Long Term Complications of Diabetes Flashcards
(49 cards)
1
Q
Microvascular complications of Diabetes
- R…pathy
- N…pathy
- N…apathy
A
- Retinopathy
- Neuropathy
- Nephropathy
2
Q
Macrovascular complications of Diabetes
- I..
- C..
- P..
A
- IHD
- CVD
- PVD
3
Q
Microvascular Complications
- Most cells are able to reduce glucose transport in response to extracellular hyperglycaemia (ones below are not able to)
- … endothelial cells
- Mesangial cells of …
- … cells and peripheral … cells
A
- Most cells are able to reduce glucose transport in response to extracellular hyperglycaemia (ones below are not able to)
- Retinal endothelial cells
- Mesangial cells of glomerulus
- Schwann cells and peripheral nerve cells
4
Q
Microvascular Complications
- Take … … to develop
- Rare before … years of T1 diabetes
- May be detected at presentation of …
A
- Take many years to develop
- Rare before 5 years of T1 diabetes
- May be detected at presentation of T2 diabetes
5
Q
What disease is shown?
A
Retinopathy
6
Q
Retinopathy
- … commonest cause of blindness in those of working age
- …+ in England blind from diabetic retinopathy
- Risk of blindness increased 1..-.. fold by DM
- (G… and c… increased)
A
- Second commonest cause of blindness in those of working age
- 4000+ in England blind from diabetic retinopathy
- Risk of blindness increased 10-20 fold by DM
- (Glaucoma and .. increased)
7
Q
The Retinal Microcirculation
- … density of capillaries
- … functional reserve
- Flow needs to respond to … needs
- … key to local regulation of flow
A
-
Low density of capillaries
- Little functional reserve
- Flow needs to respond to local needs
- Pericytes key to local regulation of flow
8
Q
Pericytes
- Pericytes are present around blood vessels in the normal ….
- Pericyte dropout is one of the major hallmarks of diabetic ….
A
- Pericytes are present around blood vessels in the normal retina.
- Pericyte dropout is one of the major hallmarks of diabetic retinopathy.
9
Q
Pathological Findings of Diabetic Retinopathy
- Loss of …
- Basement membrane …
- Capillary …
- Is…
- … production
- Increased capillary …
A
- Loss of pericytes
- Basement membrane thickening
- Capillary closure
-
Ischaemia
- VEGF production
- Increased capillary permeability
10
Q
Normal retina?
A
Yes
11
Q
Normal retina?
A
No - small dot - early sign of diabetic eye disease (dot haemorrhage or a microaneurysm)
12
Q
Normal retina?
A
No - developing hard exudates - leaking vessels - cholesterol and protein rich fluid
13
Q
Normal retina?
A
No - lots of hard exudates - leaking fluid out full of cholesterol and protein rich
14
Q
Normal retina?
A
No - circinate exudates
15
Q
Normal retina?
A
No - cotton wool spots
16
Q
Normal retina?
A
No - cotton wool spots
17
Q
Normal retina?
A
No - retina ischaemia - produce growth factors - new vessels developed - weaker than original vessels
18
Q
Normal retina?
A
No - very advanced diabetic eye disease - hard exudate, haemorrhages, cloud of new vessels growing out
19
Q
Normal retina?
A
No - new vessels - blood leaking out (rupture)
20
Q
Normal retina?
A
No - catastrophic blood leakage out of vessels - see red out of the eye
21
Q
Normal retina?
A
No - fibrous band (scar on back of retina) can cause retinal detachment - vision will go
22
Q
Normal eye?
A
No - very advanced diabetic eye disease - very rare - new vessels over iris - rubeosis iridis - advanced form of eye disease associated with glaucoma
23
Q
It is important that people are screened for diabetic eye disease - why?
A
- Possible to have extensive damage and not know about it - perfect vision but devestating sight threatening disease
- Most of UK have retinal photography - high res digital camera - temporal and nasal field - after dilation of eye with eye drops - highly trained screeners - refer to eye specialist if an issue
24
Q
Clinical Stages of Retinopathy
- Non-proliferative
- Background - examples? (3)
- Pre-proliferative (changes due to … - leave it for long - new … develop - … wool spots)
- Proliferative (new … already developed - risk of …)
- Macular Oedema
- Sight threatening
- Non sight threatening
A
- Non-proliferative
- Background (little dot haemorrhages, microaneurysms, hard exudates)
- Pre-proliferative (changes due to retinal ischaemia - leave it for long - new vessels develop - cotton wool spots)
- Proliferative (new vessels already developed - risk of bleeding)
- Macular Oedema
- Sight threatening
- Non sight threatening
25
_Diabetic Retinopathy_
* Diabetic ... important
* ... control important
* ... treatment
* Can be Pan ...
* Can be F...
* Intra-vitreal anti ... Ab
* Diabetic **control** important
* **Blood pressure** control important
* **Laser** treatment
* **Pan retinal**
* **Focal**
* Intra-vitreal anti **VEGF** Ab
26
What is shown here?
Laser burns - leave macula spaired - leaking vessels cauterised, oedema fluid reabsorbed - new vessels that were liable to blled have regressed - reduced risk of threat to sight - slight peripheral night vision - usually unimpaired - can drive
27
_Neuropathy_
* Affects up to **...**% of diabetic patients
* **...**% have painful neuropathy (cf **..**% non-diabetic population)
* Affects up to **50**% of diabetic patients
* **15**% have painful neuropathy (cf **5**% non-diabetic population)
28
_Neuropathy Types_
* What are the 3 'main' types?
