by increased severity and then affect both sides. These symptoms develop and finally affect the lower limbs so that the patient cannot sit to stand or stand to sit without assistance.

5.Autonomic Neuropathy

In this, the nerve damages are extended to the Autonomic Nervous System (ANS) which controls our body's vital organs such as heart, lungs, liver, kidneys, and various other involuntary organs.

The symptoms are similar to autonomic deficiencies such as orthostatic hypotension or postural hypotension in which you feel the lower tension during when you change the position from sitting to standing.

Other symptoms are Dry mouth, Tachycardia, Tunnel vision, Difficulty swallowing, Bowel incontinence, Blurred vision, Urinary incontinence, Constipation, Anhydrosis, Sexual problems. In simple, there is adrenergic hyperactivity.

General Symptoms of DN

1.The trouble with balance while standing or walking

2.Numbness and tingling of extremities

3.Desensthesia, abnormal sensation to a body part.

4.Diarrhea

5.Erectile problems

6.Urinary incontinence

7.Facial and eye movement difficulties

8.Vision changes

9.Dizziness

10.Muscle weakness

11.Difficulty in swallowing

12.Speech difficulties

13.Retrograde ejaculation(ejaculation into the bladder instead of the urethra)

14. Face muscle twitching.

Treatments

Treatments are primarily the treatment for the DM-Type-2 followed by other symptoms control by 

1.Tricyclic antidepressants to releive pain,e.g.Amitryptylin;imipramin 

2.Selective Serotonin-Norepinephrin Reuptake Inhibitors(SSNRI) for pain releiving,e.g.venlafaxine,duloxetine

3.Selective Serotonin Reuptake Inhibitors SSRI),e.g.fluoxetin,paroxetin

4.Anti epileptic drugs,e.g.Pregabalin,and Gabapentin 

COITAL TIME TABLE FOR CONCEPTION

TIMETABLE FOR COITUS TO CONCEIVE

This post is meant to help the couple who want to have a child. The following time table may help them provided that if their variable health conditions are otherwise normal.

Any couple at least a minimum of five years after the marriage if they do not conceive then they can come to a decision to seek medical help.

Basically, all pregnancies from fertilization to deliveries are all according to the ultimate decision and will of the Almighty. We must basically accept this. Life and Death are in his hand and up to his wish. But our responsibility is to try and leave it in the hand of God. Accept both the ends of success and failure are all for our good and benefits. 

A pregnancy starts with the fertilization of a mature ovum by the sperm. There are many variables that can affect pregnancy. Age, health,  lifestyles, climate, mental cooperation, and various other factors are all affecting the probability of conceiving in each cycle. Our control of these factors is person to person vary.

The factor most importantly that you have to control is the time programmed frequencies of coitus or intercourse.

As we have already known that the menstrual cycle is made of three phases such as the follicular phase, the ovulation phase and the luteal phase. Among this, the ovulation phase is the important one to be noted exactly as it lasts for only one day and the life cycle of an ovum is only 24 hours. But God helps us in another way by giving a lifetime to a male sperm about 72 to 120 hours that means approximately a sperm can live about 3 to 5 days in the healthy cervical fluids while an ovum lives for only 24 hours.

A fertile window is the days during which if intercourse performed may have a high probability to result in conception. The 5+1 (more exactly the 3+1) is the total lifetime of the sperm and the ovum and that is the fertile window's duration. Hence your time table of intercourse should be within these 6 days of the fertile window

More illustratively an intercourse performed roughly before 5 days and more exactly before 3 days of the ovulatory phase may have a high possibility of pregnancy.

On the contrary, if intercourse performed one day before or exactly on the day of ovulation may have a higher possibility to get pregnant.

The fertile window duration is very important. But this may vary depending upon any one of the life partner's health conditions. 

In short, the pregnancy is technically possible if intercourses are performed during the 6 (and most probably 3)days duration of the fertile window.

The chances of pregnancy are increased by multiple intercourses during these days provided your health and sperm counts are normal or higher as the frequencies of intercourses on the same day may reduce the number of sperms in the ejaculate.

To find out the exact time of ovulation and to calculate the fertile window duration is a myth as it is varying according to the individual's variables such as age, weight, BMI, food and so on

One possible indicator is the temperature rise at the time of ovulation. But it is a challenge as at the time when it was felt and expressed by our body to note by us, the time of the fertile window may already be passed.

To find out the fertile window in advance prospectively is finding the early signs of ovulation by examining the cervical fluid. The cycle statistics such as a noted time of ovulation in the previous cycle can also help.

But in a retrospective way, the method is simple. Once a clear and sustained temperature change is identified and ovulation is detected in your chart, you can see that your fertile window occurred during the six days prior to the thermal shift and your most frequent fertile days are three days prior to the shift.

But once you see the shift as we already saw, it is almost the fertile window has passed. Hence by keeping the above calculation as the base to have a trial and error method in several cycles will give an exact sense of knowledge to find out the fertile window.

Conclusively the intercourse must be accordingly programmed and timetabled.

