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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
What does ACR stand for?
Urine albumin:creatinine ratio
26
Diagnostic criteria for CKD in diabetes according to SA DOH?
Positive urine dipstix OR | ACR >3mg/mmol
27
When do you not need to send urine to exclude microalbuminuria according to the SA DOH?
Patient on ACE-inhibitor
28
Name potential causes for transient albuminuria
``` Recent major exercise UTI Febrile illness Decompensated CHF Menstrutation Acute severe blood glucose elevation Acute severe blood pressure elevation ```
29
How do you reduce the progression to diabetic nephropathy?
Optimal glycemic control | Optimal BP control (ACE-I or ARB)
30
Which diabetic treatment drug class has been shown to reduce the onset and progression of diabetic nephropathy?
SGLT2 inhibitors
31
When do you refer a patient with diabetic nephropathy?
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
32
Leading cause of working-age adult blindness
Diabetic retinopathy
33
Type 1 DM diabetic retinopathy risk
30% >10 years | 90% >30 years
34
Type 2 DM diabetic retinopathy risk
5% at diagnosis
35
Diabetic retinopathy pathophysiology
Occlusion Microvascular disease -> BM thickening + endothelial dysfx -> haematological changes -> thrombus -> retinal hypoxia -> ischaemia -> VEGF -> neovascularisation Leakage Oedema
36
Majority of diabetic retinopathy symptoms
Macular oedema | Vitreous haemorrhage``
37
Signs of diabetic retinopathy
``` Microaneurism Exudate Cotton wool spot Macular oedema Vitreous haemorrrhage Venous beading IRMA Neovascularisation ```
38
Diabetic retinopathy classifications
``` Background Preproliferative Proliferative Maculopathy Advanced disease ```
39
Signs of background diabetic retinopathy
``` Microaneurysm Exudates Dot blot haemorrhage Cotton wool spots Venous dilation ```
40
Signs of preproliferative diabetic retinopathy
``` Rapid increase in microaneurysms Multiple haemorrhages >5 cotton wool spots Venous beading, looping and duplication IRMA ```
41
Signs of proliferative diabetic retinopathy
``` NVD (new vessel on disc) NVE (new vessel elsewhere) FPD (fibrous proliferation on disc) FPE (fibrous proliferation elsewhere) Preretinal haemorrhages Vitreous haemorrhages ```
42
Signs of maculopathy
Cystoid macular oedema (diffuse/focal vascular leakage) | w/wo other signs
43
Signs of advanced diabetic retinopathy
Vitreous haemorrhage Retinal detachment NVI
44
Name risk factors for diabetic retinopathy
``` Hyperglycemia Hypertension Dyslipidemia Diabetes duration Ethnicity (hispanic, south asian) Pregnancy Puberty Cataract surgery ```
45
Prevalence of proliferative retinopathy/macular oedema is higher on insulin than oral agents True or false?
True | Logical - progressive disease and progressive treatment
46
Retinal capillary closure currently has no treatment options | True or false?
True
47
When do you screen for diabetic retinopathy in adolescent type I Dm patients?
Anually 5y after onset in individuals ≥15yo
48
When do you screen for diabetic retinopathy in type II DM?
At diagnosis | Every 1-2y following
49
What are risk factors for the progression of diabetic retinopathy?
``` Longer diabetes duration Elevated HbA1c Hypertension Dyslipidaemia Low Hb level Pregnancy w/ DMI Preotinuria Severe retinopathy ```
50
Treatment options for diabetic retinopathy
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
Fenofibrates in addition to statin therapy may be used in patients with DMII to slow established retinopathy progression True or false?
True | Not available in primary care
52
Why do you refer visually disabled individuals?
Low vision evaluation | Rehabilitation
53
When do you refer proliferative diabetic retinopathy?
Refer to ophthalm within 1-2 weeks
54
When do you refer non-proliferative diabetic retinopathy
Refer to ophthalm within 1-2mo
55
Forms of foot complications in chronic diabetes
``` Neuropathy Plantar pressure increase Charcot's foot Foot ulcers Amputations ```
56
What are the most common cause of non-traumatic lower extremity amputations?
