Microvascular Complications of Diabetes

Question 1

Prevalence of Disglycemia in Canada

Answer 1

both diabetic patients and pre=diabeteic have increased risk of microvascular and macrovascular disease

Question 2

Already Playing “Catch-up” at Diagnosis

Answer 2

Linear relationship with duration of diabetes and with retinopathy

Insulin dependent and insulin non independent diabetes in the past

9-12 yrs + disglycemia for 5 years before retinopathy!

Question 3

rank the prevalence of complications

Answer 3

At Diagnosis of Type 2 Diabetes]

nephropathy > macrovascular > retinopathy > neuropathy

Question 4

Nephropathy

Recall from IDF infographic
• Prevalence of ESRD is 10x higher
in people with diabetes

Answer 4

• Diabetes is a leading cause of renal failure
– Up to one half of people with diabetes will develop some form of renal damage during their lifetime
– People with chronic kidney disease should be considered at high risk for cardiovascular events
• Development and progression of renal damage can be reduced and slowed with intensive glycemic
control, optimized blood pressure control, and use of medications that disrupt the renin angiotensin
aldosterone system
– Check potassium concentration when adding or adjusting ACE inhibitors, ARBs, or direct renin inhibitors
• Practical implications… renal dose adjustments
• Screen with a random urine albumin-to-creatinine ratio (ACR) and estimated glomerular filtration
rate (eGFR)
– Type 1: annually, starting 5 years after diagnosis
– Type 2: annually, starting at diagnosis

Question 5

Stages of Renal Function

Answer 5

“Normal” < 30 mg albumin / 24 hours
ACR < 2.0 mg/mmol

Microalbuminuria (30 - 300 mg / 24 h)
ACR 2.0-20.0 mg/mmol

Overt Nephropathy (>300 mg / 24 h)
ACR > 20.0 mg/mmol

Renal failure
a.k.a. ESRD
(End Stage Renal Disease)

Management Implications
• Dose changes with declining renal function
• Prevention & Treatment…
See the ABCDES3

Question 6

Retinopathy

Answer 6

• Diabetes is a leading cause of adult blindness
– Visual loss can also increase the risk of falls, hip fracture, and mortality
• Diabetic retinopathy involves changes to the retinal blood vessels, leading to bleeding, fluid leakage, or vision distortion
– Macular edema: diffuse or focal vascular leakage at the macula
– Nonproliferative diabetic retinopathy: microaneurysms, intraretinal hemorrhage, vascular malformation and tortuosity
– Capillary nonperfusion: a form of vascular closure

Cloudy and blurry capillaries, microbleeding
Arrow points to microbleed

Question 7

practical problems with retinopahy

Answer 7

Can pt read med labels

Black and white is easier
Can they read the meter

Resistance and click on pen will help overcome retinopathy

Question 8

when should pt screen for vision

Answer 8

• Screening by a vision care professional (optometrist or
ophthalmologist)
– Type 1: annually, starting 5 years after diagnosis
– Type 2: every 1-2 years*, starting at diagnosis
*Frequency varies depending on severity and patient age

Question 9

Neuropathy

Answer 9

• Affects the peripheral nervous system
– Sensorimotor nerves (Distal Symmetric Polyneuropathy): neuropathic pain, changes to lower limb mobility, loss of sensation
– Autonomic nerves: cardiovascular, gastrointestinal, urogenital
• Prevalence estimates depend on the diagnostic criteria used, type of neuropathy studied, and population studied
– Approximately 50% of people with diabetes will develop a detectable sensorimotor polyneuropathy within 10 years of diabetes diagnosis

Peripherally nervous system
Neuropathic pain most common cause is diabetes
Tingling
Rub continiously on shoe

Question 10

Peripheral Neuropathy – Pathologic Processes

Answer 10

Micro blood vessels in nerve bundle
There is damage there
If it starts to get damaged like frayed wires
Stimulated otuside of normal conduction or lose conduction
Propogate inappropriately
Very painful sensaiton

Neurpoathy in vagus nerve causes decreased condution which will result in increased heaart rate
High resting heart rate
Unopposed sympathetic stimulation to heart

Question 11

Peripheral Neuropathy – Consequences

Answer 11

Consequences
• Inflammatory reaction
• increased Mechanosensitivity
• Spontaneous discharge
• Abnormal signal spread
• Excessive signal
• Loss of signal
(e.g., no pain sensation

Question 12

Autonomic Neuropathy
CV
GI
urogenital

Answer 12

Cardiovascular: resting tachycardia (fixed, elevated heart rate), decreased heart rate variability, exercise intolerance, abnormal blood pressure regulation
– Clinical implications: increased sensitivity to the cardiovascular adverse effects of medications
• Gastrointestinal: gastroparesis, constipation, diarrhea (especially at night), and incontinence
– Clinical implications: absorption of medications may be altered, drugs that increase gastrointestinal mobility (metoclopramide, domperidone, erythromycin) have limited effectiveness
• Urogenital: bladder dysfunction leading to overflow incontinence, erectile dysfunction

Can have hypotension, postural hypo
Bp doesn’t vary according to exercise
Gastroparesis is a condition that affects the normal spontaneous movement of the muscles (motility) in your stomach

Question 13

screening for neurptahy tiemline

Answer 13

Screening
– Type 1: annually, starting 5 years after diagnosis
– Type 2: annually, starting at diagnosis
• Include both careful history and physical assessment
– Temperature, pinprick, monofilament, vibration
– Visual inspection for ulcerations
• Tight glycemic control will reduce risk of onset and slow progression
• Pharmacologic therapy may be required to manage neuropathic pain

Question 14

Neuropathic Pain Management

Goals of Therapy

Answer 14

Reduce the pain intensity
– Target: 30-50% reduction
• Improve health-related quality of life
• NOTE: Given diversity of neuropathic pain symptoms, causes, and
patient responses, treatment must be individualized
– Neuroreceptor reuptake inhibitors (tricyclic antidepressants [TCAs], serotonin and norepinephrine reuptake inhibitors [SNRIs])
– Anticonvulsant medications (gabapentin, pregabalin)

Firing inappropriately
Use nuero reuptake inhibitors
Sodium based anticonvulsants (phenytoin, barbital) has more side effects so not used anymore

Question 15

Foot Ulcers & Infections

Answer 15

Diabetes is a leading cause of lower limb amputations
• Clinical Progression:
• Breakdown of skin surface
• Ulceration
• Infection (multiple organisms)
• Gangrene and osteomyelitis
• Amputation
• Screening
– Daily visual inspection of feet
– Healthcare professional should inspect the feet at least annually
• Treatment (corns, calluses, ingrown toenails, warts, splinters, or other wounds):
– Referral to foot care specialists
– Aggressive management of infections

Neuropathy Peripheral: Poor Sensation & Ambulation
Vascular Disease: Poor tissue penetration

Question 16

which vaccines to get?

mental health?

Answer 16

– Annual influenza vaccine
– Pneumococcal vaccine

– Conditions specific to diabetes include diabetes distress, psychological
insulin resistance, and persistent fear of hypoglycemic episodes.
– A wide range of psychiatric disorders, including depression, schizophrenia,
anxiety, and sleep disorders are more common in people with diabetes
compared to the general population.
– All individuals with diabetes should be regularly screened for the presence
of diabetes distress and symptoms of common psychiatric disorders.

Question 17

only 62% and 46% of T2D pts say they had their _______ and ______ checked by a health professional in past year

Answer 17

eyes, feet