Most of the ovulations are happening at the midcycle that means from 12th to 14th day. If the intercourses are programmed from the 10th day for every alternative day up to 16th day or from the day at which more LH are detectable in the cervical fluid and in urine may be a convenient time table for coital fertility. See the following videos

But everything is according to God's wish.

The following video may explain our body's readiness for fertilization

The healthy foods for good to get a conception

Please any comment on this subject you are warmly welcome in order to improve my knowledge and this site. Thanking you.

FUTURE OPTIONS OF BIRTHCONTROL

CONTRACEPTION-FUTURE OPTIONS

There are several options of contraceptives studied in order to minimize the size of the dosages, frequency of the dosages, and the side effects. The major purpose of the future options also includes increasing the maximal benefits with a minimal dose or dosage frequencies, and the side effects.

Accordingly, the researches invent a synthetic hormone replicating the brain hormone Luteinizing Hormone-Releasing Hormone which 144 times more powerful than the natural parent compound. Even though in micro dosages this drug is found as a curative for infertility yet this hormone is under research in the suitably modified dose for birth control.

The hormone is acting on the luteal phase of the menstrual cycle and shortening it, and the follicular phase is elongated and the ovulation delayed. Before ovulation happened these hormones act on the uterus to develop the endometrium and other preparation to receive the ovum which actually not present at the tube. When ovulation happened the luteal phase comes to an endpoint so that the endometrium degenerate, and the uterus becomes hostile to the coming ovum, the implantation disturbed, and the menses starts.

The powerful hormone needs a micro dosage and effects will last for longer periods. Yet the disadvantage is its side effects.

Another option researched by Alabama University Researchers Norethindrone, a progestin enclosed in microcapsules for injection which can timely release the medicines from the tiny capsules. Still, it is under consideration.

The abortive drug mifepristone is also on the line of consideration as in modified dosage it is found that it can delay ovulation.

MALE CONTRACEPTION VASECTOMY

VASECTOMY

Vasectomy is an invasive method of male contraception.In his method by using a surgical operation a small incision is made at the two vasa deferentia which carries the sperm from the two epididymis of the testicles to he ejaculatory duct in anticipation to the act of ejaculation.Afer the incision the ends of the vas ducts are tied firmly to closure so that they cannot transport sperm to ejaculatory tubes.

The above picture shows the two vas ducts indicated by the two arrows from either epididymis of the testes.

In vasectomy operations the surgeon cut the tubes by incision and tie off or clamped or sealed off the tubes so that they cannot carry sperm from the testes.The operation is simple and sure.

It causes no change in hormone production and sex desires unless if he feels and depressed psychologically that he is castrated.

After vasectomy the man can carry on his usual sexual activities with his partner satisfactorily with proper erection clmax and ejaculation.But his ejaculation contains only semen the secretions of seminal vesicles and prostate without a single sperm.But this may take several months after the vasectomy because there are already produced and transported sperms are stored in the seminal vesicles which can be ejaculated with the semen and they can still make the female partner to become pregnant.Hence even after the vasectomy one should use condoms or other means of birth control until a test of ejaculate does not contains a single sperm.

The Procedure :-

 

1.Before the procedure started the area is shaved and cleaned

2.A sedative will be given orally so that the patient can sleep inorder to relieve from the trauma

3.A local anesthetic will be injected into the scrotum 

4.Each vas deferens can be located by touch.

5.Doctor will make two small incision at the areas on the scrotum.

6.Through the openings the two vasa deferentia are pulled out sufficiently and cut by scissors and sealed or stretched together of by heat applied by electrocution.The scars formed by the heat helps firm sealing.

7.After this the two ducts will be inserted back into the scrotum and the mouth of the incision would be stretched off.

The whole procedure would take hardly 20 to 45 minutes.

Even after the vasectomy the testes can able to produce sperm but all will be absorbed by the body.

Until recently it is beleived that vasectomy is an irreversible method of contraception and a man who underwent vasectomy is sterile for life.

But modern technologies are improved so that vasectomy can be reversed by surgical methods as the above video illustrates

The following videos also shows the vasectomy reversals

 

 

 

CONTRACEPTION-BARRIER METHODS

BARRIER CONTRACEPTIVE METHODS

In this post we will deal with various barrier contracepive methods such as condoms for males,cervical caps,and diaphragm for females.

Male Condoms are meant for male contraception and is more safe and convenience.Unlike invasive surgical operations like vasectomy or contraceptive drugs they are not disturbing our body health or our systemic blood circulations.They are user friendly.They cause reversible contraception.

Most importantly they give more protection from infections such as venereal diseases like syphilis,gonorrhea,and AIDS while other methods are not.

Condoms are usually made out of special latex rubber silicon which are very thin and user friendly.Latex condoms are having a natural antiviral actions against AIDS viruses and hence they give 100% protection against AIDS when compared with condoms made out of other materials.This guarantee can be given to those who use the condoms regularly but not intermittently.

Laex condoms also can give protection against herpes virus;genital ulcers,STDs such as gonorrhea,syphilis;hepatitis-B and Chlamydia.

If the male is regularly using latex condoms it is greatly reducing the chances of PIDs(Pelvic Inflammatory Disease) and Pelvic Infections (PI) by their female partners.