Diabetic foot complications
57
Systemic risk factors for foot ulceration
``` Uncontrolled hyperglycemia Diabetes duration PAD Blindness/visual loss Chronic renal disease Older age ```
58
Local risk factors for foot ulceration
``` Peripheral neuropathy Structural foot deformity Trauma Improperly fitted shoes Callus History of prior ulcer amputation Prolonged elevated pressures Limited joint mobility ```
59
How do you screen for diabetic foot complications?
Monofilament Tuning fork Touch the toes test
60
How can you treat the pain symptoms with diabetic foot complications?
``` Anticonvulsants - gabapentine - pregabilin - valproate Antidepressants - amitryptiline oral 10-25mg at night max dose 100mg - duloxetine - venlaxafine Opioid analgesics - tramadol ```
61
Risk factors for diabetic neuropathy?
``` Elevated blood glucose Elevated triglycerides High BMI Smoking Hypertension ```
62
What do you look for on the skin to screen for diabetic foot complications?
``` Ulcers Scars Fissures Corns Calluses (increases pressure point) ```
63
What do you look for with the bone to screen for diabetic foot complications
Intrinsic mm flexors stronger than extensors -> Claw toes Hammer toes -> increased pressure points Bunions Pressure points Prev surgery
64
What do you look for vascular-wise to screen for diabetic foot complications
Dorsalis pedis pulse | Posterior tibialis pulse
65
Semmes-Weinstein monofilament test for diabetic foot complications
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
Risk categories for diabetic foot complications
``` 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
Patient foot care DOs
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
Patient foot care DON'Ts
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
Treatment for gastroparesis in diabetic neuropathy
Metoclopramide oral 10mg 8hrly before meals
70
When do you refer a diabetic neuropathy patient?
When you cannot control their pain or gastroparesis
71
Treatment for neuropathic pain has limited effects | True or false?
True Few pt have complete relief 30-50% pain reduction = clinically meaningful
72
When should you screen for peripheral neuropathy in DMII?
At diagnosis and anually thereafter
73
When should you screen for peripheral neuropathy in DMI?
After 5 years postpubertal duration of diabetes
74
Diabetic foot ulcer is a severe complication and needs referral to secondary care or higher True or false?
True | Risk amputation if not properly managed
75
What are the VIPS of diabetic foot treatment?
Vascular supply adequate Infection control Pressure offloading Surgical debridement considered
76
Clinical classification of infection
``` 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
Name causes other than infection that cause inflammatory response of the skin
``` Trauma Gout Acute Charcot neuro-osteoarthropathy Fracture Thrombosis Venous stasis ```
78
Criteria for localised infection in diabetic foot
Neither limb nor life threatening Usually assoc w/ cellulitis surrounding an ulcer Purulent debris at base of ulcer
79
Common organisms in localised infection in diabetic foot
Aerobic gram + cocci (s aureus) | Beta haemolytic streptococci
80
Antimicrobial treatment of localised infection in diabetic foot
``` Outpatient Cloxacillin Cephalexin TMP-SMX Clindamycin Amoxiclav Linezolid Doxycyline ```
81
Options for pressure offloading in diabetic foot
``` Crutches Moonboot Special shoes Total contact cast Removable cast walker ```
82
What are the 4Bs4Cs2Ts of diabetes mellitus?
``` 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
"Green zone" kidney
eGFR >60ml/min No microalbuminuria UACR <2
84
What does UACR stand for?
Urine albumin creatinine ratio
85
Why do they use a UACR?
Creatinine compensates for hydration level that affects the albumin + dipstick only picks up albumin >300m
86
Why give calcium in diabetic nephropathy treatment?
Bind phosphate (rising levels)
87
How can callus/corn lead to foot ulcers?
Increased pressure -> bleed into the space -> form an ulcer

MBChB IV Endocrinology (8 decks)

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