Long Term Complications - Micro and Macro Flashcards
How does the risk of complications change with worsening glycaemic state?
it increases
what are some macro and micro vascular complications of diabetes?
does diabetes increase the risk of cardiovascular disease?
yes
what is atherosclerosis?
● Macrophages and foam cells
● Intracellular lipids
● Extracellular lipid accumulation
● Fibrotic and calcific layers
● Damage to surface, exposure to platelets and clotting
how does diabetes affect atherosclerosis?
accelerates atherosclerosis
Dyslipidaemia is present in nearly all people with diabetes, what dislipidaemia occurs?
(disturbances in fat metabolism lead to changes in the concentrations of lipids in the blood)
HDL Cholesterol is lower
Triglycerides are higher
LDL cholesterol is in the form of small dense particles which are worse - Oxidisation of these particles promotes the features that lead to plaque formation (and glycation of the particles worsens the effect)
hwo does diabetes affect atherosclerosis?
Dyslipidaemia is present in nearly all people with diabetes
Endothelial dysfunction
Hypercoagulability
what are the effects of atherosclerosis in diabetes?
Ischaemic cerebrovascular disease - strokes
Ischaemic Heart Disease - angina, myocardial infarctions
Heart Failure - related to coronary disease and abnormal cardiac myocyte glucose handling
Peripheral vascular disease - Causes lower limb ischaemia, leading to ulcers and poor healing of these ulcers. Amputations are a potential outcome
how do you prevent macrovascular disease?
Good diabetes control
Blood pressure control
Lipid control
Smoking cessation, weight, exercise
Case A:
57M
Admitted with a non-healing foot ulcer needing investigations and IV antibiotics.
Type 2 diabetes diagnosed 8 years ago
On gliclazide 160mg BD and metformin 1gm BD.
HbA1c 87 mmol/mol (ideally <58)
Hypertension
Previous NSTEMI
On clopidogrel, ramipril, amlodipine, atorvastatin (irregularly taken)
Current smoker
BMI = 42.5 kg/m2
BP 150/95 mmHg
Total cholesterol 6.8 mmol/L (ideally <4), HDL 0.8 mmol/L (ideally >1.0), LDL cholesterol 4.0, Triglycerides 7.6 mmol/L
Poor circulation from atherosclerotic disease of femoropopliteal vessels
Impaired sensation from neuropathy
Inappropriate footwear
Poor ongoing foot care
What management is required?
Foot ulcer care – debridement, specialist podiatry
IV antibiotics
Xrays – to check for osteomyelitis? May use MRI for more subtle changes
Rest and avoidance of pressure on ulcer.
Slow healing process!
Improve glycaemic status
Optimise lipid levels – was not taking atorvastatin regularly
Review cardiac status
Smoking cessation
Education, support
Microvascular Disease: Retinopathy
what are the 2 different types?
Non Proliferative Diabetic Retinopathy
Proliferative Diabetic Retinopathy
What is Non Proliferative Diabetic Retinopathy?
Retinal capillary dysfunction, platelet dysfunction, blood viscosity abnormality
What is Proliferative Diabetic Retinopathy?
Retinal ischaemia, new blood vessel formation, vitreous haemorrhage, retinal tears/detachment
Treatment with laser photocoagulation
what is the impact of diabetic retinopathy?
Over a period of 20 years after diagnosis, 100% of people with Type 1 diabetes and 60% of those with Type 2 diabetes will have some form of retinopathy (mild-to-severe)
7% of people who are registered blind have advanced diabetic retinopathy (EnglandWales figure)
[Other eye effects of diabetes include a 50% increase in glaucoma, and a 3-fold increase in cataracts]
what is the treatment of diabetic retinopathy?
Improve glycaemic control
Laser photocoagulation
what is Nephropathy?
Nephropathy is a general term for the deterioration of proper functioning in the kidneys
what does nephropathy cause?
Microalbuminuria - leak of protein (albumin) starts
Glomerular basement membrane changes, mesangial tissue proliferation, “glomerular hypertension” all contribute to renal dysfunction. Progressive renal impairment - note kidneys do not shrink when the disease progresses
Progressive renal failure progresses to end-stage renal disease if unchecked
what is the impact of diabetic nephropathy?
