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MBChB IV Endocrinology > Complications of chronic diabetes > Flashcards

Complications of chronic diabetes Flashcards

1
Q

Does persistent albuminuria favour diabetic nephropathy or an alternate renal diagnosis?

A

Diabetic nephropathy

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2
Q

Does bland urine sediment favour diabetic nephropathy or an alternate renal diagnosis?

A

Diabetic nephropathy

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3
Q

Does slow progression of disease favour diabetic nephropathy or an alternate renal diagnosis?

A

Diabetic nephropathy

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4
Q

Does low eGFR assoc w/ overt proteinuria favour diabetic nephropathy or an alternate renal diagnosis?

A

Diabetic nephropathy

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5
Q

Does the presence of other complications of diabetes favour diabetic nephropathy or an alternate renal diagnosis?

A

Diabetic nephropathy

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6
Q

Does known duration of DM >5y favour diabetic nephropathy or an alternate renal diagnosis?

A

Diabetic nephropathy

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7
Q

Does extreme proteinuria >6g/d favour diabetic nephropathy or an alternate renal diagnosis?

A

Alternate renal diagnosis

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8
Q

Does persistent haematuria/active urinary sediment favour diabetic nephropathy or an alternate renal diagnosis?

A

Alternate renal diagnosis

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9
Q

Does rapidly falling eGFR favour diabetic nephropathy or an alternate renal diagnosis?

A

Alternate renal diagnosis

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10
Q

Does Low eGFR w/ little to no proteinuria favour diabetic nephropathy or an alternate renal diagnosis?

A

Alternate renal diagnosis

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11
Q

Does absence of other diabetic complications/lack of severity favour diabetic nephropathy or an alternate renal diagnosis?

A

Alternate renal diagnosis

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12
Q

Does known duration <5y of diabetes favour diabetic nephropathy or an alternate renal diagnosis?

A

Alternate renal diagnosis

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13
Q

Does family history or non-diabetic renal disease favour diabetic nephropathy or an alternate renal diagnosis?

A

Alternate renal diagnosis

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14
Q

Do signs/symptoms of a systemic disease favour diabetic nephropathy or an alternate renal diagnosis?

A

Alternate renal diagnosis

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15
Q

Chronic microvascular complications of diabetes mellitus

A

Diabetic nephropathy
Diabetic retinopathy
Peripheral neuropathy

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16
Q

Chronic macrovascular complications of diabetes mellitus

A

Stroke
MI
Peripheral artery disease (PAD) -> amputation

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17
Q

Name signs of diabetic nephropathy

A

Raised urine protein and/or serum creatinine

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18
Q

Name signs of diabetic retinopathy

A

Retinal changes -> blindness
Cataracts
Glaucoma

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19
Q

Name signs of peripheral neuropathy

A

Pins and needles of feet/hands

Numbness of feet -> ulcers + amputation

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20
Q

Name signs of autonomic neuropathy

A 
Bladder dysfunction
Bowel dysfunction
Erectile dysfunction
Postprandial vomiting
Tachycardia
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21
Q

What is the definition of microalbuminuria?

A

ACR≥2.0mg/mmol

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22
Q

Diabetic neprhopathy happens in a number of diabetic patients irrespective of glycemic control
True or false?

A

Often true

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23
Q

Diagnostic criteria for CKD in diabetes according to SEMDSA

A

ACR≥2.0 mg/mmol and/or
eGFR<60mL/min
If abnormal, repeat in 3 months

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24
Q

What does the lab need to convert serum creatinine to eGFR?

A

Age
Race
Sex

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25
Q

What does ACR stand for?

A

Urine albumin:creatinine ratio

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26
Q

Diagnostic criteria for CKD in diabetes according to SA DOH?

A

Positive urine dipstix OR

ACR >3mg/mmol

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27
Q

When do you not need to send urine to exclude microalbuminuria according to the SA DOH?

A

Patient on ACE-inhibitor

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28
Q

Name potential causes for transient albuminuria

A 
Recent major exercise
UTI
Febrile illness
Decompensated CHF
Menstrutation
Acute severe blood glucose elevation
Acute severe blood pressure elevation
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29
Q

How do you reduce the progression to diabetic nephropathy?

A

Optimal glycemic control

Optimal BP control (ACE-I or ARB)

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30
Q

Which diabetic treatment drug class has been shown to reduce the onset and progression of diabetic nephropathy?

A

SGLT2 inhibitors

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31
Q

When do you refer a patient with diabetic nephropathy?

