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Endocrinology > 17. Microvascular complications > Flashcards

17. Microvascular complications Flashcards

1
Q

What are the sites of microvascular complications?

A
  • Retinal arteries
  • Glomerular arterioles (kidney)
  • Vasa nervorum (supply nerves)
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2
Q

Why does high glucose lead to microvascular damage?

A
  • Oxidative stress, hypoxia etc.
  • Changes in the inflammatory cascades
  • Local activation of pro-inflammatory cytokines
  • Retinopathy, nephropathy, neuropathy

(genetic predisposition also has an affect)

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3
Q

Describe diabetic retinopathy and its progression

A

• Main cause of visual loss in people with diabetes, and blindness in people of working age
• Involves hard exudates, microaneurysms and blot haemorrhages
• Reaches ‘pre-proliferative diabetic retinopathy’ if diabetes is not controlled
- get cotton wool spots (soft exudates) - represents retinal ischaemia
• If not treated, reaches ‘proliferative retinopathy’
- visible, new vessels form within the retina
- not smooth and can haemorrhage

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4
Q

What is maculopathy?

A
  • Type of retinopathy that affects colour vision
  • Same disease, but hard exudates are near macula
  • Only affects the macula
  • Causes severe visual impairment and threatens direct vision
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5
Q

How can you prevent the progression of retinopathy?

A
  • Pan-retinal photocoagulation
  • Laser beams target parts of the retina and burn them off
  • This prevents vessel formation
  • Urgent procedure if patients have proliferative DR
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6
Q

How can you prevent the progression of maculopathy?

A
  • Grid of photocoagulation

* Just carried out on the macula

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7
Q

What are the signs of diabetic nephropathy?

A
  • Hypertension
  • Progressively increasing proteinuria
  • Progressively deteriorating kidney function
  • Classic histological features
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8
Q

What is the most common cause of kidney problems?

A

Diabetes

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9
Q

What are the histological features of diabetic nephropathy?

A 
• Glomerular changes
- mesangial expansion
- BM thickening
- glomerulosclerosis
• Vascular changes
• Tubulointerstitial changes
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10
Q

When are biopsies done on patients with diabetic nephropathy?

A
  • Rarely done
  • By the time you have diabetic nephropathy, you should already have diabetic retinopathy
  • Biopsies done when there haven’t been any changes in the eyes - suggest kidney disease is not related to diabetes
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11
Q

How does the epidemiology of diabetic nephropathy compare in T1D and T2D?

A

• T1D - 20-40% have nephropathy after 30-40 years
• T2D
- probably equivalent
- complications probably occur between 60-70
- racial factors predispose to complications
- loss due to cardiovascular morbidity

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12
Q

What is the normal and nephrotic range of proteinuria?

A
  • Normal <30mg/24hr

* Nephrotic >3000mg/24hr

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13
Q

What is hypoalbuminaemia and how is this related to diabetes?

A
  • Low albumin (protein) in the blood
  • Causes patients to become oedematous (fluid in legs and feet)
  • Part of nephrotic syndrome
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14
Q

What are the (4) stages of intervention in diabetic nephropathy?

A
  • Diabetes control
  • Blood pressure control
  • Inhibition of activity of the RAS
  • Stopping smoking
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15
Q

What are the effects of Angiotensin II?

A
  • Vasoconstriction
  • Mediation of glomerular hyperfiltration
  • Increased tubular uptake of proteins
  • Induction of pro-fibrotic and pro-inflammatory cytokines
  • Stimulation of glomerular and tubular growth
  • Podocyte effects
  • Upregulation of adhesion molecules on endothelial cells
  • Upregulation of lipoprotein receptors
  • Stimulates fibroblast proliferation
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16
Q

How do ACE inhibitors affect renal function?

A
  • Reduce worsening

* Improve function in patients with diabetic nephropathy

17
Q

What is the most common cause of neuropathy?

A

Diabetes

18
Q

When do you get neuropathy?

A

Vasa nervorum vessels get blocked

19
Q

What are the changes seen in diabetic neuropathy?

A
  • Peripheral polyneuropathy
  • Mononeuropathy
  • Mononeuritis multiplex
  • Radiculopathy
  • Autonomic neuropathy
  • Diabetic amyotrophy - muscle affected
20
Q

What is peripheral neuropathy?

A
  • Longest nerves are affected in the body e.g. those supplying the feet
  • Loss of sensation
  • More common in tall people
21
Q

How can you test sensation in the feet in the clinic?

A
  • Monofilament - metal wire with a set pressure

* Placed at different positions on the bottom of the foot

22
Q

What are the risks with having peripheral neuropathy?

A

• Danger of not sensing injury to the foot
• Risk of joint problems
- don’t know how much pressure to put on your foot
• Results in loss of ankle jerks and loss of vibration sense
• Cause multiple fractures

23
Q

What is mononeuropathy and how does it present?

A

• One part of the nerve doesn’t work (commonly affect the muscles)
• Usually sudden motor loss (wrist drop, foot drop)
• Patient may get cranial nerve palsies
- most common is a 3rd nerve palsy - double vision

24
Q

What is pupil sparing third nerve palsy?

A

• Oculomotor nerve has various parasympathetic fibres on the outside
- these don’t easily lose blood supply in diabetes - continue to work
- pupil is therefore spared and responds to light
• Eye is usually ‘down and out’
- trochlear nerve pulls it down, abducens nerve pulls it out
•

25
Q

When is third nerve palsy non-pupil sparing?

A
  • If someone has an aneurysm that causes third nerve palsy
  • Parasympathetic fibres are compressed
  • Causes fixed dilated pupil
26
Q

What is mononeuritis multiplex?

A

A random combination of peripheral nerve lesions

27
Q

What is radiculopathy?

A
  • Pain over spinal nerves

* Usually affecting a dermatome on the abdomen or chest wall

28
Q

What is autonomic neuropathy?

A
  • Loss of sympathetic and parasympathetic nerves to GIT, bladder and CVS
  • GIT - dysphagia, delayed gastric emptying, constipation/nocturnal diarrhoea, bladder dysfunction
  • Postural hypotension
  • Cardiac autonomic supply - case reports of sudden cardiac death
29
Q

When do you measure changes in the HR with an autonomic neuropathy?

A
  • Measure HR in response to Valsalva manoevre
  • Normally a change in heart rate
  • Look at ECG and compare R-R intervals

Endocrinology (17 decks)

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