* (Entrapment neuropathy increased)
* **Peripheral neuropathy**
* **Mononeuropathy**
* **Autonomic neuropathy**
29
_Peripheral Neuropathy_
* Peripheral neuropathy is nerve damage caused by chronically high blood sugar and diabetes.
* It is the ... .... complication of diabetes.
* Longest nerves are affected (therefore worse in what areas?)
* Does it follow a dermatomal pattern?
* Peripheral neuropathy is **nerve** damage caused by chronically high blood sugar and diabetes.
* It is the **most** **common** complication of diabetes.
* Longest nerves are affected (therefore worse in what areas?) - **worse in distal areas e.g. hands, feet (usually legs more so as they are longer)**
* Does it follow a dermatomal pattern? - **NO**
30
_Peripheral Neuropathy - Symptoms_
* You can get w..., ... pains, n..., b.../ti...
* You can get **weakness, sharp pains, numbness, burning/tingling**
31
What type of ulcer?
Neuropathic ulcer - nerve damage will do this
* Lots of callus build up
32
What is shown?
Callus - build up of hard skin - keep walking on it - painful - may start before neuropathic ulcer if you have impaired sensation and leave it and continue to walk on it
33
What is shown here? (Caused by ...)
* Charcot foot (Caused by peripheral neuropathy)
* Inflammatory process - dense nerve damage - unable to feel much - very good blood supply usually - redness, swelling of foot
* Usually misdiagnosed
34
Diabetes - what has happened here?
Mononeuropathy - third nerve palsy - A complete third nerve palsy causes a completely closed eyelid and deviation of the eye outward and downward. The eye cannot move inward or up, and the pupil is typically enlarged and does not react normally to light
35
_Autonomic Neuropathy_
* Gastro...
* ... hypotension
* ... dysfunction
* ... sweating
* Dia..
* **Gastroparesis**
* **Postural hypotension**
* **Erectile dysfunction**
* **Gustatory sweating**
* **Diarrhoea**
36
_Nephropathy_
* Commonest cause of ... in Western World
* Accounts for deaths of ...% of type 1 and ...% of type 2 patients
* Commonest cause of **ESRD (End Stage Renal Disease)** in Western World
* Accounts for deaths of **21**% of type 1 and **11**% of type 2 patients
37
_Renal Microcirculation_
* ... glomerular capillaries
* ... membrane
* Highly specialised ...
* **Fenestrated** glomerular capillaries
* **Basement** membrane
* Highly specialised **podocytes**
38
_Pathological Findings of Diabetic Nephropathy_
* Basement membrane ...
* Loss of ... charge
* P... loss
* Loss of integrity of ... barrier
* Glomerular s...
* M... expansion
* Basement membrane **thickening**
* Loss of **negative** charge
* **Podocyte** loss
* Loss of integrity of **filtration** barrier
* Glomerular **sclerosis**
* **Mesangial** expansion
39
This is showing Clinical stages of...
**Diabetic Nephropathy**
40
_Diabetic Nephropathy_
* ... ... control important
* Blockers of ... system preferred
* Glucose control important but less so once overt ...
* Associated with increased ... risk
* Ultimately ... replacement / transplantation
* **Blood pressure** control important
* Blockers of **RAS** system preferred
* Glucose control important but less so once overt **proteinuria**
* Associated with increased **CVD** risk
* Ultimately **renal** replacement / transplantation
41
What is this?
Section of an artery - macrovascular disease - atheromatous disease
42
_Macrovascular Disease_
* Dramatic increase in risk with ...
* Patients with ... have multiple RF
* Dramatic increase in risk with **diabetes**
* Patients with **type 2 diabetes** have multiple RF
43
Many people with T2 diabetes have ...
Metabolic syndrome
44
Study below - investigating risk factors for what?
CVS disease - number over 1 suggests increased risk - diabetes increases, smoking increases risk etc
45
_Macrovascular Disease_
* Patients with type ... diabetes have long disease duration
* Presentation depends upon ... bed affected
* A.../MI
* S...
* PVD - what is this?
* Patients with type **1** diabetes have long disease duration
* Presentation depends upon vascular bed affected
* **Angina/MI**
* **Stroke**
* **PVD (peripheral vascular disease)**
46
_Macrovascular Disease - attention to all modifiable risk factors_
* ... p...
* L...
* S...
* (... control)
* **Blood pressure**
* **Lipids**
* **Smoking**
* **(Glucose control)**
47
_Diabetic Foot_
* Diabetes is the ... cause of non-traumatic lower limb amputation
* P..
* N... (... ulcer, ... change)
* Impaired ... function
* •Diabetes is the **commonest** cause of non-traumatic lower limb amputation
* **PVD**
* **Neuropathy (neuropathic ulcer, Charcot change)**
* Imapaired **leucocyte** function
48
* What study is this? (Diabetes)
* What type of Diabetes?
* Results?
_UKPDS study - Microvascular Endpoints_
* UK Prospective Diabetes Study
* Results = 25% relative risk reduction in microvascular endpoints - statistical significance - first evidence that trying to control blood glucose was relevant in terms of end points
* Also looked at Blood pressure control (Shown) microvascular endpoints - can see that lower BP better in terms of eye complications and renal complications
* Exclusively T2 patients
49
* What study is this? (Diabetes)
* What type of Diabetes?
* Results?
* DCCT
* T1 Diabetes patients
* Managed intensively or conventionally
* Intensive = multiple daily injfections or insulin pump therapy
* Non intensive - twice a day mixed insulins
* Results = glucose control worsens = increased risk of developing microalbuminuria, increased risk of nerve damage, increased risk of overt proteinuria, increased risk of eye damage
* **Glucose control was important in terms of risk of microvascular complications in T1 Diabetes**
