micro and macrovascular compl of t2d

Question 1

3 types of microvascular complications

Answer 1

retinopathy, nephropathy, neuropathy

Question 2

3 types of macrovascular disease

Answer 2

ischaemic heart disease, cerebrovascular disease, peripheral vascular disease

Question 3

when does risk of microvascular disease increase exponentially? (what factor)

Answer 3

blood glucose/ hyperglycemia- target hba1c- below 53

Question 4

what factor other than blood glucose do you need to check to avoid microvascular complications? (proportional relationship- linear)

Answer 4

blood pressure- HYPERTENSION

Question 5

what are 2 blood-content related factors that are associated with microvascular complications

Answer 5

hyperlipidaemia (high cholesterol)- clogs arteries

hyperglycaemic memory- when for a period of time you had high-uncontrolled gluc levels and this can cause problmes later on (due to endothelial damage)

Question 6

what are other factors that can increase risk of microvascular complications

Answer 6

duration of diabetes - when had for longer- since younger - think t1d usually- you need to monitor more

smoking - endothelial dysfunction

genetic factors - some people control glu less well and dont get compl and vise versa

Question 7

when we say microvascular damage what part pf the vessel is actually being damaged?

Answer 7

endothelium

Question 8

mechanism of microvascular damage (endothelium)

Answer 8

1) hyperlipidaemia and hyperglycaemia lead to
2) OXIDATIVE STRESS leads to
3) increased formation of mitochondrial superoxide free radicals (leads back to 2)
+
4) glycation of plasma porteins leaidng to advanced glycation poducts (AGEs)

5) activation of inflammatory pathways

6) damaged endothelium : a)leaky capillaries
b) ischaemia

Question 9

what is the main cause of
visual loss in people with diabetes and blindness in people of working age?

Answer 9

diabetic retinopathy

Question 10

how often do diabetics get screened for diabetic retinopathy and why?

Answer 10

annually because it initially is asymptomatic and we want to catch before it causes visual loss/ disturbance (irreversible)

Question 11

what is another cause of visual disturbance in diabetes? what type fo disturbance?

Answer 11

blurry vision at start of diabetes due to thickening of lens in eye- part of osmotic sympotms- reversible and NOT THE SAME AS RETINOPATHY

Question 12

What are the 2 normal features seen in a normal retina, where is each located and which is bright/ dark (in examination)

Answer 12

optic disc - side- bright
macula/ fovea - centre - dark (high resolution central colour vision)

Question 13

what are the 4 pathologies in the eye?

Answer 13

background retinopathy
pre-proliferative retinopathy
proliferative retinopathy
maculopathy

Question 14

which type of retinopathy is the least and which is most dangerous

Answer 14

least: background
most: proliferative

Question 15

features in background retinopathy

Answer 15

1) dot (aneurisms) and blot haemorages

2) hard exudate - cheese colour from lipids

Question 16

features in pre-proliferative retinopathy

Answer 16

“cotton wool” spots/ soft exudate - they are bright- represent retinal ischaemia (here we dont have the dots and blots- only these bright spots)

Question 17

features of proliferative retinopathy

Answer 17

you see more branches on the retinal vessels/ more vessels (on disc or elsewhere in retina)

Question 18

features of maculopathy

Answer 18

hard exudate but only around macula (Looks like background retinopathy but ONLY around macula as opposed to around the whole retina)

Question 19

what does the management of all the eye pathologies involve before we move onto any kind of treatment?

Answer 19

Improve HbA1c, stop smoking, lipid lowering, good blood pressure control <130/80 mmHg

Question 20

what is the management of background retinpathy?

Answer 20

continued annual surveillance

Question 21

management of pre-proliferative retinopathy?

Answer 21

if left untreated will rpogress to proliferative so - early PANRETINAL photocoagulation

Question 22

management for proliferative retinopathy

Answer 22

pnretinal photocoagulation

Question 23

management for diabetic maculopathy

Answer 23

its oedema so: injection of anti-VEGF (vascular endothelial growth factor) straight into the eye

and grid photocoagulation

Question 24

what is seen in the retina after pan retinal photocoagulation? what does this mean clinically?

Answer 24

black spots on the periphery of the retina- loss of some peripheral vision - its worth it bc if you leave it to proliferate it will lead to uncontrolled loss of vision

Question 25

What stage of diabetic retinopathy can be observed rather than treated?

Answer 25

background retinopathy

Question 26

3 reasons why diabetic nephropathy is important/ serious

Answer 26

associated with cardiovascular complications, associated with END STAGE renal failure which requires haemoDIALYSIS healthcare burden

Question 27

what is an appropriate measurement for diabetic nephropathy surveillance?

Answer 27

Urine Albumin: creatinine ratio (UACR)

Question 28

what is normal ACR and what are the 3 progression stages?

Answer 28

normal ZERO microalbuminurea: >3 mg/mmol proteinurea: >30mg/ mmol nephrotic range: >3000mg/ 24hr

Question 29

what do you do if a UACR comes back positive and why?

