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Flashcards in Complications of DM Deck (51):
1

Pathogenesis of Diabetic Tissue Damage (4)

1. Oxidative Stress
2. Inflammation
3. Glucotoxicity-->Advanced glycosylation end products (AGE)
4. Vasoconstriction, angiogenesis, coagulation,

2

Retinopathy Statistics: Onset/prevalence

Type1DM: Onset 3-5 yr after dx; nearly all patients have it within 20 years

Type 2DM: Onset 5-7yr before dx; 20% before dx; 40-80% incidence after 20 years

3

Pathophysiology of Diabetic Retinopathy (3)

Hyperglycemia: dysregulated retinal blood flow, oxidative stress, increased vascular permeability, microthrombosis (ischemia), endothelial proliferation

Genetics
Hypertension

4

Mild NPDR Signs (3)

Microaneurysms
Dot hemorrhages
Hard exudate (lipid leakage within mø)

5

Moderate/Severe NPDR Signs (3)

Soft exudates: "Cotton wool spots" (nerve infarcts)
Venous beading
Intraretinal microvascular abnormalities (IRMA)-->Occluded vessels, dilated/tortuous capillaries

6

What risk increases with severity of NPDR?

Risk of progression to PDR

7

Macular Edema:

Edema and thickening of retina
Accounts for 75% of blindness

Requires special fundoscopic exam

8

Proliferative Diabetic Retinopathy Signs (4)

Neovascularization (new blood vessels leaky-->hemorrhage)
Preretinal and vitreous hemorrhage-->acute vision loss that resolves spontaneously
Fibrosis-->Retinal traction/detachment
Ischemia

9

Prevention of retinopathy: Cornerstones (2) and Weaker links (3)

Glycemic control and antihypertensives
Weaker evidence for:
Lipid lowering meds
Antiplatelet meds
Carbonic anhydrase inhibitors

10

Effect of Glycemic Control on Retinopathy

Best as primary prevention (metabolic memory)-->Favorable effects persist for up to 10 years
Positive but less pronounced effect on mild/moderate NPDR
More effective in T1DM than T2DM

11

Treatment of Retinopathy:
NPDR
High Risk/severe PDR
Vitrectomy

NPDR: focal photocoagulation
High-risk/severe PDR:
panretinal photocoagulation (PRP)
Meds: VEGF-inhibitors, intravitreal glucocorticoids

Vitrectomy for nonresponsive shit

12

Nephropathy: Epidemiology--Onset and Risk

Onset 5-20 yr after diabetes (lifetime=25-35%
More common in T2DM
Most common cause of kidney failure (40% of dialysis patients)

Risk factor for CV/overall mortality

13

Risk factors for nephropathy (8)

Poor glycemic control, obesity, race, hypertension, age, tobacco use, retinopathy

14

Pathologic changes of Nephropathy: Glomerular changes (3)

Mesangial expansion
Thickening of glomerular basement membrane
Glomerular sclerosis

15

Course of Nephropathy (6)

Hyperfiltration (increased kidney size)-->Microalbuminuria-->Regress to normal-->Macroalbuminuria-->Decresed GFR-->ESRF

16

Prevention of Nephropathy (3)

Glycemic control
Blood pressure control (

17

Treatment of Nephropathy (4)

ACE Inhibitors/ARB: Improves albuminuria but not prevent onset
Other hypertensive agents: diltiazem/verapamil
Dietary restriction: salt/protein
Weight loss

18

Neuropathy: Prevalence

50-70% lifetime
Most common microvascular complication

19

Risk Factors for Diabetic Neuropathy (big list)

Age, duration of diabetes, poor glucose controls, blood vessel damage, mechanical injury to nerves, genetics, HTN, dyslipidemia, tobacco use, alcohol use

20

Peripheral Neuropathy (aka distal, symmetric polyneuropathy): Symptoms (4) and Distribution

Stocking glove distribution

Decreased sensation, paresthesia, hyperesthesia, worse at night

21

Polyneuropathy: clinical findings
Physical exam (2)
Electrodiagnostics (2)

Physical exam: sensory loss (proprioception/vibration), loss of ankle reflexes
Electr Tests: Decreased nerve conduction velocity and amplitude of evoked potentials

22

Treatment of painful neuropathy (6)

Anticonvulsants
TCAs
SNRIs
Topical agents
Opioids
Antioxidants
TENS (nerve stim)

