Complications of Diabetes

Question 1

Examples of CHRONIC complications of Diabetes

Answer 1

Microvascular:

• Retinopathy
• Nephropathy
• Neuropathy

Macrovascular:

• Stroke
• Heart Disease
• PVD

Question 2

The most prevalent microvascular complication of diabetes

Answer 2

Diabetic Retinopathy

Question 3

Compared to conventional insulin therapy, intensive insulin therapy reduced risk of what complications?

Answer 3

microvascular complications (retinopathy, nephropathy and neuropathy)

Question 4

Despite reduced risk of retinopathy, What is a common complication of INTENSIVE insulin therapy?

Answer 4

HYPOglycemia

Question 5

Pathology of Diabetic Retinopathy

Answer 5

NPDR:

• Thickened capillary basement membrane
• Exudates
• Aneurysms
• Hemorrhages

PDR:

• Stenosis –> Ischemia
• Neovascularization (inc. VEGF causing angiogenesis)

Question 6

Clinical features of NPDR

Answer 6

• IRMA (intraretinal microvascular abnormalities)
• micro-aneurysms
• intraretinal hemorrhages
• hard exudates (lipid)
• Cotton wool spots
• Venous beading

Question 7

Clinical features of PDR

Answer 7

• Preretinal neovascularization (hallmark of PDR)
• vitreous hemorrhage
• fibrous tissue prolifearation
• traction retinal detachment
• can cause blindness due to Macular Edema

Question 8

Pathology of PDR

Answer 8

hyperglycemia causes stenosis of retinal microvasculature –> ischemia –> new FRAGILE blood vessels form

Question 9

Primary cause of vision loss in DR

Answer 9

CSME

Question 10

Pathology of CSME

Answer 10

permeable vascular walls –> leakage and accumulation of intraretinal fluid

Question 11

(True/False) ME may occur in all stages of NPDR and PDR

Answer 11

True

Question 12

Vision loss/blindness in DR results from what two main causes?

Answer 12

1. Leakage –> hemorrhage, exudate, vascular leakage –> NPDR/CSME
2. Ischemia –> Neovascularization –> PDR

Question 13

Treatments for Diabetic Retinopathy

Answer 13

1. Sugar, lipid, and BP management
2. Injected therapies (VEGF inhibitors)
3. Laser photocoagulation
4. Vitrectomy

Question 14

Pathogenesis of Diabetic Nephropathy

Answer 14

Chronic hyperglycemia –> glycation of basement membrane –> Thickened BM and efferent arteriole –> hyperfiltration (increased GFR) –> increase in intraglomerular pressure –> glomerular hypertrophy/scarring –> worsening filtration capacity –> nephrotic syndrome

Question 15

Three major histological changes of DNephro

Answer 15

1. Mesangial (cell & matrix) expansion
2. Glomerular BM thickening
3. Glomerulosclerosis
   - Hyalinization
   - Kimmelstiel-Wilson nodules

Question 16

UA findings of DNephro

Answer 16

1. Proteinuria (earliest sign of DN)
   - Microalbuminuria (30-299mg) –> macroalbuminuria (>300mg)
2. Decreased GFR in more advanced DN

Question 17

GFR in ESKD

Answer 17

GFR <15

Question 18

Leading cause of End-Stage Kidney Disease

Answer 18

Diabetic Nephropathy

Question 19

Average age onset of ESKD due to DNephro

Answer 19

60

Question 20

Modifiable contributing factors of DNephro

Answer 20

smoking
hypertension
dyslipidemia
high protein diet

Question 21

Treatments for Diabetic Nephropathy

Answer 21

1. ACE inhibitors/ARBs
2. BP management
3. low protein diet

Question 22

ACE inhibitors and ARBs should be started in patients with

Answer 22

1. diabetes w/ elevated MA/cr ratio

OR

2. diabetes w/ elevated urinary 24 hour protein

OR

3. hypertension

Question 23

Most common form of diabetic neuropathy

Answer 23

Symmetric PERIPHERAL neuropathy

Question 24

Which nerves are most prone to Diabetic Neuropathy

Answer 24

Longer nerves are most vulnerable (affect feet first –> later on hands)

“stocking-glove” pattern

Question 25

Examples of symptoms of AUTONOMIC Neuropathy

Answer 25

- Orthostatic hypotension - Gastroparesis - ED

Question 26

What makes diabetics prone to feet/lower extremity problems (ulceration, cellulitis, bony deformity, gangrene, amputation)

Answer 26

- Loss of protective sensation - PVD (peripheral vascular disease) - HTN - Smoking

Question 27

Relatively painless, progressive and degenerative arthropathy of joints in the foot; associated with diabetes, but also syphilis (tabes dorsalis)

Answer 27

Charcot Foot

Question 28

Visual inspection of feet, palpation, semmes-weinstein monofilament (poking), and tuning fork can be used to

Answer 28

screen diabetic foot

Question 29

Treatments for Diabetic Neuropathy

Answer 29

1. Pain - Gabapentin - Pregabalin - Duloxetine 2. Autonomic symptoms - Anti-emetics for gastroparesis - Phosphodiesterase (PDE) inhibitors for ED 3. Specialized footwear (to off load pressure from feet)

Question 30

Examples of MICROvascular complications of Diabetes (3 total)

Answer 30

1. Retinopathy 2. Nephropathy 3. Neuropathy

Question 31

Examples of MACROvascular complications of Diabetes (3 total)

Answer 31

1. Brain (Cerebrovascular Disease) 2. Heart (Coronary Heart Disease) 3. Peripheral vessels (Peripheral Artery Disease)

Question 32

Organ or limb complications of atherosclerosis affecting medium and large vessels

Answer 32

Macrovascular disease

Question 33

#1 cause of mortality in Diabetes

Answer 33

Cardiovascular disease

Question 34

Macrovascular disease in diabetes is a result of hyperglycemia +

Answer 34

MULTIPLE other risk factors - HTN - dyslipidemia - smoking - thrombosis - etc.

Question 35

Treatment/Preventatives for MACROvascular disease in Diabetics

Answer 35

- Control HTN - Statins - Smoking cessation - Anti-platelet therapy *sugar control not proven to affect, as opposed to MICROvascular

Question 36

The relationship between blood sugar control and the reduction for both Macro and Microvascular disease is different (True or False)

Answer 36

True: proven effective for MICROvascular disease, but not MACROvascular

Question 37

Although controlling blood glucose has NOT been shown to reduce MACROvascular complications, why is it important to control BG?

Answer 37

Early glycemic control resulted reduced LATER MACROvascular events and CV death

Question 38

What non-vascular complications are associated with diabetes?

Answer 38

- GU infections - CHF - Fatty liver (steatohepatitis) - Cataracts - Gingivitis - Chronic mental illness