Answer 29

you need to repeat it to confirm because its ommon to have false positives due to UTI, fever

Question 30

what are some innapropriate measurements for screening for diabetic nephropathy?

Answer 30

GFR and creatinine because these would change only in PROGRESSED kidney disease- its too late to prevent then

Question 31

mechanism of diabetic nephropathy

Answer 31

1) Hypertension and hyperglycaemia 2) hypertension in glomerulus 3) PROTEINUREA 4) fibrosis of GLOMERULUS and INTERSTITIAL space 5) GLOMERUAL FILTRATION DECLINE 6) renal failure

Question 32

what treatment should people with microalbuminurea/ porteinurea get?

Answer 32

ARB or ACEi even if normotensive these drugs imptove progression of diabetic nephropathy AND reduce bp NEVER FORGET HOLLISTIC APPROACH- popping them on a drug is not enough bc still theres risk for cardiovascular disease so need to control other facotors, smoking ect.

Question 33

specific OTHER things to consider in diabetic nephropathy other than drugs

Answer 33

Aim for good glycaemic control (HbA1c <53 mmol/mol)Reduce BP (aim <130/80 mmHg) usually through ACEi or A2RB Stop smoking Start an SGLT-2 inhibitor if T2DM?

Question 34

how is angiotensin 2 made?

Answer 34

1) angiotensinogen from liver 2) stimulated by renin from the kidney to turn into angiotensin I 2) STIMULATED BY ACE to turn into angiotensin II

Question 35

where does angiotensin II act on and what are the effects?

Answer 35

on angiotensin receptors in 1) blood vessels for vasoconstriciton 2) zona glomerulosa of adrenal cortex for aldosterone secretion

Question 36

what are 2 types of antihypertensives?

Answer 36

ACEi : ace inhibitors and ARBs - angiotensin receptor blockers

Question 37

what do the ACEi drugs and ARBs drugs names end with?

Answer 37

-pril -sartan

Question 38

what is the name of small vessels supplying nerves?

Answer 38

vasa nervosum

Question 39

when do you get neuropathy (pathophysio)

Answer 39

when vasa nervosum get blocked

Question 40

most common cause of neuropathy and therefore lower limb amputation

Answer 40

diabetes mellitus

Question 41

unique risk factors for diabetic neuropathy

Answer 41

age height (longer nerves in lower limbs of tall people) presence of diabetic retinopathy

Question 42

why is neuropathy more common in feet?

Answer 42

bc longest nerves

Question 43

why is diabetic neuropathy in feet clinically relevant

Answer 43

1) can be painful 2) patients may not sense injury-> infection

Question 44

what are the 2 main factors u need to check for in diabetic foot

Answer 44

factors you want to check for: 1) sensation 2) blood flow

Question 45

how do you check for these factors in diabetic foot

Answer 45

1) inspect- look for deofrmity - ulceration 2) sense test with monofilament - ankle jerks 3) asses foot pulses: dorsalis pedis and posterior tibial

Question 46

what are patients with reduced sensation to feet and reduce vascular supply to feet at risk for and what are the med names of the two thongs mentioned above?

Answer 46

peripheral neuropathy peripheral vascular disease risk of ulceration

Question 47

peripheral neuropathy management

Answer 47

. Regular inspection of feet by affected individual 2. Good footwear 3. Avoid barefoot walking Podiatry and chiropody if needed

Question 48

periptheral neuropathy with ulceration management

Answer 48

Multidisciplinary diabetes foot clinic Offloading Revascularisation if concomitant PVD Antibiotics if infected Orthotic footwear Amputation if all else fails

Question 49

2 other types of neuropathy

Answer 49

mononeuropathy autonomic neuropahty

Question 50

what are 2 common forms of mononeuropathy

Answer 50

1) drop of one wrist. leg 2) 3rd CN/ occulomotor PALSY: eye looks down and out (think eye drops like the rest)

Question 51

what is autonomic neuropathy

Answer 51

damage to sympathetic and parasympathetic nerves along multiple systems: cardiovascular, GI, bladder

Question 52

GI sympotms of autonomic neuropathy and problems it causes with diabetes

Answer 52

diarrhoea constipation vomiting + nausea (late GASTRIC emptying )- CHALLENGING with short acting glucose doses

Question 53

CARDIO sympotms of autonomic neuropathy

Answer 53

postural hypotension - colapse when standing sudden cardiac death - cardiac autonomic supply

Question 54

effect of hyperglycaemic management on cardiovascular disease (MACRO vascular complic)

Answer 54

MINOR EFFECT

Question 55

modifiable RISK factors for macrovascular disease

Answer 55

dyslipidaemia central obesity diabetes mellitus smoking hypertension

Question 56

non modif risk factors for macrovascular disease

Answer 56

age sex birth weight genes

Question 57

Managing cardiovascular risk in diabetes mellitus

Answer 57

Smoking status – support to quit Blood pressure < 130/80 mmHg if microvascular complication or increased metabolic risk (NB often needs multiple agents) Lipid profile – total chol <4, LDL <2 Weight – discuss lifestyle intervention +/- pharmacological treatments Annual urine microalbuminuria screen – risk factor for cardiovascular disease