CHAPTER I

INTRODUCTION
Diabetic nephropathy is a complication of long-term diabetes mellitus most
commonly found and cause high morbidity and mortality in diabetics. Even when it is known
that diabetic neuropathy may also occur in conditions of impaired glucose tolerance and
metabolic syndrome in the absence of hyperglycemia. Diabetic neuropathy is a group of
clinical symptoms that affect various nervous system either singly or jointly. Clinical signs
and symptoms can be non-specific, hidden and growing slowly and not be detected or may
manifest with clinical signs and symptoms that resemble other illnesses. Because the
diagnosis of diabetic neuropathy obtained by eliminating other causes of neuropathy.
There is still a lack of knowledge regarding diabetic neuropathy resulting in clinicians
not immediately diagnosed. As a result, patients with diabetic neuropathy comes in a state of
foot ulceration, gangrene and limb weakness. Diabetic neuropathy increases the risk of
amputation by 1.7 times, 12 times if there are deformities and 36-fold if there is a history of
previous ulceration. Diabetic neuropathy also disrupt the quality of life of people with
diabetes. Currently diabetic autonomic neuropathy is upheld then the life will take place
bleak and the mortality rate will reach 25% to 50% within 5 to 10 years. Integrated
Management in preventing the incidence of diabetic neuropathy is needed.
This literature review is expected to broaden the knowledge of diabetic neuropathy
that can make the diagnosis early and do the proper treatment of diabetic neuropathy

CHAPTER II
LITERATURE
2.1 Definition
Diabetic nephropathy (ND) is one of the most common chronic complication
of diabetes mellitus (DM). Peripheral neuropathy in the conference in February 1998
in San Antonio is mentioned that ND is a term descriptif which showed the presence
of interference, whether clinical or subclinical, which occurs in diabetes mellitus
without other causes of peripheral neuropathy. Neuropathy disorders include somatic
or autonomic manifestations of the peripheral nervous system.
2.2 Epidemiology
Epidemiology and natural trips diabetic neuropathy is still not widely known.
The prevalence of diabetic neuropathy increases with age and is more common in
patients with type 2 diabetes mellitus compared to diabetes mellitus type 1. The
highest prevalence of diabetic neuropathy in people with diabetes more than 25 years.
Numerous studies show that the prevalence of neuropathy is estimated that 30% of all
hospitalized patients. While on a sample population of close to 20%. The prevalence
of diabetic neuropathy in the elderly of about 50%, varying from 14% to 63%
depending on the type of population studied and the criteria used for the definition of
diabetic neuropathy
The overall prevalence of diabetic peripheral neuropathy in the National
Health and Nutrition Examination Survey (NHANES) amounted to 14.8% which is
more than three-quarters of them asymptomatic. Ziegler and his friends get diabetic
autonomic neuropathy prevalence of 16.8% in patients with type 1 DM and 22.1% in
patients with DM type 2 diabetes multicenter study in France found nearly 25% of
patients had symptoms of diabetic autonomic neuropathy.
2.3 Pathogenesis
1. Metabolic factors (Line Polyol)
ND starts the process of prolonged hyperglycemia. Persistent hyperglycemia
causes increased activity of the polyol pathway, which occurs activation of the
enzyme aldose-reductase that converts glucose to sorbitol, which is then converted
2

into fructose. Accumulation of sorbitol and fructose overload causing a state of

hypertonic intracellular causing nerve edema. In addition reaction of polyol pathway
also cause a decrease in NADPH nerve supply which is essential cofactor in
counteracting free radicals and the production of Nitric Oxide (NO).
2.Vascular Disfunction
Persistent hyperglycemia stimulates the production of oxidative free radical called
reactive oxygen species (ROS). This makes the free radical damage that affects the
vascular endothelium to a reduction in vascular vasodilatation to nerve decreased
blood flow.
3.Activity of growt Nerve Factor (NGF)
NGF is required to accelerate and sustain the growth of nerves. In people with
diabetes, NGF levels tend to decline.
2.4 Classification
1.Symetric Neuropathy.
a.Diabetic peripheral neuropathy
Diabetic neuropathy Peripheral neuropathy is the most common syndrome
found. Clinically obtained length pattern of sensory loss-related with starting from the
toes and spread to the soles of the feet and legs in the distribution of socks.

Picture 1. Distribution "gloves and socks" on peripheral diabetic nephropathy.

B. Autonomic Neuropathy
This type of neuropathy of the nerves that control the heart, blood pressure
and blood sugar levels. Besides the internal organs causing digestive disorders,
micturition, sexual response and eyesight.
1.Digestif System

Damage to the nerves in the digestive tract usually cause constipation.