23

Types of autonomic neuropathy (4)

CV, GI, genitourinary, peripheral

24

CV Neuropathy Symptoms (4): P-MET

Postural hypertension
MI
Exercise intolerance
Tachycardia

25

GI Autonomic Neuropathy: Esophageal enteropathy (2)

Gastro-esophageal reflux disease
Transient Lower Esophageal Sphincter relaxation

26

GI Autonomic Neuropathy: Diabetic enteropathy (3)

Small bowel dysfunction: diarrhea, steatorrhea
Colonic dysfunction: constipation
Anorectal dysfunction: fecal incontinence

27

GI Neuropathy: Gastroparesis--Symptoms (2)

Early satiety, nausea, vomiting
Worsening of glycemic control

28

GI Neuropathy: Gastroparesis--treatment (3)

Glycemic control
Diet (decrease fat/fiber)
Prokinetic agents: erythromycin/azithromycin

29

Genitourinary Autonomic Neuropathy: Px (2)

Urinary retention: UTIs and incontinence
ED

30

Peripheral Autunomic Nueorpathy (sudomotor neuropathy): Presentation (4)

Impaired perspiration: dry skin, itchiness
Peripheral edema
Callus formation (can form ulcers)
Neuroarthropathy

31

Describe Acute Onset Mononeuropathy: Onset and resolution

Sudden weakness or pain in single nerve that resolves spontaneously

32

How does acute onset mononeuropathy present? CN and Peripheral locations

CN: Opthalmoplegia (CN III,IV,VI) or Bell's Palsy (CNVII)
Peripheral: Carpal tunnel or foot drop

33

Acute Onset Radiculopathy: Types (2), location and px

Diabetic amyotrophy: L2-L4
Acute asymmetric pain and weakness in proximal legs, hips and butt
Truncal polyradiculopathy: T4-T12
Severe abdominal pain in band-like patter

34

Prevention of Neuropathy (5)

Glucose control
BP control
Treatment of dyslipidemia
Smoking cessation
Decreased alcohol intake

35

Diabetic Foot Ulcers: Risk factors (4)

Neuropathy: decreased pain sensation/dry skin/calluses
Foot deformity
Peripheral vascular disease
Poor glycemic control (impaired wound healing)

36

Prevention of Foot Ulcers (6)

Avoid walking barefoot, proper fitting shoes, trim toe nails, daily foot inspection, daily foot washing, moisturizer

37

What are main chronic macrovascular complications? (3)

Coronary artery disease
Cerebrovascular disease
Peripheral vascular disease

38

CVD in DM Stats:

75% all diabetes deaths
2-4x risk of CVD
Disease more likely to be asymptomatic and more likely to have worse outcomes than non-DM

39

Risk factors for CVD (big list)

age, duration of DM, poor glucose control, HTN, dyslipidemia, renal disease/albuminuria, Women, obesity, smoking, sedentary lifestyle

40

What is most important factor for microvascular disease in T1DM? When is risk highest?

Duration of diabetes-- risk highest after 20-25 years

41

What are factors for microvascular disease in T2DM?

Usually pre-existing--insulin resistance and presence of multiple other risk factors

42

Prevention of microvascular disease (7)

Glucose control, BP control lipid control, reduction of microalbuminuria, weight loss/exercise, smoking cessation, aspirin

43

What are results of DCCT for T1DM?

Intensive therapy reduces retinopathy, nephropathy and neuropathy
Nonsignificant decrease in CVD

44

What are results of EDIC for DCCT follow up?

A1c converged
Metabolic memory: risk reduction persisted
Reduction in CVD and death

45

What are results of UKPDS for T2DM?

Intensive therapy reduces microvascular diseases
No difference in CV outcomes

46

What are results of BP control in UKPDS?

Reduction in retinopathy and loss of visual acuity

47

What are results of monitoring post-trial for UKPDS?

Decrease in MI, diabetes-related death
Metabolic memory: decreased risk of microvascular complications persisted

48

Retinopathy Screening

Annual dilated eye: T1DM (5 years) T2DM (at dx)

Counsel preggers on risk

49

Nephropathy Screening

Annual urine microalbumin: T1DM (5 years) T2DM (at dx)

Confirm abnormal tests and initiate ACE inhibitor

50

Neuropathy Screening

Annual exam : T1DM at 5yr T2DM at dx

51

CV Screening

Check BP at first visit (goal