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Phase 2 3. Endocrinology > Microvascular complications of diabetes > Flashcards

Microvascular complications of diabetes Flashcards

(55 cards)

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1
Q

What are acute complications of T1DM?

A

> Ketoacidosis

> Hypoglycaemia

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2
Q

What are chronic microvascular complications of T1DM?

A

Retinopathy
Neuropathy
Nephropathy

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3
Q

What are chronic macrovascular complications of T1DM?

A

Ischaemic heart disease
Peripheral vascular disease
Cerebrovascular disease

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4
Q

Name the two landmark trials comparing conventional with intensive treatment

A

> DCCT

> UKPDS

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5
Q

Describe the intensive treatment used in T1DM

A

Injection of long-acting insulin once a day = basal - prevents ketone formation

Bolus insulin at meal times

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6
Q

What is glycaemic control important for?

A

Can help to prevent microvascular disease

Isn’t important for macrovascular disease

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7
Q

What factors are important in macrovascular disease?

A

General cardiovascular risk factors

  • cholesterol levels
  • HTN
  • smoking
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8
Q

What are the causes of microvascular disease?

A

> Capillary damage

> Metabolic damage

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9
Q

Describe how capillary damage leads to microvascular disease

A

hyperglycaemia -> structural/functional abnormalities in small blood vessels -> increased blood flow -> increased capillary pressure -> thickened/damaged vessel walls -> endothelial damage = exudate (leakage of albumin and other proteins)

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10
Q

Describe how metabolic damage leads to microvascular damage

A

Most tissues require insulin to take up glucose except retina/kidneys/nerves
Glucose flows across cell membranes and is metabolised to sorbitol by aldose reductase

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11
Q

What metabolic changes occur as a result of glucose conc. rising?

A
  • Excessive glucose enters polyol pathway (insulin-independent glucose pathway)
  • sorbitol accumulates
  • Less NADPH is available for cell metabolism
  • Build-up of ROS and oxidative stress
  • Cell damage ensues
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12
Q

What disease is associated with microvascular complications?

A

Diabetes-specific

Only occurs with longstanding hyperglycaemia

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13
Q

Which type of diabetes is microvascular complications more of an issue for?

A

T1DM

T2DM will usually die of CV disease first

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14
Q

What is the common onset of microvascular complications in diabetic patients?

A

T1DM = takes a few years to develop

T2DM = may be present at diagnosis because they may have had the condition for a long time already

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15
Q

What is the treatment for microvascular complications?

A

No cure

Early detection is key

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16
Q

What are the common features of early stage (non-proliferative retinopathy?

A
  • Microaneurysms
  • Dot haemorrhages
  • Hard exudates
  • Cotton wool spots
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17
Q

Describe how microaneurisms occur in early stage retinopathy?

A

Hyperglycaemia causes damage to small vessel wall -> microaneurysms

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18
Q

Describe how dot haemorrhages occur in early stage retinopathy?

A

Occur when the vessel wall is breached

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19
Q

Describe how hard exudates form in early stage retinopathy?

A

From the protein and fluid left behind

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20
Q

Describe how cotton wool spots occur in early stage retinopathy?

A

As a result of micro-infarcts

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21
Q

What are common features of late stage retinopathy?

A
  • Damage to veins
  • Ischaemia
  • Fluid build up
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22
Q

Describe the results of venous damage in late stage retinopathy

A

Causes:

  • venous budding
  • blockage of blood supply
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23
Q

Describe the results of ischaemia in late stage retinopathy

Study These Flashcards
A

-> VEGF and other growth factors

  • neovascularisation occurs but these new blood vessels are very fragile and can easily rupture -> Haemorrhages
  • proliferative retinopathy
  • vitreous haemorrhage
24
Q