75% of people with diabetes have some renal effects, and 20% go on to overt kidney disease that may need treatment
Diabetes is the biggest single cause of end stage renal disease needing renal replacement therapy (dialysis)
Renal failure ultimately leads to death in 21% of people with Type 1 and 11% of people with Type 2 diabetes
what is the prevention and treatment of nephropathy?
Screening of urine for albumin is vital!
Diabetes control
Renin-angiotensin system blockade - ACE inhibition, angiotensin receptor blockade, renin inhibition - Very good results in slowing/preventing progression of renal disease (ACE-I, ARB)
Hypertension control
what is neuropathy?
Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes
High blood sugar (glucose) can injure nerves throughout your body
Diabetic neuropathy most often damages nerves in your legs and feet
Little blood vessels around the nerves
And the nerves are starved slowly
what type of loss and nerves can neuropathy cause?
Sensory, Motor, Autonomic
Sensory - objective loss, particularly in feet & lower legs; subjective symptoms, especially paresthesia
Can be symptomatically troublesome. However, lack of sensation can lead to the development of neuropathic ulcers, which, alongside poor macro-vasculature, leads to severe foot infections
Autonomic neuropathy can cause GI effects (stomach, intestines), or the cardiovascular system (tachycardia, blood pressure fluctuations). Watch out for silent myocardial infarction!
what foot care is required in a neuropathy?
what is charcot foot?
Charcot foot is a condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy)
The bones are weakened enough to fracture, and with continued walking, the foot eventually changes shape
All blood vessels in the foot under the ankle go haywire and the foot swells up and the bone goes spongy
Poorly understood
Can be triggered by trauma
Nothing you can do that helps it
End up with special moon boot things to alleviate pressure
Something that happens to the vasculature
what are other conditions that may be caused by diabetes?
Erectile dysfunction/sexual dysfunction
Depression - possibly twice as common as in the general population
Case B:
42F
Admitted with diabetic ketoacidosis (DKA)
Also has problems with severe hypogycaemia, with lack of awareness of low blood glucose levels (among other factors, autonomic neuropathy contributes to the loss of normal autonomic responses to low glucose)
Type 1 diabetes diagnosed at age 14
On insulin: long-acting Lantus once a day (bedtime) and short-acting Novorapid with each meal.
HbA1c 78 mmol/mol (ideally <53)
Nephropathy with significant proteinuria, deteriorating renal function – under monitoring from Renal team with anticipatory planning for dialysis
Retinopathy – laser treatment
Peripheral neuropathy and peripheral vascular disease, non-healing ulcer on L 5th toe with osteomyelitis, leading to amputation of that toe previously
BMI = 22 kg/m2
what management is required?
Acute complication of DKA treated using IV insulin as per standard protocol, with good recovery
Deteriorating renal functions worsening – followup arranged in the pre-dialysis clinic
Attempts to improve glycaemic control while addressing the risk of impaired hypoglycaemia awareness
Newer techniques for glucose monitoring to help improve glycaemic control
Possibility of kidney-pancreas transplantation in the setting of established end-stage renal disease
____vascular and ____vascular complications of diabetes are a major problem
Macrovascular disease (coronary, stroke disease and heart failure) can be prevented by controlling ____ factors as well as ________ status
Microvascular disease (nephropathy, retinopathy, neuropathy) must be ________ for, and some preventative measures are good, e.g., for nephropathy, while some treatments are valuable in preventing severe __________, e.g., retinal laser treatment. Good _________ control reduces risk of progression
Macrovascular and microvascular complications of diabetes are a major problem
Macrovascular disease (coronary, stroke disease and heart failure) can be prevented by controlling risk factors as well as glycaemic status
Microvascular disease (nephropathy, retinopathy, neuropathy) must be screened for, and some preventative measures are good, e.g., for nephropathy, while some treatments are valuable in preventing severe dysfunction, e.g., retinal laser treatment. Good glycaemic control reduces risk of progression
