1b Micro and Macro-Vascular Complications of Diabetes

Question 1

What are the three main microvascular complications of diabetes?

Answer 1

retinopathy
nephropathy
neuropathy

Question 2

What are the three main macrovascular complications of diabetes?

Answer 2

Cerebrovascular Disease
Ischaemic Heart Disease
Peripheral vascular Disease

Question 3

What is the target HbA1c level to reduce risk of microvascular complications?

Answer 3

< 53 mmol/mol

Question 4

What does prevention of microvascular complications involve?

Answer 4

Reduction in HbA1c and Blood Pressue

Question 5

What are some other factors which influence the development of microvascular complications of diabetes?

Answer 5

Smoking
Duration of Diabetes
Genetics
Hyperlipideamia
Hyperglycaemic memory

Question 6

What is meant by hyperglycaemia memory?

Answer 6

When inadequate glucose control early on can result in higher risk of complications LATER - even if HbA1c is improved

Question 7

What forms as a result of endothelial damage?

Answer 7

Mitochondrial superoxide free radicals in the endothelium

Question 8

What are AGEs?

Answer 8

Glyctaed plasma proteins - forms Advanced Glycation End Products

Question 9

What does the formaiton of AGE’s result in?

Answer 9

Kick starts the inflammatory pathways

Question 10

What are the consequences of a damaged endothelium?

Answer 10

Leaky Capillaries
Ischaemia

Question 11

What causes the blurred vision which is sometimes seen in patients with diabetes?

Answer 11

Swelling of the lens due to more glucose in the blood = not the same as retinopathy

Question 12

Why is screening for retinopathy needeD?

Answer 12

Early stages of retinopathy is asymptomatic , therefore screening is needed to detect it early on before it causes a visual disturbance

Question 13

What are the three main characteristics of background retinopathy?

Answer 13

Hard exudates
Microaneurysms
Blod Haemorrhages

Question 14

What are hard exudates?

Answer 14

Leakages of lipid from the capillary

Question 15

What are the signs of pre-proliferative retinopathy?

Answer 15

Cotton wool Spots / soft exudates
haemorrhage

Question 16

What do the changes associated with pre-proliferative retinopathy indicate?

Answer 16

Retinal ischaemia

Question 17

What is the sign of proliferative retinopathy?

Answer 17

Visible new blood vessels - on the disc or elsewhere in the retina

Question 18

What is maculopathy?

Answer 18

Same disease as background retinopathy - hard exudates, but NEAR THE MACULA

Question 19

Why is maculopathy particularly threatening?

Answer 19

Macula is important for nearby colour vision, so loss can threaten vision significantly

Question 20

What is the first step in treating any stage of retinopathy?

Answer 20

1. improve HbA1c, Stop Smoking, Lower Lipids
2. Good blood pressure control

Question 21

What is the treatment of background retinopathy?

Answer 21

Continued annual surveillace

Question 22

What is the treatment of pre-proliferative retinopathy?

Answer 22

panretinal photocoagulation

Question 23

What is the treatment of proliferative retinopathy?

Answer 23

Panretinal photocoagulation

Question 24

What is the treatment of maculopathy?

Answer 24

Anti-VEGF directly into the eye
Vascular Endothelial Growth Factor

Grid Photocoagulation

Question 25

What is the side effect of pan-retinal photocoagulation?

Answer 25

reduces peripheral vision

Question 26

What is diabetic nephropathy associated with?

Answer 26

increase risk of Cardiovascular events

Question 27

What is the early sign of diabetic kidney damage?

Answer 27

Microalbuminuria - >2.5 mg/mol

Question 28

What is needed for a diagnosis of nephropathy?

Answer 28

1. Progressive proteinuria 2. Increased blood pressure 3. Deranged renal function 4. Peripheral oedema - advanced

Question 29

how is proteinuria measured?

Answer 29

Albumin:Creatinine Ratio (ACR)

Question 30

What is the mechanism of diabetic nephropathy?

