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Year 2 Endo > Microvascular complications of Diabetes > Flashcards

Microvascular complications of Diabetes Flashcards

(45 cards)

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1
Q

What are the sites of microvascular complications?

A

Retinal arteries
Renal glomerular arterioles
Vasa nervosum

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2
Q

What are Vasa Nervosum

A

tiny blood vessels that supply nerve

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3
Q

What is the relationship of risk with rising HbA1c?

A

Extent of hyperglycaemia (as judged by HbA1c) is strongly associated with the risk of developing microvascular complications

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4
Q

What is the relationship at high HbA1c’s?

A

At higher HbA1c levels the line gets steeper

For a small increase in HbA1c you get a large increase in risk

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5
Q

What does the large risk increase mean for management?

A

Huge margins to gains from a small reduction in HbA1c

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6
Q

What is the relationship between hypertension and risk?

A

Clear relationship between rising systolic BP and risk of MI and microvascular complications in people with T2DM and T1DM

Therefore prevention of complications requires reduction in HbA1c and BP control

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7
Q

What other factors relate to the development of microvascular complications?

A

Severity of hyperglycaemia

Hypertension

Genetic factors – some people develop complications despite reasonable control

Hyperglycaemic memory – inadequate glucose control early on can result in higher risk of complications LATER, even if HbA1c improved

Duration? Glucose variability?

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8
Q

What is the mechanism of damage?

A

Oxidative stress
Production of advanced glycated end product which disrupts production of proteins
Local activation of pro-inflammatory cytokines

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9
Q

What are the main features of diabetic retinopathy?

A

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

early stages of retinopathy are all asymptomatic

therefore screening is needed to detect retinopathy at a stage at which it can be treated before it causes visual disturbance / loss

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10
Q

How is early detection of retinopathy achieved?

A

annual retinal screening, which involves retinal imaging: national screening programme.

People with advanced retinopathy are referred to a specialist for treatment and may be seen more frequently

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11
Q

What is the mechanism of diabetic neuropathy?

A

Hyperglycaemia leads to protein kinase C activation

Disruption of the endothelium

Retinal ischaemia (leaky vessels)

Vascular oedema

Releases factors that lead to retinal neovascularisation

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12
Q

What are the 3 stages of retinopathy?

A

Background
Pre-proliferative
Proliferative

Maculopathy, which can occur at any stage of retinopathy

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13
Q

What are the features of background retinopathy?

A 
Hard exudates (cheese colour, lipid)
Microaneurysms (“dots”)
Blot haemorrhages
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14
Q

What are the features of pre-proliferative retinopathy?

A

Cotton wool spots also called soft exudates

Represent retinal ischaemia

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15
Q

What are the features of proliferative retinopathy?

A

Visible new vessels

On disk or elsewhere in retina

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16
Q

What are the features of maculopathy?

A

Hard exudates / oedema near the macula
Same disease as background, but happens to be near macula
This can threaten direct vision

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17
Q

How do you treat background retinopathy?

A

Continued annual surveillance

Feedback to person living with diabetes

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18
Q

How do you treat pre-proliferative retinopathy?

A

If left alone will progress to new vessel growth

So, early panretinal photocoagulation

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19
Q

How do you treat proliferative retinopathy?

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A

Panretinal photocoagulation

20
Q

How do you treat maculopathy?

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A

Oedema: Anti-VEGF injections

Grid photocoagulation

21
Q

What causes diabetic nephropathy?

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A

Hypertension
Progressively increasing proteinuria
Progressively deteriorating kidney function
Classic histological features

22
Q

How are people screened for diabetic nephropathy?

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A

Actively screened for and monitored with by measurement of albumin in urine

This can be done in a spot urine sample (rather than a 24-hr collection) and expressed as a ratio to creatinine: Urine albumin creatinine ratio.

23
Q

Why is nephropathy important?

Study These Flashcards
A

Associated with progression to end-stage renal failure requiring haemodialysis

Healthcare burden

Associated with increased risk of cardiovascular events

24
Q

What is the relationship between macro and micro vascular complications?

