Chronic Complications of Diabetes Flashcards
Diabetic Eye Disease, Diabetic Nephropathy, Diabetic Neuropathy
What are the main chronic complications of diabetes?
Macrovascular
= IHD, stroke (due to atherosclerosis)
Microvascular
= Neuropathy, nephropathy, retinopathy (diabetes-specific)
Other
= Cognitive dysfunction, erectile dysfunction, psychiatric complications.
What are the microvascular complications of diabetes?
Neuropathy, nephropathy, and retinopathy
What are the macrovascular complications of diabetes?
Ischaemic heart disease (IHD) and stroke (due to atherosclerosis)
What is the pathophysiology behind diabetic microvascular complications?
Excess glucose overwhelms mitochondria, leading to
AGE formation → inflammation, tissue damage
Sorbitol accumulation → osmotic damage
Increased ROS → oxidative stress
Inflammation & fibrosis → tissue injury
What are the key screenings in a diabetic annual review?
Retinal screening, foot risk assessment, urine ACR, and serum creatinine
What is diabetic retinopathy?
Damage to the retina due to chronic hyperglycaemia
What are the four stages of diabetic retinopathy?
- Mild non-proliferative (background) 2. Moderate non-proliferative
- Severe non-proliferative
- Proliferative
What are the key retinal findings in diabetic retinopathy?
(1) Dot/blot/flame haemorrhages
(2) Cotton wool spots
(3) Hard exudates
(4) IRMA (intra-retinal microvascular abnormalities)
What happens in non-proliferative diabetic retinopathy (NPDR)?
Small vessel damage
→ microaneurysms, haemorrhages, hard exudates, cotton wool spots
What is the key feature of proliferative diabetic retinopathy (PDR)?
Neovascularisation due to VEGF release from ischaemic retina
What is IRMA and how is it different from neovascularisation?
IRMA (Intra-retinal microvascular abnormalities) = precursor to neovascularisation, but vessels are not leaking
What is the major risk of proliferative diabetic retinopathy?
Vitreous haemorrhage → sudden vision loss
What is the primary screening tool for diabetic retinopathy?
Fundoscopic examination (digital retinal screening)
What imaging is used for diabetic macular oedema?
Optical coherence tomography (OCT)
What is the main treatment for proliferative diabetic retinopathy?
Panretinal photocoagulation (laser therapy) – reduces retinal oxygen demand
What is the emergency referral indication in diabetic retinopathy?
Vitreous haemorrhage – immediate ophthalmology referral.
What treatment is used for diabetic macular oedema?
Intravitreal anti-VEGF (vascular endothelial growth factor) injections
What are two common non-retinal eye complications in diabetes?
- Cataracts
- Glaucoma
How frequently should people with diabetes have routine retinal photography?
On an annual (yearly) basis
Other than retina photography assessment, what other eye tests are routinely performed for people with diabetes?
Visual acuity test
A 64-year-old woman with a 27-year history of type 1 diabetes attends the retinal screening clinic for her retinopathy screen. This is performed using digital photography following pupil dilatation.
Which features on retinal examination would be a trigger for immediate referral to the ophthalmology service?
(1) Proliferative retinopathy - R3 (new blood vessels)
(2) Vitreous haemorrhage
(3) Advanced retinopathy with retinal detachments
A 60-year-old woman with a history of type 2 diabetes presents with a gradual decrease in her vision. She also complains of floaters and difficulty seeing at night.
What is the most appropriate initial test to evaluate her ocular condition?
Fundoscopic examination
A 54-year-old woman with a 15-year history of type 2 diabetes mellitus presents for her annual ophthalmology review. She reports no visual symptoms. Her recent HbA1c is 69 mmol/mol. On fundoscopic examination, there is moderate non-proliferative diabetic retinopathy with macular oedema.
What is the most appropriate next step in the management of this patient?
Intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy
A 58-year-old man with a 15-year history of type 2 diabetes mellitus presents for a routine eye examination. He has not experienced any changes in his vision but mentions that he often forgets to take his diabetes medication. His most recent HbA1c level was 9.2%. On fundoscopic examination, the ophthalmologist notes multiple microaneurysms, dot haemorrhages, and hard exudates in both eyes.