Moreover, it can also cause loss of motility and emptying of the stomach that is too
slow, causing gastroparesis. Severe gastroparesis cause persistent nausea and
vomiting, belching and no appetite.
Gastroparesis also cause fluctuations in blood sugar due to abnormal food
digestion. Damage to the esophagus can also cause difficulty swallowing, whereas
due to bowel disorders may arise constipation alternating with diarrhea that is often
uncontrole especially at night and overall cause weight loss.
2.Cardiovascular System
Heart and circulatory system are part of the cardiovascular system to control
the circulation of blood. Damage to the autonomic nerves of the cardiovascular
system disturb the body's ability to regulate blood pressure and heart rate causing
postural hypotension after sitting or standing, and the patient will feel light head,
floating or syncope occurs. Damage to the autonomic nerves that regulate heart rate
can cause tachycardia heart rate in response to normal body functions and exercises
moment.
3. The sweat glands
Autonomic neuropathy may affect the nerves that regulate the sweat glands so
that the body can not regulate its temperature properly and usually appear excessive
sweating during meals and at night. If it is found then the symptoms will usually be
settled. Anhidrosis foot due to sympathetic denervation is a contributing factor for the
occurrence of diabetic foot dry skin and easily scratched.
4.Eyes
Autonomic neuropathy can also cause interference with the pupil so that it
becomes less responsive to light and having visions is less clear when the light is
turned on suddenly in the dark room or have difficulty driving at night.
5.Traktus urinary and sexual organs
Autonomic neuropathy often affects the organs that control micturition and
sexual function. Blocking nerve damage perfect emptying of the bladder and cause
retention of urine so bacteria can grow in the bladder and kidney infections often
result in urinary tract. Moreover, it can also occur because the patient's urinary
incontinence can not feel when the bladder is full and can not control the muscles for
micturition. Autonomic neuropathy may reduce sexual response in men and women.

Men will experience erectile problems or may reach sexual climax without ejaculating
while the women will have difficulty lubrication and orgasm.
2.Asimetric Neuropathy
Asymmetrical or focal neuropathy neuropathy is a well-known complication
in diabetes complications. Usually rapid onset and recover sooner. It is different with
chronic peripheral diabetic neuropathy, in which there is no improvement on
symptoms in several years after onset.
a. Amiotrofi diabetik (Proxymal Neuropathy Diabetic)
Syndrome of asymmetric limb weakness and atrophy of proximal progressive
first described by Garland as diabetic amyotrophy. This term is also known as the
"proximal motor neuropathy, diabetic neuropathy, lumbosacral radikulopleksus or
femoral neuropathy". Patients with severe pain on the inner thigh, sometimes
perceived as burning and extends to the knees. Patients with type 2 diabetes mellitus
over the age of 50 years are often exposed.
On examination found quadriceps muscle damage marked weakness of this
muscle group functions though the flexor muscles and pelvic abductor may also be
affected. Adductor thigh, gluteus and hamstring muscles are also related. Movement
of the knee is usually diminished or absent. Weakness can result in difficulty rising
from a chair or climbing stairs more low. Sensory disturbances are rare and if there is
usually concurrent with diabetic peripheral neuropathy.
b. Mononeuropati kranial
Cranial mononeuropathy The most common is the third cranial nerve palsy.
Patients present with sudden pain behind and above the eyes precedes ptosis and
diplopia. The healing process takes more than three months
c. Radikulopati trunkal
Radiculopathy

truncal

or

torakoabdominal

diabetic

neuropathy

is

characterized by the onset of acute pain in dermatomal distribution over the thorax or
abdomen followed cutaneous sensory disturbances or hiperestesi. Pain is usually
unilateral and herniation of the abdominal muscles can occur, although rarely
d. Pressure palsies

Carpal Tunnel Syndrom

Some diabetics are prone to nerve pressure on diabetes. Patients
usually complain of pain and paresthesias of the hands that sometimes spreads
to the entire arm, especially at night. In severe cases, the clinical examination
5

may show loss of sensation central area of the hand and thenar muscle
damage.
The clinical diagnosis was confirmed with ease using the median
nerve conduction studies and treatment involves surgical decompression of the
carpel tunnel in the wrist. Response to surgery is usually good, although often
recurrent pain symptoms than patients without diabetes.