Answer 30

1. Hyperglycaemia and Hypertension causes pressure to build up in the glomerulus 2. This causes proteinuria as pressure is forced out into the urine 3. This leads to glomerular and interstitial fibrosis which damages the glomerulus 4. GFR declines, leading to renal failure

Question 31

Describe how the RAS system works?

Answer 31

1. Liver releases Angiotensinogen 2. Renin from the kidney converts Antiotensinogen to Angiotensin I 3. Angiotensin I -> Angiotensin II through ACE

Question 32

What are the two main effects of Angiotensin II?

Answer 32

1. vasoconstriction 2. Acts on the zona glomerulosa of the adrenal cortex to promote water reabsorption

Question 33

What are the two antihypertensive medications which are given to treat nephropathy

Answer 33

ACEi ARB

Question 34

All diabetes patients with microalbuminuria/proteinuria should be given what?

Answer 34

ACEi / ARB, even if they have a normal blood pressure

Question 35

Microalbuminuria is a risk factor for what?

Answer 35

Cardiovascular complications

Question 36

What is the management of diabetic nephropathy?

Answer 36

1. tighter glycaemic control 2. ACEi/ARB 3. Reduce BP 4. Stop smoking

Question 37

What is neuropathy?

Answer 37

Damage to nervex

Question 38

What is the name of the small blood vessels which supply nerves called?

Answer 38

Vasa nervorum

Question 39

When does neuropathy occur?

Answer 39

When vasa nervorum get blcoked

Question 40

Describe the effect of height in diabetic nephropathy?

Answer 40

Taller = longer nerves = more vulnerable to neuropathy

Question 41

Why is diabetic neuropathy most common in feet?

Answer 41

Longest nerves supply the feet - so more common

Question 42

What is the most common distribution of diabetic neuropathy?

Answer 42

Glove and Stocking distribution - worse at night

Question 43

What two things are assessed for in the foot clinic for patients at risk of diabetic neuropathy?

Answer 43

Assess Sensation Assess Foot Pulses

Question 44

What is looked for in the annual foot check?

Answer 44

Foot ulceration

Question 45

Which patients have a higher risk of foot ulceration?

Answer 45

When you have reduced sensation to the feet - peripheral neuropathy When you have poor vascular supply to the feet - peripheral vascular disease

Question 46

What is the management of peripheral neuropathy?

Answer 46

1. regular foot checks 2. Good footwear / avoid being barefoot

Question 47

What is the management of peripheral neuropathy with ulceration?

Answer 47

1. DIabetes foot clinic 2. Offloading 3. revascularisation if needed 4. Antibiotics if affected 5. Orthotic footwear 6. Amputation

Question 48

What is mononeuropathy?

Answer 48

Sudden motor loss eg foot drop / wrist drop

Question 49

What palsy is an example of mononeuropathy?

Answer 49

3rd nerve palsy - eye looks down and out

Question 50

What is autonomic neuropathy?

Answer 50

Damage to the sympathetic and parasympathetic nerves innnervating the GI Tract, bladder and CV system

Question 51

What are the GI effects of autonomic neuropathy?

Answer 51

Delayed gastric emptying: nausea and vomiting Constipation / nocturnal diarrhoea

Question 52

What are the cardiovascular complications of autonomic neuropathy?

Answer 52

Postural hypertension when the blood pressure gets too low Cardiac autonomic supply - sudden cardiac death

Question 53

What does the prevention of macro-vascular disease involve?

Answer 53

aggressive management of multiple risk factors

Question 54

What are the non-modifiable risk factors for macrovascular disease?

Answer 54

Age Sex birth Weight FH/genes

Question 55

What are the modifiable risk factors for macrovascular complications?

Answer 55

Dyslipidaemia Hypertension Smoking DM Central Obesity

Question 56

How is the CV risk managed in DM?

Answer 56

Smoking Cessation Blood Pressure - might need multiple agents Lipid profile Weight - discuss lifestyle intervention Annual microalbuminuria screen