DM - Complications

Question 1

For every 1% decrease in HbA, there is a ___% decrease in mortality and ____% decrease in microvascular complications

Answer 1

21%, 37%

Question 2

1 cause of chronic kidney disease (CKD),

ESRD, & CKD requiring renal replacement
therapy (aka Dialysis)

Answer 2

Diabetic Nephropathy

Question 3

Most common cause of Nephrotic Syndrome

Answer 3

40% of DM II
30% of DM I

Question 4

Nephrotic Syndrome

Answer 4

• Loss of protein from plasma into urine
  2° ↑ glomerular permeability
• Leads to generalized edema,
  hypoalbuminemia, hyperlipidemia, &
  frank proteinuria (detectable with urine
  dipstick)

Question 5

Etiology/Pathogenesis of Diabetic nephropathy

Answer 5

Glomerular Damage
↓
leaking protein into urine
↓
Hypoalbuminemia

Question 6

Hypoalbuminemia process

Answer 6

↓osmotic pressure
↑ edema
↓ vascular volume
↓ blood pressure
↑ kidney renin production
↑ aldosterone
↑ sodium & water retention
↑ intravascular fluid
↑ edema

Question 7

40% of patients with diabetes develop diabetic ____

Answer 7

nephropathy

Question 8

T/F Smoking accelerates the decline in renal function

Answer 8

T

Question 9

Annual assessments for Diabetic nephropathy

Answer 9

• Serum Creatinine (Cr) to determine eGFR
• Urine Albumin & Cr to determine
  Albumin/Cr ratio
• Begin annual screening 5 years after diagnosis of DM I or At diagnosis of DM II or DM I

Question 10

When Management of Diabetic Nephropathy requires Nephrologist referral

Answer 10

✅ Atypical presentation
✅ Rapid decline in eGFR OR albuminuria progression
✅ Stage 4 CKD

Question 11

Management of Diabetic Nephropathy

Answer 11

1. Smoking cessation
2. RAAS blockade for albuminuria
3. Nephrologist referral

Question 12

1 cause of preventable blindness in adults

Answer 12

Diabetic Retinopathy

Question 13

Epidemiology of Diabetic Retinopathy

Answer 13

• 86% of DM I
• 40% of DM II

Question 14

Risk Factors of Diabetic Retinopathy

Answer 14

• African-American, Hispanic, South Asian
• ↓ age at Dx of DM
• HTN
• Dyslipidemia
• Pregnancy
• Puberty
• Cataract surgery

Question 15

Clinical Presentation of Diabetic Retinopathy

Answer 15

• *Often Asymptomatic!
• Blurred or double vision
• ↓ field of vision
• Seeing dark spots
• Pressure or pain in eyes
• ↓ vision in dim light
• Sudden blindness (rare)

Question 16

Clinical features on funduscopic exam vary by disease severity

Answer 16

• Neovascularization
• Ischemia
• Microaneurysms: Earliest clinical sign

Question 17

Diabetic Neuropathy in multiple systems

Answer 17

• Cardiovascular → resting tachycardia & orthostatic hypotension
• Genitourinary → Gastroparesis & bladder-emptying abnormalities
• Skin → Hyperhidrosis of the upper extremities & anhidrosis of the lower
  extremities result from sympathetic nervous system dysfunction
  Anhidrosis of the feet → dry skin → cracking → ↑ risk of foot ulcers
• Endocrine → Autonomic neuropathy may ↓ counter-regulatory
  hormone release (esp. catecholamines) → ↓ sensation of hypoglycemia

Question 18

Assessment of Diabetic Neuropathy

Answer 18

Begin assessment
5 years after diagnosis of DM I
At diagnosis of DM II

Complete neurologic examination
annually
Assess for Heart Rate Variability
Deep inspiration
Valsalva maneuver
Change in position from supine
to standing

Question 19

FDA approved for Diabetic Neuropathy

Answer 19

duloxetine (Cymbalta®)
amitriptyline (Elavil®)
pregabalin (Lyrica®)
Capsaicin 8% patch

Question 20

Management of Large-fiber neuropathies

Answer 20

↓ joint position, vibration sensation & sensory ataxia

Question 21

Management of Small-fiber neuropathies

Answer 21

↓ pain, temperature & autonomic function

Question 22

Treatment of Diabetic Neuropathy

Answer 22

Improved glycemic control
Hydrate
Chew your food
Small meals low in fat/fiber
Prevent bezoar
Liquid nutritional supplements
E.g. Glucerna®
Otherwise tx are inadequate

Question 23

____ Study showed ↑ in PAD, CAD, MI, & CHF

Answer 23

Framingham Heart

Question 24

American Heart Association has designated DM as a
“_______” & DM II patients without a prior MI
have a similar risk for coronary artery–related events as nondiabetic individuals who have had a prior MI.

Answer 24

CHD risk equivalent

Question 25

DM is the ___ cause of nontraumatic lower
extremity amputation in the US

Answer 25

1

Question 26

___% of all lower limb amputations in patients with DM are preceded by a foot ulcer

Answer 26

85

Question 27

Management of lower extremity complications in DM patients

Answer 27

Educate high-risk patients on ulcer prevention, every visit
Screen for asymptomatic PAD

Question 28

↓ risk factors for vascular disease in Lower extremity complications of DM patients

Answer 28

Smoking cessation
Dyslipidemia
Hypertension
Tight glycemic control

Question 29

When to refer lower extremity complications to Podiatry

Answer 29

Protracted wound healing & skin
ulceration
Callus deformities
Nail deformities
Annual Exam
Orthotic shoes, inserts, & devices
Education about off the shelf
footwear

Question 30

Most common skin manifestations of DM are

Answer 30

Xerosis and Pruritus

Question 31

DERMATOLOGIC MANIFESTATIONS in DM

Answer 31

Bullosa Diabeticorum: DM related bullae
Vitiligo: ↑ frequency in T1 DM
Acanthosis Nigricans: Hyperpigmented velvety plaques, signals severe insulin resistance
Lipoatrophy & lipohypertrophy: insulin injection sites