A

Chronic, progressive kidney function loss
ACR persistently >60mg/mmol
eGFR<30ml/min
Unable to achieve target BP
Unable to remain on renal protective therapy due to hyperkalemia
>30% increase in serum creatinine w/in 3months of ACE-I/ARB

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32
Q

Leading cause of working-age adult blindness

A

Diabetic retinopathy

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33
Q

Type 1 DM diabetic retinopathy risk

A

30% >10 years

90% >30 years

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34
Q

Type 2 DM diabetic retinopathy risk

A

5% at diagnosis

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35
Q

Diabetic retinopathy pathophysiology

A

Occlusion
Microvascular disease -> BM thickening + endothelial dysfx -> haematological changes -> thrombus -> retinal hypoxia -> ischaemia -> VEGF -> neovascularisation
Leakage
Oedema

36
Q

Majority of diabetic retinopathy symptoms

A

Macular oedema

Vitreous haemorrhage``

37
Q

Signs of diabetic retinopathy

A 
Microaneurism
Exudate
Cotton wool spot
Macular oedema
Vitreous haemorrrhage
Venous beading
IRMA
Neovascularisation
38
Q

Diabetic retinopathy classifications

A 
Background
Preproliferative
Proliferative
Maculopathy
Advanced disease
39
Q

Signs of background diabetic retinopathy

A 
Microaneurysm
Exudates
Dot blot haemorrhage
Cotton wool spots
Venous dilation
40
Q

Signs of preproliferative diabetic retinopathy

A 
Rapid increase in microaneurysms
Multiple haemorrhages
>5 cotton wool spots
Venous beading, looping and duplication
IRMA
41
Q

Signs of proliferative diabetic retinopathy

A 
NVD (new vessel on disc)
NVE (new vessel elsewhere)
FPD (fibrous proliferation on disc)
FPE (fibrous proliferation elsewhere)
Preretinal haemorrhages
Vitreous haemorrhages
42
Q

Signs of maculopathy

A

Cystoid macular oedema (diffuse/focal vascular leakage)

w/wo other signs

43
Q

Signs of advanced diabetic retinopathy

A

Vitreous haemorrhage
Retinal detachment
NVI

44
Q

Name risk factors for diabetic retinopathy

A 
Hyperglycemia
Hypertension
Dyslipidemia
Diabetes duration
Ethnicity (hispanic, south asian)
Pregnancy
Puberty
Cataract surgery
45
Q

Prevalence of proliferative retinopathy/macular oedema is higher on insulin than oral agents
True or false?

A

True

Logical - progressive disease and progressive treatment

46
Q

Retinal capillary closure currently has no treatment options

True or false?

A

True

47
Q

When do you screen for diabetic retinopathy in adolescent type I Dm patients?

A

Anually 5y after onset in individuals ≥15yo

48
Q

When do you screen for diabetic retinopathy in type II DM?

A

At diagnosis

Every 1-2y following

49
Q

What are risk factors for the progression of diabetic retinopathy?

A 
Longer diabetes duration
Elevated HbA1c
Hypertension
Dyslipidaemia
Low Hb level
Pregnancy w/ DMI
Preotinuria
Severe retinopathy
50
Q

Treatment options for diabetic retinopathy

A
  1. Laser therapy
    - panretinal coagulation in severe non-proliferative/proliferative
  2. Intraocular pharmacologicals
    - VEGF antagonists
    - e.g Ranibuzimab
    - e.g Bevacizumab’
  3. Surgical
    - vitrectomy
51
Q

Fenofibrates in addition to statin therapy may be used in patients with DMII to slow established retinopathy progression
True or false?

A

True

Not available in primary care

52
Q

Why do you refer visually disabled individuals?

A

Low vision evaluation

Rehabilitation

53
Q

When do you refer proliferative diabetic retinopathy?

A

Refer to ophthalm within 1-2 weeks

54
Q

When do you refer non-proliferative diabetic retinopathy

A

Refer to ophthalm within 1-2mo

55
Q

Forms of foot complications in chronic diabetes

A 
Neuropathy
Plantar pressure increase
Charcot's foot
Foot ulcers
Amputations
56
Q

What are the most common cause of non-traumatic lower extremity amputations?

A

Diabetic foot complications

57
Q

Systemic risk factors for foot ulceration

A 
Uncontrolled hyperglycemia
Diabetes duration
PAD
Blindness/visual loss
Chronic renal disease
Older age
58
Q

Local risk factors for foot ulceration

A 
Peripheral neuropathy
Structural foot deformity
Trauma
Improperly fitted shoes
Callus
History of prior ulcer amputation
Prolonged elevated pressures
Limited joint mobility
59
Q

How do you screen for diabetic foot complications?

A

Monofilament
Tuning fork
Touch the toes test

60
Q

How can you treat the pain symptoms with diabetic foot complications?

A 
Anticonvulsants
- gabapentine
- pregabilin
- valproate
Antidepressants
- amitryptiline oral 10-25mg at night max dose 100mg
- duloxetine
- venlaxafine
Opioid analgesics
- tramadol
61
Q

Risk factors for diabetic neuropathy?

A 
Elevated blood glucose
Elevated triglycerides
High BMI
Smoking
Hypertension
62
Q

What do you look for on the skin to screen for diabetic foot complications?

