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Yr 2 LCRS - Endo > 17 - Microvascular Complications > Flashcards

17 - Microvascular Complications Flashcards

(47 cards)

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1
Q

What does diabetes damage to cause the majority of its associated complications?

A

Poor control of diabetes causes a higher risk of micro and macrovascular complications by damaging blood vessels

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2
Q

Where are the overall main sites of microvascular damage in diabetes?

A

Eyes - retinopathy

Kidneys - nephropathy

Nerves - neuropathy

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3
Q

What arteries are damaged as microvascular complications in diabetes?

A

Eyes

  • retinal arteries

Kidneys

  • glomerular arterioles

Nerves

  • vasa nervorum (tiny blood vessels that supply nerves)
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4
Q

What is the link between HbA1c and microvascular complications?

A

The higher the HbA1c (higher glucose), the greater the risk of developing microvascular complications

In both T1DM and T2DM

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5
Q

What factors can increase a person’s risk of developing microvascular complications?

A

Severity of hyperglycaemia

Hypertension

Genetics

Hyperglycaemic memory

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6
Q

What is the link between hypertension and microvascular complications?

A

The higher a patient’s blood pressure, the more likely they are to develop microvascular complications

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7
Q

Is tissue damage in microvascular complications reversible?

A

Although initially reversible, it later becomes irreversible due to alterations in proteins

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8
Q

What is hyperglycaemic memory?

A

This metabolic memory effect contributes substantially to the pathology of various diabetic complications, such as diabetic retinopathy, hypertension, and diabetic nephropathy. Due to the metabolic memory in cells, diabetic patients suffer from various complications, even after hyperglycemia is controlled.

Even if a person’s sugar is well controlled now, previous damage can still cause issues

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9
Q

What are the mechanisms of glucose damage?

A

Look at pathway on picture attached

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10
Q

What is diabetic retinopathy?

A

Main cause of visual loss in people with diabetes and the main cause of blindness in people of working age

Diabetic patients should be screened for this every year

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11
Q

Explain the pathophysiology of diabetic retinopathy

A

See picture attached and read study highlighted

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12
Q

Where is the optic disc located?

A

Behind the eye, in a nasal direction (towards the nose)

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13
Q

What is located just laterally of the optic disc?

A

Fovea (macula)

  • involved in colour vision
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14
Q

What background changes occur with regards to retinopathy in diabetic patients?

A

Before development of full retinopathy

  • Hard exudates
    • protein like structures that go past vessels in the eye
    • cheese colour
    • liquid
    • photo attached shows this
  • Microaneurysms
    • bulges in vessels
    • dots
    • photo attached shows this
  • Blot haemorrhages
    • photo attached shows this
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15
Q

What are the stages of diabetic retinopathy development?

A
  1. Background Chaneges
  2. Pre-proliferative diabetic retinopathy
  3. Proliferative retinopathy
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16
Q

What occurs in pre-proliferative diabetic retinopathy?

A

Soft exudates

  • “cotton-wool spots”
  • fluffy changes in the eye
  • represent retinal ischaemia
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17
Q

What occurs in proliferative retinopathy?

A

Visible new vessels

  • on disk or elsewhere in retina
  • can denote that person may experience vision loss
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18
Q

What is maculopathy?

A

Variant of diabetic retinopathy

Hard exudates near the macula

Same disease as backgroud, but happends to be near the macula

Can threaten direct vision

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19
Q

How do you manage diabetic retinopathy?

Study These Flashcards
A

Background

  • improve control of blood glucose
  • warn patient that warning signs are present

Pre-Proliferative

  • suggests general ischaemia
  • if left alon, new vessels will grow
  • patients need pan retinal photocoagulation
  • this is firing of a laser beam onto retina

Proliferative

  • visible new vessels
  • urgently need pan retinal photocoagulation

Maculopathy

  • only have problem around macula
  • need only a GRID of photocoagulation
  • don’t need pan retinal photocoagulation

Attached photo shows laser scars on retina

20
Q

What are the clinical features of patient’s with diabetic nephropathy?

Study These Flashcards
A
  • Hypertension
  • Progressively increasing proteininuria
  • Progressively deteriorating kidney function
    • measured using GFR
  • Classic histological features
    • by biopsy
21
Q

Why is it important to know about diabetic nephropathy?

Study These Flashcards
A

Diabetes is a leading cause of kidney disease

Patients with DN have a high risk of developing cardiovascular disease

Associated with morbidity and mortality

Health care burden

  • dialysis

Treatment options are present

22
Q

What is important to remember in terms of cardiovascular health and diabetes?

Study These Flashcards
A

Diabetes increases the risk of a person devloping cardiovascular disease

However, diabetes and kidney disease further increases this risk (even more so than having kidney disease and no diabetes)

Patients need:

  • good glucose control
  • blood pressure control
  • sometimes statins
23
Q

What are the histological features of diabetic nephropathy?

Study These Flashcards
A

Glomerular Changes

  • Mesangial expansion
  • Basement membrane thickening
  • Glomerulosclerosis

Shown in first half of picture attached

24
Q

What growth factors and cytokines are involved in diabetic nephropathy?