What is the most appropriate next step in management? and wy?
Strict glycemic control and regular follow-up
= For non-proliferative diabetic retinopathy, the primary management involves achieving and maintaining strict glycemic control to slow the progression of the disease
What is Mild Non-Proliferative Diabetic Retinopathy (NPDR) characterised by?
(1) Microaneurysms
(2) Dot haemorrhages on fundoscopy
What is Severe Non-Proliferative Diabetic Retinopathy (NPDR) characterised by?
(1) Beaded veins
(2) Intraretinal microvascular abnormalities (IRMA)
(3) Extensive retinal haemorrhages
What is Moderate Non-Proliferative Diabetic Retinopathy (NPDR) characterised by?
(1) Presence of microaneurysms
(2) Dot and blot haemorrhages cotton-wool spots
(3) Hard exudates on fundoscopy
What is diabetic nephropathy?
Progressive kidney disease caused by damage to the capillaries in the glomeruli
What is another name for diabetic nephropathy?
Kimmelstiel-Wilson Syndrome or Nodular Glomerulosclerosis
What are the key pathological features of diabetic nephropathy?
Proteinuria and diffuse scarring of the glomeruli
How is microalbuminuria defined?
ACR <30 mg/mmol or PCR <50 mg/mmol
How is microalbuminuria confirmed?
Repeat test twice
(2 out of 3 positive tests confirm diagnosis)
Does microalbuminuria show up on a urine dipstick?
No, it does not show as protein++
How is overt proteinuria (nephropathy) defined?
ACR >30 mg/mmol or PCR >50 mg/mmol
What should be done if overt proteinuria is detected?
Repeat on early morning urine (EMU) to confirm
Does proteinuria show up on a urine dipstick?
Yes, it will be positive for protein
What is the first-line treatment for microalbuminuria?
ACE inhibitors (ACEi) or ARBs
Why do ACEi/ARBs cause a slight GFR decline?
They dilate renal arterioles, reducing filtration pressure
Which medication should all diabetic patients with microalbuminuria be started on?
SGLT2 inhibitors (SGLT2i)
regardless of HbA1c
What is the target blood pressure for diabetics?
<140/80 mmHg
How can diabetic nephropathy be prevented?
(1) Strict glycaemic control
(HbA1c ~53 mmol/mol)
(2) Aggressive BP control
What are the key complications of diabetic nephropathy?
(1) Hypertension
(2) Decline in renal function
(3) Vascular disease
What is the typical rate of renal function decline if untreated?
GFR decreases by ~1 ml/min/month
A 58-year old woman with long-standing type 2 diabetes and CKD is reviewed in the nephrology clinic. She is currently taking metformin, gliclazide, ramipril, empagliflozin and rosuvastatin at optimised doses. She was referred to the clinic because her urine albumin-to-creatinine ratio (ACR) was 90 mg/mmol.
What should her target blood pressure be?
<130/80 mmHg
What is diabetic neuropathy?
Damage to the peripheral nervous tissue due to prolonged hyperglycaemia
What is the pattern of diabetic peripheral neuropathy?
‘Glove and stocking’ distribution’
What are the symptoms of peripheral neuropathy?
(1) Numbness, tingling
(2) Burning, sharp pains
(3) Sensitivity to touch
(4) Loss of balance/coordination
How is Charcot’s foot managed?
Non-weight bearing, total contact cast, or air cast boot to prevent further damage
What are the 1st-line treatments for neuropathic pain?
Amitriptyline, duloxetine, gabapentin, pregabalin
What is the 2nd-line treatment for localised pain?
Topical capsaicin cream
Which focal neuropathy is most common?
Carpal tunnel syndrome
A 65-year-old male with long-standing type 1 diabetes mellitus presents to the GP with burning in his feet which is keeping him awake at night. The GP diagnoses diabetic neuropathy and decides to start medical management for it.
What treatment is the first-line treatment of diabetic neuropathy?
Pregabalin, Duloxetine, and Gabapentin
