Chronic Vascular Complications

Question 1

What are the vascular complications of diabetes

Answer 1

Retinopathy, nephropathy, neuropathy

Question 2

What are the microvascular complications

Answer 2

Diabetic retinopathy, nephropathy, neuropathy, amputation

Question 3

What are the macrovascular complications

Answer 3

CHD, ischaemic stroke, congestive heart failure

Question 4

How long does it take for the manifestation of vascular complications of diabetes to occur

Answer 4

5-10 years

Question 5

How does glucose alter angiogenesis in retinopathy

Answer 5

Protective angiogenesis altered due to high glucose. New blood vessel formation in the retina are abnormal - more fragile and delicate. More prone to bleeding. Can get retinal detachment

Question 6

What is the pathogenesis of retinopathy

Answer 6

Hyperglycaemia and chronic inflammation leads to local inflammation -> elevated levels of vascular endothelial GF -> angiogenesis with elevated vascular permeability -> haemorrhage. Vascular damage leads to macular oedema -> visual loss

Question 7

What occurs in the pre-proliferative phase of retinopathy

Answer 7

Basement membrane thickening
Micro-aneurysm formation (microvessel dilatation secondary to peripheral loss of pericytes -> venous statis -> focal proliferation of capillary endothelial cells)
Micro-aneurysm complication: in vessel permeabiltiy with accumulation of exudate and haemorrhage due to rapture
Vascular occlusions: ischaemic lesion with alteration of normal vessel permeability - cotton wool spots = small infarct within the nervous fibre layer)

Question 8

What occurs in the proliferative phase of retinopathy

Answer 8

New vessel formation anterior to the retina on its inner surface within vitreous
Traction of new vessels with haemorrhages formation
Retinal detachment

Question 9

What is diabetic nephropathy a major cause of

Answer 9

End stage renal failure (stage IV)
Microalbuminuria/proteinuria
Increase risk of CVD

Question 10

How does the RAAS system work in diabetes

Answer 10

RAAS over-activated. Drives oxidative stress, inflammation and hypoxia
AGII key effector molecules driving vasoconstriction, increase in aldosterone, efferent constriction, PT reabsorption

Question 11

What drugs are first line in hypertensive treatments

Answer 11

ACE inhibitors and angiotensin receptor blockers

Question 12

How is GFR affected by diabetes

Answer 12

Progressive fibrosis drive by cytokine, GFR starts to fall
More proteinuria occurs
As proteinuria occurs - px has lost 505 of renal function

Question 13

What are the severe debilities in neuropathy

Answer 13

Neuropathic pain, autonomic failure, contribution to diabetic foot ulceration

Question 14

What are the generalised sensory neuropathies

Answer 14

Painful: distal, burning pain at night. Parastheisa/hyperasthesia
Painless: asymptomatic sensory loss, impaired light touch/vibration/temperature
Absent reflexes
Autonomic dysregulation - warm skin, bounding pulses

Question 15

What are the autonomic neuropathies

Answer 15

CV: resting tachycardia, postural hypertension, risk of cardiac arrhythmias/sudden death
GI: gastroparesis, autnomic diarrhoeas
Genitourinary: bladder dysfunction, erectile dysfunction

Question 16

What is the screening procedure of diabetes

Answer 16

Urine tests: ACR over 3 mg/mmol sign of nephropathy
BP
eGFR
Cholesterol
Smoking status
Retinal photography
Foot check
Done at least once a year

Question 17

How can risks be reduced for diabetes

Answer 17

Glycaemic control: new insulins, new oral agents, CBG testing
BP control
ACE inhibitors/SGLT2 antagonist 
Cholesterol control
Smoking cessation