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Endocrine > Diabetes: Complications > Flashcards

Diabetes: Complications Flashcards

1
Q

Chronic complications

A

Macrovascular

  • IHD
  • Stroke
Microvascular
- Neuropathy
-Retinopathy
-Nephropathy 
(Strong relationship of HbA1c to risk of microvascular complications)

Cognitive dysfunction dementia

Erectile dysfunction

Psychiatric

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2
Q

Screening

A

At annual review

  • Digital retinal screening
  • Foot risk assessment
  • ACR (albumin creatinine ratio)
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3
Q

Glucose Metabolism (Pathophysiology)

A

Normally, glucose is completely oxidised via both glycolysis and mitochondrial metabolism via TCA

Glycolysis is inefficient but high throughput
Mitochondrial metabolism is efficient but low throughput

When faced with excess glucose, glycolic flux is high but mitochondria can’t keep up
–> Alternative pathways are used

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4
Q

Consequences of hyperglycaemia

A

Inflammation
Fibrosis
Osmotic Damage
Release of reactive oxygen species

Excess glucose exposure (and impaired mitochondrial metabolism) results in increased flux of glucose via alternative pathways, many of which precipitate inflammation and increased ROS.

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5
Q

Diabetic Retinopathy

A

Disorder of the retina resulting in impairment or loss of vision

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6
Q

Diabetic Retinopathy Aetiology

A

Long-standing diabetes with poor glycemic control

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7
Q

Pathology

A

Damage to the blood-retina barrier

Damage causes occlusion or leakage in the retinal circulation

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8
Q

Classification of diabetic retinopathy

A

Background Retinopathy
Pre-proliferative Retinopathy
Proliferative Retinopathy
Advanced retinopathy

Mild, moderate and severe non-proliferative
Proliferative

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9
Q

Background retinopathy

A

(HOME)

Haemorrhage

  • leakage of blood into retina
  • dot, blot, flame-shaped

Oedema

  • leakage of fluid (transudate)
  • diabetic macular oedema can occur even in background disease

Microaneurysms

  • out pouching of venous end of capillaries
  • earliest sign of retinopathy, found in central macula

Exudates

  • leakage of lipid
  • yellowish deposits, usually in macula
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10
Q

Pre-proliferative Retinopathy

A

Cotton Wool Spot
- Blockage of fine retinal capillaries flow is slowed, producing a feathery whitish area- represents focal infarct

Vein Abnormalities

  • characterize an ischaemic retina
  • venous looping, beading and engorgement
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11
Q

Intra-retinal microvascular abnormalities(IRMA)

A

Areas of capillary dilatation and intraretinal new vessel formation

Arise within retinal ischaemia

Present in numbers: Pre-proliferative

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12
Q

Retinal detachment

A

As new vessel mature, connective tissue and fibrosis (gloss) occurs allow vitreous to exert traction which may cause detachment

If detachment extends across fovea - vision loss

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13
Q

Retinopathy treatment

A

Laser

  • Pan retinal photo coagulation
  • reduces oxygen retirement of retina. Reduces ischaemia that is driving retinopathy

Vitrectomy
- if virtual haemorrhage

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14
Q

Diabetic macular oedema treatment

A

Optical coherence tomography
- Assess oedema

Intraviteal Anti-VEGF
- mainstay of treatment

Grid laser to macula may be required

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15
Q

Nephropathy

A

Progressive kidney disease caused by damage to the capillaries in kidneys glomeruli

Diabetes commonest cause of kidney failure and dialysis in the UK

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16
Q

Nephropathy Characteristics

A

Proteinuria
Diffuse scarring of glomeruli
Nodular glomerulosclerosis

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17
Q

Consequences of nephropathy

A

Development of hypertension

Relentless decline in renal function
- reduction of GFR of 1ml/min/month if untreated

Accelerated vascular disease

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18
Q

Screening for nephropathy

A

Urinary albumin concentration and serum creatinine measure at diagnosis and at regular intervals

Urinary albumin conc
- Random urine sample

Urinary albumin: creatinine ratio
- laboratory method

Abnormal result requires to be confirmed by a further 1st pass sample without delay

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19
Q

Urine Protein Measures

A

Microalbuminuria

  • Dipstick -ve
  • PCR > 15
  • ACR >2.5/3.5 (M/F)
  • Need to repeat test and have ⅔ +ve due to variation and false positives

Proteinuria

  • Dipstick +ve
  • PCR >50
  • ACR >30

Nephrotic Range Proteinuria

  • Dipstick +++
  • PCR >300
  • ACR > 250
20
Q

Nephropathy Treatment

A

First Line
- ACEi/ ARB

BP should be maintained <140/80mmHg (target is 130/70)