Describe the results of fluid build up in late stage retinopathy

Study These Flashcards
A

fluid not cleared from the macular area -> macular oedema

25
How can retinopathy be prevented?
- Good glycaemic control - Smoking cessation - Good BP control
26
How can retinopathy be treated?
``` Address risk factors Opthalmic review: - laser - VEGF inhibitors (bevacizumab) - vitectomy ```
27
How is retinopathy screened?
- Annual retinal screening from the age of 12 years old - camera - refer to opthalmology if sight threatening
28
What are the stages of diabetic nephropathy?
- Renal enlargement and hyperfiltration - Microalbuminuria - Macroalbuminuria - End stage renal failure Process occurs over many years
29
What is microalbuminuria?
Tiny traces of albumin - too small to be detected on dipstick defined as 30-300 mg albumin/24 hours (normal <20) ACR > 3.5mg/mmol Independent CV disease predictor
30
What is the pathophysiology of microalbuminuria
> renal hypertrophy > increase in GFR > afferent arteriole vasodilates - golmerular pressure is increased - thickened glomerular basement membrane - capillary damage due to shear stress on endothelial cells End result = leakage of protein into urine
31
What is the pathophysiology of the later steps of microalbuminuria?
- Progressive glomerulosclerosis - Glomeruli destroyed - Progressive proteinuria - nephrotic range - Renal failure
32
How is nephropathy screened?
Microalbuminuria is screened every year from diagnosis
33
How is microalbuminuria treated?
If present, start with ACEi/angiotensin receptor blocker (helps to prevent progression to macroalbuminuria) Aggressive CV risk reduction - BP <125/75 - Statin - Smokin cessation Improve glycaemic control Refer to renal clinic once patients develop CKD (eGFR <30)
34
What are the different types of neuropathy?
Peripheral (sensory) neuropathy -> most common )glove and stoking distribution) Autonomic neuropathy Mononeuritis multiplex = peripheral neuropathy with damage to 2+ areas Diabetic amyotrophy = proximal diabetic neuropathy
35
What tissue changes are noted in diabetic neuropathy?
capillary damage, including occlusion in the vasa nervorum reduced blood supply to the neural tissue results in impairments in nerve signalling that affect both sensory and motor function
36
How does diabetic neuropathy occur?
Glucose leads to inability to transmit signals through nerves Diabetic neuropathy: - metabolic changes = sorbitol accumulation - vascular changes = capillary damage - structural changes
37
What are the signs of diabetic neuropathy?
- Numbness or loss of feeling (asleep or 'bunched up sock under toes' sensation) - Prickling/tingling - Aching pain - Burning pain - Lancinating pain (sudden, sharp, severe burst of pain) - Unusual sensitivity or tenderness when feet are touched (allodynia)
38
What are the symptoms of diabetic neuropathy?
- Diminished vibratory perception - Decreased knee and ankle reflexes - Reduced protective sensation such as pressure, hot and cold, pain - Diminished ability to sense position of toes and feet
39
What are the treatment options for diabetic neuropathy?
Duloxetine (or amitriptyline) - SSRI Amitriptyline (or pregabalin) - TCA Refer to pain clinic: - Try tramadol (opiod) - Try topical lidocaine (anaesthetic)
40
What is diabetic foot?
Combination of neuropathy (damaged nerve supply) and peripheral vascular disease - infection - ulcers - ischaemia -> reduced blood flow impairs healing
41
What does NICE classify as low risk features for diabetic foot and what recommendations are given?
Normal sensation and pulses | Annual review
42
What does NICE classify as medium risk features for diabetic foot and what recommendations are given?
Neuropathy OR absent pulses | Review by podiatrist ever 3-6/12
43
What does NICE classify as high risk features for diabetic foot and what recommendations are given?
Deformities OR ulceration | Review by podiatrist every 1-3/12
44
What is Charcot foot?
Progressive degeneration of weight-bearing joint
45
How does Charcot foot occur?
Numb foot - no sensations - repetitive microtrauma results and goes unnoticed - stress fractures Increase in dysregulated blood flow to the foot due to vascular disease - increased bone turnover - fragile bone
46
How does Charcot foot present?
With a hot, red, flat foot
47
How is Charcot foot treated?
Needs to be completely immobilised in a plaster cast
48
What are the effects of autonomic neuropathy on different systems?
``` CV = postural hypotension GU = erectile dysfunction GI = gustatory sweating (sweating after ingesting food), gastroparesis (delayed gastric emptying ```
49
What are the different autonomic neuropathies?
Diabetic amyotrophy - painful proximal neuropathy - usually affects thigh/buttock - msucle wasting or weakness, pain, or changes in sensation/numbness of the leg Mononeuritis multiplex - painful, asymmetrical motor and sensory neuropathy - 2 or more nerves
50
What does the annual review of a diabetic patient comprise of?
``` HbA1c Cholesterol, HDL, TG Creatinine Microalbuminuria Lifestyle (exercise, diet, smoking) Drug therapy Mental well-being Visual acuity Retinal screening Pedal pulses Foot sensation BMI BP Erectile dysfunction Contraception ```
51
What needs to be considered in pregnancy for a diabetic patient?
HbA1c at time of conception (key to reducing risk of congenital malformations) Glycaemic control during pregnancy helps to prevent macrosomia Measure baby's abdominal circumference weekly until birth
52
How do insulin pumps work?
deliver insulin in a more physiological way - basal rate then bolus around meals
53
What are the disadvantages of insulin pumps?
no background insulin in system if pump fails training and self management
54
What is continuous glucose monitoring
monitor sits in interstitial fluid and gives a reading every 5 minutes - insulin can be adjusted according to pattern
55
What is a closed loop system
artificial pancreas aim is to remove patient management from equation creating a closed loop between pump and monitor

Phase 2 3. Endocrinology (25 decks)

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