If used in a correct manner the condoms are giving a good record of birth control and that means if used properly condoms give pregnancy about 3 to 36% only.

Latex allergy and some other medical conditions are the restrictions for the use of latex condoms.To these patients condoms made out of natural membrane like polyurethane the one branded as Avanthi are available to protect from pregnancy but not from infections. 

Female Condoms are available such as Reality condoms. diaphragm and cervical caps for those partners among whom the male partner does not want to use male condoms.

Female condoms are made of a polyurethane sheath with flexible rings at each end.It can be inserted into either the vagina like a diaphragm or into the anus to line or cover the uterus or rectum respectively.The anal insertion is mostly ment for the homosexual male partners.When inserted it provides a barrier against semen and microbes such as HIV.If used perfectly it give approximately a 95% protection from pregnancy.But an improper use may result in a 26% increased chance of pregnancy.Another drawback is it is not so  economical.In U.S a piece of the condom costs about US$ 5 to US$ 6 or may be more.It is available in US in the brand name of Reality.

The Diaphragm

Diaphragms are the common method of female contraception.As in the above picture it is looking like a small cap or dome with an outer ring like spring at the rim.It is made out of silicon latex or natural rubber.Silicon diaphragms are more convenient and last for 10 years for re use where as rubber diaphragms are lasting for 4 to 5 years.The spring forms a seal against the wall of the vagina.During the usage after the insertion the diaphragm should be left atleast 8 hours in the vagina after the last ejaculation of the male partner during the intercourse.

The above video is embedded here purely for illustrative purposes how to use a diaphragm and cervical cap.
Cervical Cap this is also a female condom similar to diaphragm and are unlike Reality these are economical.If used properly they prevent pregnancy 82% to 94%.

The following video illustrates how to insert cervical cap

As look in the above picture these are cap like female condoms to be inserted into the vagina to cover the cervix and block sperm to enter into the uterus. 

WOMEN GYNACOLOGY-PART-X-INTRA UTERINE DEVICES

OTHER METHODS OF BIRTH CONTROL

INTRA UTERINE DEVICE or IUD is a fashioned historical method to prevent pregnancy by inserting a device into the vigina and make to to stay there to produce longer effects of contraception.

Historically it was rumored that some Arab pagans inorder to prevent the births of several calfs as a burden to their female camels they inserted small stones into their uteruses through their vagina to prevent conception.

This historical basics has been used to develop devices with higher technology.

There are two types of IUDs,the hormonal and non hormonal.The hormonal IUDs contains usually a progestin such as a slow release levonorgestrel.The other nonhormal IUDs contains a copper spring.Both the IUDs are yielding a reversible contraception.The effects of copper IUDs are longer than the hormonal IUDs.The hormonal IUDs like Mirena is found to be effective upto 5 years while as the copper IUDs can give the effects upto 7 years.

The insertion should be done by an experienced physician.

 As seen in the above figure the IUD should be correctly positioned by the help of a speculum a medical device used for inserting a device through any small opening or orifice like vagina.

Before insertion the pelvic portion should be thoroughly examined for any inflammation,injury or infection like chlamydia and gonorrhea.The position and shape of the uterus should be confirmed through the pelvic exam.

During the insertion the vagina is held open by a speculum.The cervix should be grasped by a grasping instrument.The leangth of the uterus must be measured for proper insertion.Now the IUD must be carefully inserted through the cervix by using a narrow tube into the uterus.A short narrow monofilament plastic/nylon string attached to the device should be come and hang out through the vagina for the convenience of the patient to check the IUD position later on at times.

 The above video gives an explanation of the inserting methods.

Mechanisms of Actions

1.Make uterus hostile to the fertilized ovum

2.The endometrium becomes thin and not hospitable to the ovum

3.The cervix become thick and sperm cannot penetrate it.

4.Unimportantly sometimes ovulation is retarded

Advantages:-

1.Longer effects

2.No need to take any systamic medications like pills and injections

3.Most of the released hormone from the hormonal IUDs are absorbed and stay within the uterus by leaving a negligible minute quantity into the system.

4.Reversible contraception

5.Inexpensive as they are made out of plastics.

6.The copper IUDs are totally harmless during breast feeding.But there are no known guarentee for hormonal IUDs.

7.No prior care or preparations needed before sex,but the patient has to check the string at times to ensure the device is staying in proper place.

Disadvantages:-

1.Risks of ectopic pregnancy,the pregnancy happened outside the uterus usually at the tube.

2.Irregular heavier periods and spotting

3.Menstrual cramping and back pain. 

4.Painful intercourse experienced by some women.

5.Rare but serious perforation of uterus.

6.Pelvic pain and inflammation leads to serious infections.

Conraindications:-

1.Patients who take blood hinners like aspirin,warfarin and clopidrogel

2.Those who use copper IUD must avoid exposure to microwaves or any short waves such as ultra violet radiations.

3. Teen agers and women who gave several births are commonly experiencing displacement or expulsion of the device and hence should be careful in their movements.

4.Pelvic infections