Study These Flashcards
A

See picture attached

Read around this topic

25
What is the prevalance of diabetic nephropathy in T1DM and T2DM patients?
Type 1 DM * 20-40% after 30-40 years Type 2 DM * Probably equivalent * However, because T2DM patients tend to develop at later ages, it tends to be that patients die of other issues and never experience the microvascular complications fully
26
What epidemiological factors can affect development of diabetic nephropathy in T2DM patients?
* Age at development of disease * Racial factors * South Asia = diabetes * African = hypertension * Age of presentation * Loss due to cardiovascular morbidity
27
How is proteinuria measured for?
**Urine dipsticks** **Show how much protein is in the urine** Normal Range * \<30mg in 24hrs Microalbuminuric Range * 30-300mg in 24hrs Assymptomatic Range * 300-3000mg in 24hrs Nephrotic Range * \>3000mg in 24hrs
28
What are the strategies for intervention to prevent diabetic nephropathy?
Diabetes control Blood Pressure control * Inhibition of the activity of RAS system via ACE inhibitors Stop Smoking
29
What is Angiotensin 2 and how does it affect blood pressure?
Try to stop the production of angiotensin 2 because it has a lot of negative factors that promote worsening of hypertension: * Vasoactive effects * Mediation of glomerular hyperfiltration * Increased tubular uptake of proteins * Induction of pro fibrotic cytokines * Stimulation of glomerular and tubular growth * Podocyte effects * Induction of pro inflammatory cytokines * Generation of ROS & NF-kB * Stimulates fibroblast proliferation * Up regulation of adhesion molecules on endothelial cells * Up regulation of lipoprotein receptors
30
What are the target points of the RAS system for treatment of hypertension in diabetic nephropathy?
Look at picture attached
31
What is Irbesartan?
Angiotensin 2 inhibitor
32
Why is it important to stop smoking in patients developing diabetic nephropathy?
These patients already have a high cardiovascular risk This is even more increased by smoking
33
What is the link betwen diabetes and neuropathy?
Diabetes is the most common cause of neuropathy Diabetes is therefore also the most common cause of lower limb amputation
34
How can you investigate whether a diabetic patient is developing diabetic neuropathy?
Check their feet to look for signs
35
What is neuropathy?
Small vessels supplying nerves are called vasa nervorum Neuropathy results when these get blocked * can get blocked in diabetes due to high glucose
36
What are the different forms of diabetic neuropathy?
* Peripheral polyneuropathy * Mononeuropathy * Mononeuritis multiplex * Radiculopathy * Autonomic neuropathy * Diabetic amyotrophy
37
What is the pathophysiology of neuropathy initiation and progression?
Hyperglycaemia Leads to inflammation Causes pathological changes (see picture attached and read paper associated)
38
What is peripheral neuropathy?
Longest nerves supply feet Loss of sensation in feet and hands More common in tall people Danger is that patients will not sense an injury to the foot
39
Which people are more likely to develop peripheral neuropathy?
* Tall patients * Patients with poor glucose control
40
What is a monofilament examination?
Examine the feet with a fine metal device Exerts a constant pressure Can determine if patients have sensation
41
What are the clinical features of peripheral neuropathy?
* Loss of ankle jerks * no reflex with patellar hammer * Loss of vibration sense * using tuning fork * Multiple fractures on foot x-ray * may not be walking in the correct way and cannot tell due to loss of sensation * more prone to fractures * condition called Charcot's joint (can cause deformity long-term(
42
What is mononeuropathy?
One nerve involved Usually results in sudden motor loss * Wrist drop * Foot drop * Cranial nerve palsy * Double vision due to 3rd nerve palsy (as shown in attached picture)
43
What is a pupil sparing third nerve palsy?
Eye is usually "down and out" 6th nerve pulls eye out and 4th nerve pulls it down Pupil does respond to light Parasympathetic fibres on outside of 3rd nerve * thus do not easily lose blood supply in diabetes However, if a patient has a space occupying lesion such as tumour, it can compress parasympathetic fibres. This can cause pupil dilation.
44
What is mononeuritis multiplex?
A random combination of peripheral nerve lesions
45
What is radiculopathy?
Pain over spinal nerves, usually affecting a dermatome on the abdomen or chest wall
46
What is autonomic neuropathy?
Loss of sympathetic and parasympathetic nerves to GI tract, bladder, cardiovascular system GI tract symptoms: * difficulty swallowing * delayed gastric emptying * constipation/nocturnal diarrhoea * bladder dysfunction Cardiac symptoms: * postural hypotension * blood pressure drops on standing * can be disabling * collapsing on standing * cardiac autonomic supply * case reports of sudden cardiac death
47
How can you test for autonomic neuropathy?
* Measure changes in heart rate in response to Valsalva manoevre * blow into very tight instrument * increase in pressure * should cause increase in heart rate * Normally there is a change in heart rate * Look at ECG and compare R-R intervals

Yr 2 LCRS - Endo (28 decks)

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