A 
Ulcers
Scars
Fissures
Corns
Calluses (increases pressure point)
63
Q

What do you look for with the bone to screen for diabetic foot complications

A

Intrinsic mm flexors stronger than extensors ->
Claw toes
Hammer toes
-> increased pressure points

Bunions
Pressure points
Prev surgery

64
Q

What do you look for vascular-wise to screen for diabetic foot complications

A

Dorsalis pedis pulse

Posterior tibialis pulse

65
Q

Semmes-Weinstein monofilament test for diabetic foot complications

A

Show to patient
Touch to patient’s head/sternum so that pt understands the sensation
10g of pressure exerted, press and buckle
Say “yes” everytime sensation perceived
Start with dorsum of great toe proximal to nail bed and use smooth motion for 1second
Perform 4 times in arrythmic manner
Score of <4 = probable neuropathy

66
Q

Risk categories for diabetic foot complications

A 
Low risk 
- no risk factors and no prev history 
- follow up once a year
Intermediate risk
- 1 risk factor and no prev history
- follow up w/ every visit
High risk
- >1 risk factor and/or prev history 
- follow up w/ every visit
67
Q

Patient foot care DOs

A

Check your feet everyday for cuts, cracks, bruises, blisters, sores, infections and unusual markings
Use a mirror to see the bottom of your feet if you can not lift them up
Check the colour of your legs & feet – seek help if there is swelling, warmth or redness
Wash and dry your feet every day, especially between the toes
Apply a good skin lotion every day on your heels and soles. Wipe off excess
Change your socks every day
Trim your nails straight across
Clean a cut or scratch with mild soap and water and cover with dry dressing
Wear good supportive shoes or professionally fitted shoes with low heels (under 5cm)
Buy shoes in the late afternoon since your feet swell by then
Avoid extreme cold and heat (including the sun)
See a foot care specialist if you need advice or treatment

68
Q

Patient foot care DON’Ts

A

Cut your own corns or callouses
Treat your own in-growing toenails or slivers with a razor or scissors. See your
doctor or foot care specialist
Use over-the-counter medications to treat corns and warts
Apply heat with a hot water bottle or electric blanket – may cause burns unknowingly
Soak your feet
Take very hot baths
Use lotion between your toes
Walk barefoot inside or outside
Wear tight socks, garter or elastics or knee highs
Wear over-the-counter insoles – may cause blisters if not right for your feet
Sit for long periods of time
Smoke

69
Q

Treatment for gastroparesis in diabetic neuropathy

A

Metoclopramide oral 10mg 8hrly before meals

70
Q

When do you refer a diabetic neuropathy patient?

A

When you cannot control their pain or gastroparesis

71
Q

Treatment for neuropathic pain has limited effects

True or false?

A

True
Few pt have complete relief
30-50% pain reduction = clinically meaningful

72
Q

When should you screen for peripheral neuropathy in DMII?

A

At diagnosis and anually thereafter

73
Q

When should you screen for peripheral neuropathy in DMI?

A

After 5 years postpubertal duration of diabetes

74
Q

Diabetic foot ulcer is a severe complication and needs referral to secondary care or higher
True or false?

A

True

Risk amputation if not properly managed

75
Q

What are the VIPS of diabetic foot treatment?

A

Vascular supply adequate
Infection control
Pressure offloading
Surgical debridement considered

76
Q

Clinical classification of infection

A 
At least 2 of the following
- local swelling/induration
- erythema >0.5cm 
- local tenderness/pain
- local warmth
- purulent discharge
Rule out other skin inflammatory responses
77
Q

Name causes other than infection that cause inflammatory response of the skin

A 
Trauma
Gout
Acute Charcot neuro-osteoarthropathy
Fracture
Thrombosis
Venous stasis
78
Q

Criteria for localised infection in diabetic foot

A

Neither limb nor life threatening
Usually assoc w/ cellulitis surrounding an ulcer
Purulent debris at base of ulcer

79
Q

Common organisms in localised infection in diabetic foot

A

Aerobic gram + cocci (s aureus)

Beta haemolytic streptococci

80
Q

Antimicrobial treatment of localised infection in diabetic foot

A 
Outpatient
Cloxacillin
Cephalexin
TMP-SMX
Clindamycin
Amoxiclav
Linezolid
Doxycyline
81
Q

Options for pressure offloading in diabetic foot

A 
Crutches
Moonboot
Special shoes
Total contact cast
Removable cast walker
82
Q

What are the 4Bs4Cs2Ts of diabetes mellitus?

A 
4Bs of Control
- Blood glucose
- Blood pressure
- Blood cholesterol (LDL<1.8mmol/l) 
- Breathe air, not smoke
4Cs
Check eyes, teeth, kidneys, feet annually 
2Ts
- Test 
- Treat
83
Q

“Green zone” kidney

A

eGFR >60ml/min
No microalbuminuria
UACR <2

84
Q

What does UACR stand for?

A

Urine albumin creatinine ratio

85
Q

Why do they use a UACR?

A

Creatinine compensates for hydration level that affects the albumin
+ dipstick only picks up albumin >300m

86
Q

Why give calcium in diabetic nephropathy treatment?

A

Bind phosphate (rising levels)

87
Q

How can callus/corn lead to foot ulcers?

A

Increased pressure -> bleed into the space -> form an ulcer

MBChB IV Endocrinology (8 decks)

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