18. Long term diabetic complications

Question 1

What are long term diabetic complications split into?

Answer 1

Macrovascular and microvascular

Question 2

What are some microvascular complications?

Answer 2

retinopathy
nephropathy
neuropathy

Question 3

Macrovascular complications

Answer 3

IHD
CVD
PVD

Question 4

Microvascular complications

Answer 4

Most cells are able to reduce glucose transport in response to extracellular hyperglycaemia
• Retinal endothelial cells
• Mesangial cells of glomerulus
Schwann cells and peripheral nerve cells

• Microvascular complications take many years to develop
• Rare before 5 years of type 1 diabetes
• May be detected at presentation of type 2 diabetes

Question 5

Describe retinopathy

Answer 5

Second commonest cause of blindness in those of working age
4000+ in England blind from diabetic retinopathy
Risk of blindness increased 10-20 fold by DM

(Glaucoma and cataract increased)

Question 6

Retinal microcirculation

Answer 6

Low density of capillaries
Little functional reserve
Flow needs to respond to local needs
Pericytes key to local regulation of flow

Question 7

pathological findings of diabetic retinopathy

Answer 7

Loss of pericytes
Basement membrane thickening
Capillary closure
Ischaemia
VEGF production
Increased capillary permeability

Question 8

Clinical stages of retinopathy

Answer 8

Non-proliferative
Background
Pre-proliferative
Proliferative

Macular Oedema
Sight threatening
Non sight threatening

Question 9

Diabetic retinopathy

Answer 9

Diabetic control important
Blood pressure control important

Laser treatment
- Pan retinal
- Focal
Intra-vitreal anti VEGF Ab

Question 10

neuropathy types

Answer 10

Peripheral neuropathy
Mononeuropathy
Autonomic neuropathy

(Entrapment neuropathy increased)

Question 11

autonomic neuropathy

Answer 11

Gastroparesis
Postural hypotension
Erectile dysfunction
Gustatory sweating
Diarrhoea

Question 12

nephropathy

Answer 12

Commonest cause of ESRD in Western World

Accounts for deaths of 21% of type 1 and 11% of type 2 patients

Question 13

renal microcirculation

Answer 13

Fenestrated glomerular capillaries
Basement membrane
Highly specialised podocytes

Question 14

pathological findings of diabetic nephropathy

Answer 14

Basement membrane thickening
Loss of negative charge 
Podocyte loss
Loss of integrity of filtration barrier
Glomerular sclerosis
Mesangial expansion

Question 15

clinical stages of diabetic nephropathy

Answer 15

Normoalbuminuria -> microalbuminuria (20-200mg.min-1 30-300 mg.24hr -1) -> albuminuria (>200mg.min-1 >300 mg.24hr -1)

Dipstick negative -> dipstick positive

declining GFR with albuminuria

Question 16

Diabetic nephropathy

Answer 16

• Blood pressure control important
• Blockers of RAS system preferred
• Glucose control important but less so once overt proteinuria
• Associated with increased CVD risk
Ultimately renal replacement / transplantation

Question 17

Macrovascular disease

Answer 17

Dramatic increase in risk with diabetes
Patients with type 2 diabetes have multiple RF
Patients with type 1 diabetes have long disease duration
Presentation depends upon vascular bed affected
- Angina/MI
- Stroke
- PVD

Question 18

Risk factors in macrovascular complications of diabetes

Answer 18

Attention to all modifiable risk factors:

• Blood pressure
• Lipids
• Smoking
• (Glucose control)

Question 19

The diabetic foot

Answer 19

Diabetes is the commonest cause of non-traumatic lower limb amputation
PVD
Neuropathy (neuropathic ulcer, Charcot change)
Imapaired leucocyte function