Study These Flashcards
A

Microvascular complications increase risk for Macrovascular complications

25
What are the histological features of diabetic nephropathy?
GLOMERULAR CHANGES Mesangial expansion Basement membrane thickening Glomerulosclerosis
26
What is the epidemiology of nephropathy?
Type 1 DM : 20-40% after 30-40 years Type 2 DM : Probably equivalent – BUT Age at development of disease Ethnic differences Age at presentation
27
How do you diagnose nephropathy?
Progressive proteinuria (urine ACR - Albumin:Creatinine ratio) Increased blood pressure Deranged renal function (eGFR) Advanced: peripheral oedema
28
What are the ranges for microalbuminuria?
>2.5 mg/mmol (men) | >3.5 mg/mmol (women)
29
What is the mechanism of nephropathy?
Diabetes associated with hypertension High BP at glomerular level Destruction of glomeruli Interstitial fibrosis Decreased GFR
30
What are the strategies for intervention for nephropathy?
Decreasing HbA1c reduces risk of microvascular complications Manage blood pressure Inhibit the renal-angiotensin-aldosterone system SGLT-2 inhibition
31
Why does a blockade of RAS work?
Mediation of glomerular hyperfiltration Increased tubular uptake of proteins Induction of pro fibrotic cytokines Stimulation of glomerular and tubular growth Generation of ROS & NF-kB Stimulates fibroblast proliferation Up regulation of adhesion molecules on endothelial cells Up regulation of lipoprotein receptors
32
Summarise nephropathy treatment?
1. Aim for tighter glycaemic control 2. Reduce BP as much as tolertated 3. Usually through ACEi or A2RB 4. Stop smoking 5. Start an SGLT-2 inhibitor if T2DM?
33
What are the main features of diabetic neuropathy?
Diabetes is the most common cause of neuropathy and therefore lower limb amputation Small vessels supplying nerves are called vasa nervorum Neuropathy results when these get blocked
34
What are the different types of diabetic neuropathy?
``` Peripheral polyneuropathy Mononeuropathy Mononeuritis multiplex Radiculopathy Autonomic neuropathy Diabetic amyotrophy ```
35
Why are people with diabetes at risk of foot issues?
Longest nerves supply feet Loss of sensation More common in tall people Danger is that patients will not sense an injury to the foot (eg. Stepping on a nail) All people with diabetes: annual foot check with GP
36
What are the clinical features of peripheral neuropathy?
Loss of sensation (10g monofilament) Loss of vibration sense Loss of temperature sensation Loss of proporioception Loss of ankle jerks Classic ‘glove and stocking’ distribution Danger is no sense an injury to the foot (eg. Stepping on a nail)
37
How do you manage peripheral neuropathy?
1. Regular inspection of feet by affected individual 2. Good footwear 3. Avoid barefoot walking Podiatry and chiropody if needed
38
How do you manage peripheral neuropathy with ulceration?
``` Multidisciplinary diabetes foot clinic Offload pressure Revascularisation if concomitant Peripheral Vascular Disease Antibiotics if infected Orthotic footwear Amputation if all else fails ```
39
What is mononeuropathy?
Usually sudden motor loss wrist drop, foot drop Cranial nerve palsy: double vision due to 3rd nerve palsy
40
What is mononeuritis multiplex?
A random combination of peripheral nerve lesions
41
What is radiculopathy?
Pain over spinal nerves, usually affecting a dermatome on the abdomen or chest wall
42
What is autonomic neuropathy?
Loss of sympathetic and parasympathetic nerves to GI tract, bladder, cardiovascular system
43
What is autonomic neuropathy?
Loss of sympathetic and parasympathetic nerves to GI tract, bladder, cardiovascular system
44
What are the GI symptoms of autonomic neuropathy?
Difficulty swallowing Delayed gastric emptying: nausea and vomiting Constipation / nocturnal diarrhoea Bladder dysfunction
45
What are the Cardiovascular symptoms of autonomic neuropathy?
Postural hypotension: can be disabling: collapsing on standing. Cardiac autonomic supply: case reports of sudden cardiac death

Year 2 Endo (15 decks)

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