SGLT2i

  • T2Dm started on SGLT2i irrespective of HbA1c
  • Reduce filtration pressure by decreasing renal afferent dilatation

Good glycemic control

21
Q

Role of ACEi/ ARBs in diabetic nephropathy

A

Dilation of renal arteries
Decrease filtration pressure
Decrease proteinuria
–> Decrease GFR

(Allow up to 20% deterioration of eGFR)

22
Q

Neuropathy

A

Disease of peripheral nerves

23
Q

Types of neuropathy (4)

A

Peripheral Neuropathy
Proximal neuropathy
Autonomic neuropathy
Focal neuropathy

24
Q

Peripheral neuropathy

A

Pain/ loss of feeling in feet +/- hands

25
Q

Proximal neuropathy

A

Pain in thighs, hips or buttock leading to weakness in legs

26
Q

Autonomic neuropathy

A

changes in

  • bowel function
  • bladder function
  • sexual response
  • Sweating
  • HR
  • BP
27
Q

Focal neuropathy

A

sudden weakness in one nerve or a group of nerves causing muscle weakness or pain

28
Q

Neuropathy Risk factors

A 
Increased length of diabetes 
Poor glycemic control 
T1DM>T2DM (related to length of disease) 
High cholesterol/ lipids 
Smoking 
Alcohol 
Genetics
Mechanical Injury
29
Q

Peripheral neuropathy

A

Distal symmetric or sensorimotor neuropathy

‘glove and stocking distribution’

30
Q

Peripheral neuropathy symptoms

A 
Numbness/ insensitivity 
Tingling/ burning 
Sharp pain or cramps 
Sensitivity to touch 
Loss of balance and co-ordination
31
Q

Peripheral neuropathy consequences

A

Charcot foot
Painless trauma
Foot ulcer
- may require hospitalisation

32
Q

Diabetic foot aetiology

A

Peripheral neuropathy

  • neuropathic ulcer
  • clawing of toes

Peripheral vascular disease

  • proximal arterial occlusion
  • digital gangrene
  • Charcot foot
33
Q

Charcot Arthropathy

A

Destructive inflammatory process

Fractures/ bony destruction

Deformity of the foot

34
Q

Charcot Arthropathy Presentation

A

Hot swollen foot in someone with neuropathy

35
Q

Charcot Arthropathy Investigations

A

MRI can help to differentiate from infection

36
Q

Charcot Arthropathy Natural History

A

Active destruction ~3months
Healing Phase- 4 to 8 months
Chronic Phase 8+ months

37
Q

Charcot Arthropathy treatment

A

Non-weight bearing

- total contact cast or air cast boot

38
Q

Painful neurp[athy treatment

A

Amitryptylline
Duloxetine
Gabapentin
Pregablin

Localised Pain
- Topical capasaicin cream

39
Q

proximal neuropathy

A

Diabetic amyotrophy

Typically more common in elderly T2DM

40
Q

Proximal neuropathy presentation

A

Starts with pain in thigh, hips, buttocks or legs. Usually on one side of the body

Proximal muscle weakness

often associated with marked weight loss

41
Q

Autonomic Neuropathy

A

Affects nerves regulating HR and BP as well as internal organs

Impacts digestive system, sweat glands, heart and blood vessels

42
Q

Autonomic Neuropathy: Digestive System

A

Gastric slowing/ frequency

Gastroparesis

  • slow stomach emptying
  • Nausea and vomiting, bloating, loss of appetite
  • Blood glucose levels can fluctuate due to abnormal food digestion

oesophagus nerve damage

43
Q

Autonomic Neuropathy; Gastroparesis Treatment

A 
Improved glycemic control 
Dietary 
Promotility drugs (metoclopramide) 
Anti-nausea
Pain relief
Gastric pacemaker
44
Q

Autonomic Neuropathy: Sweat Glands

A

Prevents sweat glands from working properly

Body unable to properly regulate temperature
- nerve damage can cause profuse sweating at night/ while eating

Treatment
–> Topical glycopyrrolate

45
Q

Autonomic Neuropathy: Heart & Blood vessels

A

Nerve damage interferes with body’s ability to adjust blood pressure and heart rate

BP may drop sharply after sitting or standing –> feeling faint

HR may stay high

46
Q

Mononeuropathy

A

Can increase risk of

  • carpal tunnel syndrome
  • VI cranial nerve palsy

Endocrine (25 decks)

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