Vascular complications of DM Flashcards by Ell Loukily

what are the microvascular complications of diabetes mellitus?

retinopathy
nephropathy
neuropathy

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what are the macrovascular complications of diabetes mellitus?

cerebrovascular disease
ischaemic heart disease
peripheral vascular disease

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what is the target HbA1c to reduce risk of microvascular complications?

53mmol/mol (<7%)

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what are the other risk factors (besides HbA1c) for complications of diabetes?

duration of diabetes
smoking- endothelial dysfunction
genetic factors
hyperlipidaemia
hyperglycaemic memory- inadequate glucose control early on can lead to higher risk of complications later even with improved HbA1c
hypertension

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how do we aim to detect retinopathy?

through screening as early stages are asymptomatic

we want it to be early when it can be treated before visual disturbances/loss

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describe the appearance of a normal retina

optic disk: bright spot visible
thin veins semi visible
macula: dense/pink spot visible

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describe background retinopathy?

hard exudates (white cheesy spots)
microaneuyrsms (dots)
blot haemorrhages
enhanced blood vessels

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describe pre proliferative retinopathy

more extensive haemorrhage
soft exudates (cotton wool spots)
represents retinal ischaemia

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describe proliferative retinopathy

new vessels visible

on disk or elsewhere in retina

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describe maculopathy retinopathy

hard exudates/oedema near macula
(same as background just near macula)
can threaten vision

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how do you treat background retinopathy?

you can’t.
annual surveillance
lifestyle changes

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how do you treat pre proliferative retinopathy

early panretinal photocoagulation

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how do you treat proliferative retinopathy?

panretinal photocoagulation

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how do you treat diabetic maculopathy?

grid photocoagulation

anti-VEGF injections directly into eye

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what are the risks of panretinal photocoagulation?

loss of some peripheral vision

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how do you diagnose diabetic nephropathy?

Progressive proteinuria (urine albumin:creatinine ratio):
- Microalbuminuria: >2.5mg/mmol
- Proteinuria = ACR >30mg/mmol
- Nephrotic range >3000mg/24hr
Increased BP
Deranged
 eGFR
Advanced: peripheral oedema

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what is the mechanism of diabetic nephropathy?

hypertension & hyperglycaemia lead to glomerular hypertension
this leads to proteinuria, glomerular &interstitial fibrosis
glomerular filtration rate decline
renal failure

what is the renin-angiotensin system?

angiotensinogen in liver, kidney produces renin which converts this to angiotensin I
angiotensin converting enzyme converts this to angiotensin II which causes vasoconstriction and release of aldosterone from the zona glomerulosa of the adrenal cortex

what is given to prevent further decline of nephropathy?

Block RAS with ACE inhibitors (ACEi) or angiotensin-2 receptor blockers (ARB)- no evidence that both at the same time is beneficial (Can lead to hyperkalemia)

when are nephropathy treatments prescribed?

even when normotensive with microalbuminuria or proteinuria

how is nephropathy managed?

smoking cessation
tighter glycaemic control 
reduce blood pressure via ACEi or A2RB
aim for BP <130/80mmhg
start SGLT-2 inhibitor if T2DM

when does diabetic neuropathy occur?

Small blood vessels supplying nerves are called vasa nervorum
Diabetic neuropathy occurs when vasa nervorum get blocked (blood vessels supplying nerves)

what are the risk factors of diabetic neuropathy?

age
duration of diabetes
poor glycaemic control
height
smoking
prescence of diabetic retinopathy

where is most common for diabetic neuropathy to show?

What is an associated danger?

glove & stocking distribution
longest nerves supply feet- so most common in feet
danger is that patients will not sense injury foot

what is included in annual foot checks?

``` inspection for foot deformity, ulceration assess sensation (monofilament, ankle jerks) assess foot pulses (dorsalis pedis, posterior tibial) ```

when is the risk of ulceration highest?

patients with reduced foot sensation (peripheral neuropathy) | poor vascular supply to feet (peripheral vascular disease)

what is the management of peripheral neuropathy with ulceration?

``` multidisciplinary diabetes foot clinic offloading revascularisation if concomitant PVD antibiotics if infected orthotic footwear amputation ```

presentation of mononeuropathy

usually sudden motor loss (foot drop, wrist drop) | cranial nerve palsy - double vision due to 3rd nerve palsy

what is autonomic neuropathy?

damage to sympathetic & parasympathetic nerves innervating GI tract, bladder, CV system

what are the GI effects of autonomic neuropathy?

delayed gastric emptying (makes post prandial insulin hard) | constipation/nocturnal diarrhoea

how is the CV system affected by autonomic neuropathy?

``` postural hypertension (collapsing on standing) cardiac autonomic supply causing sudden cardiac death ```

what are the non-modifiable risk factors for macrovascular complications of DM?

age sex birth weight FH/genetics

what are the modifiable risk factors for macrovascular complications of DM?

dyslipidaemia hypertension smoking central obesity

how is CV risk in DM managed?

``` support smoking cessation blood pressure control lipid profiles weight interventions annual microalbuminuria screens ```

What is the mechanism of damage leading to microvascular complications?

Increased formation of mitochondrial superoxide free radicals in endothelium Generation of glycated plasma proteins to form advanced glycation end products (AGEs) Activation of inflammatory pathways (pro-inflammatory cytokines) Damaged endothelium results in: - leaky capillaries - ischaemia

What are 3 things hyperglycemia and hyperlipidemia can lead to in the mechanism of damage?

Oxidative stress AGE-RAGE Hypoxia

How is diabetic retinopathy screened for in the uk?

Annual screening for all patients with diabetes

Why is diabetic nephropathy important?

Associated with progression to end-stage renal failure requiring haemodialysis Healthcare burden Associated with increased risk of CV events

what is the management of peripheral neuropathy no ulceration?

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

Whos most at risk of cardiovascular mortality?

Males with T1DM | Females with T1DM