Chronic complications of diabetes Flashcards
Name the main MACROvascular complications of diabetes.
- Metabolic syndrome - Coronary artery disease: myocardial ischaemia/infarction, chest pain, SOB; can be asymptomatic - Peripheral vascular disease - toe, foot, limb ischaemia and infarction, intermittent claudication, acute ischaemia (pain, pallor, cold, pulseless), foot ulceration - Cerebrovascular disease: TIA, stroke, neurological symptoms eg speech, gait, power, sensory symptoms
What is the leading cause of mortality in both T1DM and T2DM?
Cardiovascular disease 80% of global deaths.
What is the process that underpins Cardiovascular disease?
Atherosclerosis. 1. Injury and chronic inflammation in arterial wall results in accumulation of oxidised lipids and LDL in endothelium 2. inflammatory response leads to Macrophage infiltration, foam cell formation and smooth muscle cell proliferation 3. The lipid rich lesion that forms can eventually rupture causing an acute ischaemic event
How does diabetes worsen atherosclerosis?
Atherosclerosis is accelerated in diabetes because hypoglycaemia stimulates production of advanced glycation end products which cause inflammation and vasoconstriction.
What are the key features of metabolic syndrome that accelerate the cardiovascular risk?
Endothelial dysfunction Hypercoaguability Hypertension Dyslipidaemia Central obesity
What are the key lifestyle measures in patients with diabetes to prevent cardiovascular disease?
- Lifestyle measures (diet, exercise, alcohol moderation, smoking cessation, weight loss) - Blood pressure control using ACEi, ARBs, CCB, thiazide diuretics, K sparing diuretics - Lipid lowering therapy (statins)
How should you manage hypertension in diabetes, which occurs in 75% of patients?
- Measure blood pressure every year in those with no history of hypertension or renal disease - Target blood pressure should be less than 140/80 - In those with retinopathy, nephropathy or known CVD target blood pressure should be less than 130/80 - usual hypertension medication eg CCB, thiazide diuretics eg.
Name the main MICROvascular complications that occur in diabetes.
- Mononeuropathy esp cranial nerves III and IV, median, ulnar and radial nerves - diabetic nephropathy (microalbuminuria and proteinuria) - autonomic neuropathy (CVS, GI, genitourinary) - diabetic peripheral neuropathy (glove and stocking distribution, neuropathic pain “electric shock” pain, lack of sensation, ulceration)
Which processes are driven by hyperglycemia are thought to have a role in disease development?
- advanced glycation end products/AGEs - reactive oxygen species - cytokines eg vascular endothelial growth factor VEGF - hypertension and RAAS activation. ALL result in CELLULAR DAMAGE
Name the three main systems are nerves affected in autonomic neuropathy and at least two symptoms of each
CVS: resting tachycardia, postural hypotension, silent ischaemia, sudden cardiac death GI: gastroparesis, diarrhoea constipation, oesophageal dysmotility Genitourinsry: erectile/bladder dysfunction
Name the management of autonomic neuropathy, and specifically management of gastroparesis and specifically management of erectile dysfunction
Generally - treat symptoms, good glycemic controo Gastroparesis - antiemetics, erythromycin, gastroelectrical stiumlation Erectile dysfunction - phosphodiesterase 5 inhibitors eg tadalafil
Define diabetic nephropathy
Microalbuminuria (20-200μg/min) Proteinuria (>0.5g/24h)
Describe the general principles of managing diabetic nephropathy
- Screen early by Yearly measurement of urinary albumin (creatinine ratio calculated) and yearly measurement of eGFR - Aim for target BP of less than 130/80mmHg - use ACEi and ARBs to control BP and prevent progression of microalbuminuria to proteinuria and End stage renal disease - good glycemic control
When should a referral to a nephrologist be considered in diabetic nephropathy?
If - eGFR falls below 30mL/min/1.73m2 - rapid decline in eGFR in presence of uncontrolled hypertension or unexplained anemia - proteinuria of non diabetic origin (eg if retinopathy is absent)
Describe the three key features of diabetic retinopathy
Caused by 1. Small vessel occlusion 2. Ischaemia leading to new vessel formation 3. Capillary leakage and fibrosis
What are the 4 main changes that occur in diabetic retinopathy?
- Background retinopathy 2. Maculopathy 3. Pre proliferative retinopathy 4. Proliferative retinopathy
Describe this image as seen through an opthalmoscope
This is background diabetic retinopathy.
micro aneurysms (‘dots’), small intraretinal haemorrhages (‘blots’) and lipid exudates forming around a leaking blood vessel (hard exudates).
Describe this image as seen through an opthalmoscope
This is diabetic maculopathy.
Background retinopathy visible within one disc diameter of macula
Describe this image as seen through an opthalmoscope. What is the arrow pointing to?
Describe this image as seen through an opthalmoscope
This is proliferative retinopathy i.e. new vessel formation at the disk or elsewhere
Describe this image as seen through an opthalmoscope
This is laser treated retinopathy.
What are the risk factors for foot ulcer development?
- Peripheral neuropathy reduces awareness of trauma and pain caused by foreign bodies in footwear and shoes.
- Autonomic neuropathy - anihidrosis - skin dries and cracks so portal of infection
- Peripheral vascular disease - local ischaemia - delayed wound healing
- other microvascular complications
- Lack of diabetes minutiring and lack of previous feet examinations
- Trauma/injury
How do you treat AT RISK feet with no ulceration?
Hygiene advice
care with footwear
regular podiatry review
daily examination of feet by patient and/or carer
modified/special footwear
avoid walking barefoot
How should existing diabetic foot ulcers be managed?
All ulcers considered involving bone until proven otherwise.
optimise diabetic control
reduce odema to help healing
regular debriment of callus and dead tissue
infection control
reducing trauma and pressure relief in neuropathic ulcers eg padded socks, aircast boot
revascularisation eg vascular angioplasty
What is Charcot’s athropathy?
Initial insult eg minor trauma causes a fracture leading to progressive bony deformity and destruction
Patients present with acutely swollen hot red foot
“progressive degeneration of a weight bearing joint, a process marked by bony destruction, bone resorption, and eventual deformity due to loss of sensation”
How is a diabetic ulcer severity established?
SINBAD
Site, ischaemia, neuropathy, bacterial infection, area and depth
