2- diabetic complications Flashcards
what are some main chronic complications of diabetes?
- macrovascular (IHD, stroke)
- microvascular (neuropathy, nephropathy, retinopathy)
- cognitive dysfunction like dementia
- erectile dysfunction
- psychiatric
- microalbuminuria (kidney disease)
what causes microvascular complications in diabetes?
normally = glucose metabolised by glycolysis and makes lots of ATP in citric acid cycle
hyperglycaemia = glucose metabolised in glycolysis but then big blockage traffic jam at citric acid cycle cause so much glucose. this means that it goes through lots of alternative pathways making toxic effects like osmotic damages, reactive oxygen species and inflammation etc
what is retinopathy?
= umbrella term for diseases affecting retina
- diabetic retinopathy
- diabetic macular oedema (maculopathy)
- clouding of lens
- glaucoma (increase in fluid pressure in eye leading to optic nerve damage)
- acute hyperglycaemia= visual blurring
how often do people have retina screening if
a) have no signs
b) have some signs of damage?
a) 2 years
b) 1 year
what are
a) types of haemorrhages
b) cotton wool spots
c) hard exudates
d) IRMA (intraretinal microvascular abnormalities)
e) neovascularization
on retinal screening?
a) dot, blot, flame
b) ischaemic areas
c) lipid breakdown products
d) dilated, torturous capillaries that are precursors to new blood vessels (more stable than neovascularizations)
e) when not enough oxygen →body makes more blood vessels = poorly formed blood vessels though so are very high risk of haemorrhage (bad)
what is outcome for each stage of retinopathy?
mild nonproliferative = rescreen in 12 months
moderate nonproliferative = rescreen in 6 months
severe nonproliferative = refer
proliferative = refer
what is outcome if see
a) hard exudates?
b) blot haemorrhage within 1 disc diameter of fovea?
a) 6 month rescreen
b) refer
what is treatment of retinopathy?
laser = pan retinal photocoagulation
→they zap the retina, best treatment
→go around edge of retina (as don’t need edge to see), destroy retina so reduce oxygen requirement as less of it. basically destroy bits that don’t matter so bits that do matter can get oxygen
= reduces ischaemia that drives retinopathy
what is diabetic macular oedema? how diagnosed & treatment?
= type of maculopathy (disease of macula) where macula swollen with fluid due to leaky blood vessels caused by diabetes
→diagnosed with OCT (optic coherence tomography) = shows if any lifting or distorting of retina
treatment →injections of anti-VEGF (vascular endothelial growth factor) like ranibizumab, sometimes laser too (but can’t destroy macula because that’s how you see so would go blind)
what is nephropathy?
= progressive kidney disease caused by damage to capillaries in kidneys glomeruli
→scarring of kidney characterised by proteinuria - nodular glomerulosclerosis
*in diabetes = filtration system leaks protein in urine
microalbuminuria = incipient nephropathy
proteinuria = overt nephropathy
what is diagnosis of nephropathy?
- egFR below 60 - twice, 3 months apart = reduced kidney function
- elevated urine protein (albumin) = leaky kidneys
*need one or 2 or both for diagnosis
what is eGFR?
estimated glomerular filtration rate = how much filtrates in 1 min. normally 120ml per min
what is ACR and PCR? normal ACR?
ACR = albumin : creatinine ratio
PCR = protein : creatinine ratio
*normal ACR = less than 2.5 in men and less than 3.5 in women
what is urine creatinine?
how concentrated urine is (if drink a lot then lower creatinine)
what is ACR and PCR for diagnosis of microalbuminuria?
ACR = below 30
PCR = below 50
what is ACR & PCR in proteinuria?
ACR = above 30
PCR = above 50
why are multiple urine tests needed to diagnose microalbuminuria?
needs twice with 3 months in between because urine albumin excretion rate varies a lot (during the day, day to day, exercise etc)
- there’s also lots of false positive les menstruation, vaginal discharge, UTI, pregnancy etc
what is treatment for nephropathy?
ACE inhibitor (or ARB) and SGLT2 inhibitor
*ACEi is to reduce pressure & SGLT2 is since they’re good for kidneys
what are types of neuropathy?
- peripheral (stocking)= pain/loss of feeling in hands & feet. most common *IMPORTANT ONE
- proximal = rare, muscle weakness & pain in thighs, hips, butt
- autonomic = changes in bladder, bowel, sexual response, sweating, HR, BP. usually after long history of poor control diabetes
- focal neuropathy = rare, sudden weakness in 1 nerve or nerve group. like carpal tunnel, foot drop
what are symptoms of peripheral neuropathy?
numbness then tingling & burning then sharp pains and cramps then sensitivity to touch then numbness which comes with loss of balance & coordination
*make sure to tell them to check feet everyday as won’t feel if trauma
what is diabetic foot? signs?
the start of peripheral neuropathy (if at worst it’s up to knee and hand too) but mostly found when at foot.
= symptoms can be caused by neuropathy or peripheral vascular disease
neuropathy causes - neuropathic ulcer, clawing toes, charcot foot
PVD - proximal arterial occlusion, digital gangrene
what is charcot arthropathy? treatment?
funky deformed foot = it’s inflammatory process caused by neuropathy which involves fractures & bone destruction
3 different phases:
active = 3 months (hot swollen, destructive phase)
healing = 4-8 months
chronic = +8 months
treat = encourage non weight bearing with cast or aircast (as weight bearing = more deformity)
what medications can help painful neuropathy?
amitriptyline & duloxetine (anti-depressants)
gabapentin & pregabalin (anti-epileptic)
what are some main presentations of autonomic neuropathy?
- gastroparesis = persistent nausea & vomiting since stomach doesn’t empty. dehydrated (treat metoclopramide & anti-emetic)
- oesophagus stuff = difficult swallowing
- dysfunction sweat glands = profuse sweating at night & while eating, poor temp regulation
- orthostatic hypotension
- high HR