Entrapment ulnaris nerve dan other isolir nerve

The ulnar nerve is also susceptible to pressure on the elbow, resulting
in damage to the dorsal interossei especially on the first dorsal interosseous. In
the lower limbs, peroneal (lateral popliteal) is the most commonly affected
nerve. Compression at the fibular head that causes foot drop. Unfortunately
the overall healing is rare. The lateral cutaneous nerve of the thigh are usually
also affected by diabetic neuropathy entrapment

2.5 Diagnosis
a. Anamnesis
History can be searched through complaints or symptoms associated
with diabetic neuropathy such as:
Sensory disturbances, negative symptoms appear such as numbness, tingling,
such as wearing gloves, often attacking the distal limbs, especially the lower
limbs. The pain can occur together or without the above symptoms.
Assessment of pain is an important aspect in determining the diagnosis of
diabetic neuropathic pain. In the early stages the necessary history of pain,
location of pain, quality of pain, pain distribution, how influence on palpation
or touch, factors that relieve or aggravate. Patients can give the complaint
more than one type of pain, history of pain can help the patient to gather
information about what types of neuropathic pain or nociceptive pain is a
response to the occurrence of the activity of pain receptors to the stimulus
noksisous.
Motor disturbances may be impaired coordination, parese proximal or distal,
manifested in the form of hard climbing stairs, difficulty rising from a chair or
the floor, frequent falls, hard work or raise the arm above the shoulder, smooth
movement of the hands of disturbed, easy to stumble, legs easily collide.
6

 Symptoms of an autonomous form of interference sweating, feeling of

floating in a standing position, syncope during bowel movements, coughing or
sneezing, impotence, difficult ejaculation, retrograde ejaculation, difficult to
hold bowel or small, diarrhea at night, constipation, impaired adaptation in the
dark and bright.
b.Physical Examination
Physical examination in patients with diabetic nephropathy done on all
body systems, related to complications that may occur in DM. including blood
pressure and heart rate. Patients with symptoms or signs of disturbances in the
extremities necessary to check noise and peripheral pulses because there is the
possibility of occlusive vascular disorders. If there are complaints of visual field
examination ophthalmology. Skin checks carried out especially in the legs, if there
is slow to heal wounds or ulcers.
A neurological examination includes examination of cranial nerves,
muscle tone, strength, presence of fasciculation, atrophy, examination of the
patellar tendon reflex and Achilles. Observations regarding how to walk, run in
place, walk with the toes and heel. Sensory testing is done with the examination of
vibration, temperature, touch and propioception examination.
C. Investigations

Laboratory
All patients with diabetic neuropathy should do blood sugar tests, urinalysis,

HbA1c, total cholesterol, HDL and LDL cholesterol, triglycerides, uric acid, and
other examinations when indicated as electrolyte, counts of blood cells, serum
protein electrophoresis, vitamin B12, folate, keratin kinase, erythrocyte
sedimentation rate, antinuclear antibody, thyroid function and electrocardiography.
2.6 Different Diagnosa
a.Mielopathy
b.Claudicatio Intermitten
c. Guillen-Barre Syndrom
d.Post Herpetic Neuralgia

2.7 Management
7

Management patients with complaints of Diabetic Neuropathy is

divided into 3 parts, namely ND diagnosis as early as possible, controlling
blood sugar levels, and foot care as well as possible.
a.General care for Legs
Keep your skin, avoid trauma to the foot like a shoe narrow. Prevent
repetitive trauma to the compression neuropathy.
b.Controlling blood sugar
Can be made various efforts to control blood sugar levels like
Carbohydrate Diet, regular exercise, and the use of drugs to control blood
glucose.
c.Drugs
This is intended to reduce and prevent further complications. Can be
used several drugs, namely:

Group aldose-reductase inhibitors are able to inhibit the accumulation of

sorbitol and fructose, Sorbinil 400mg / day.
Giving Neurotropin.

ND pain management guidelines recommended are:

NSAIDs, ibuprofen 600mg 4x1.
Tricyclic antidepressants, amitriptyline 50-150mg night.
d.Advice therapy
2.8 Prognosis
If it can be diagnosed as early as possible and get treatment appropriate
blood sugar control reduces the risk for amputation.Conversly, when handling
chronically late and is already underway, the prognosis gets worse

CHAPTER III
CONCLUTION
8

Diabetic neuropathy is one of the chronic complications of diabetes with the

prevalence and clinical manifestations vary widely. Of the three factors (Metabolic,
Vascular, and NGF), which acts on the pathogenic mechanisms ND, prolonged
hyperglycemia as a component of metabolic factors is the main basis pathogenesis of
ND. Therefore, in the prevention and management of ND in patients with DM, the
important thing is the diagnosis followed by blood glucose control and foot care as
much

as

you.

Efforts

to

deal

with

complaints

of

pain

generally

simtomatis.Nonfarmacology treatment including education is important in view of a

complete recovery are very difficult to achieve.