Complications of Diabetes

Question 1

Why do complications occur?

Answer 1

• long term hyper = vessel closure and permeability
• closure = decreased supply of oxygen and nutrients
• permeability = vessels dilate and leak unwanted substances

Question 2

RF of complications

Answer 2

• smoking (most potent)
• hypertension
• dyslipidaemia
• hyperglycaemia (least potent)

Question 3

Name the microvascular complications

Answer 3

Retinopathy
Nephropathy
Neuropathy (peripheral sensorimotor and autonomic)

Question 4

Name the macrovascular complications

Answer 4

CHD
Cerebrovasc disease
PVD

Question 5

Other complications

Answer 5

Skin
Rheumatological
Liver

Question 6

Diabetic retinopathy

Answer 6

• 50% diabetics >10yrs have some form

- commonest cause of blindness in working age

Question 7

How to prevent retinopathy

Answer 7

• bp control
• reg. eye screening
• glycaemic control

Question 8

Non-prolif retinopathy

Answer 8

• background
• not involving macula
• microaneurysms
• dot haemorrhages
• hard exudates
• mild, mod, severe
• severe = cotton wool spots may be (retinal ischaemia)

Question 9

Proliferative retinopathy

Answer 9

• ischaemic retina = GF production and neovascularisation
• NVD = new vessels on disc
• NVE = new vessels everywhere

Question 10

Diabetic maculopathy

Answer 10

• retinopathy within 1 disc diameter around macula
• focal or exudative = hard exudates around macula -> oedema and visual loss
• or diffuse
• or ischaemic (retinal vessel closure)

Question 11

How to prevent diabetic retinopathy

Answer 11

• yearly digital retinal screen for diabetics
• tight glycaemic control <53 HbA1c
• achieve good bp and cholesterol control
• laser photocoagulation for sight preservation for prolif retinopathy or maculopathy

Question 12

Types of diabetic neuropathy

Answer 12

• peripheral sensory
• autonomic
• proximal motor (amyotrophy)
• mononeuropathy (cranial nerve palsies, median nerve - carpal tunnel)

Question 13

Peripheral sensory neuropathy

Answer 13

• glove and stocking distribution
• high risk ulceration and amputation
• numbness, pins and needles, burning, shooting
• screen for high risk ulceration = reduced vibration, fine touch sense, ankle reflexes, muscle wasting)

Question 14

Diabetic autonomic neuropathy

Answer 14

Genito-urinary = ED, atonic bladder (difficulty voiding and urinary incontinence)
GI = gastroparesis, chronic constipation, diarrhoea, gustatory sweating
CV = postural hypotension

Question 15

What is gastroparesis

Answer 15

• recurrent vomiting and early satiety

- due to gastric outflow problems

Question 16

RF of diabetic nephropathy

Answer 16

• duration of diabetes
• hypertension
• poor glycaemic control
• smoking
• male
• South Asian/Afro-Caribbean
• relative with hypertension

Question 17

Clinical features of diabetic nephropathy

Answer 17

TRIAD = hypertension, albuminuria, declining renal function

- Kimmelstein-Wilson pathological lesion on renal biopsy

Question 18

Screening for microalbuminuria

Answer 18

• diabetic neuropathy sign
• measure ACR
• <2.5mg/mmol men normal
  <3.5 women normal
• if elevated repeat twice
• 2/3 positive = microalbuminuria

Question 19

Treatment of nephropathy

Answer 19

• maintain bp at 130/80 = ACEi, ARB if not tolerated, normally more than 1 anti-hypertensive
• blood glucose control so <53
• CV risk manage
• stop metformin if eGFR<30
• refer to specialist if eGFR<45
• renal replacement therapy? (dialysis/transplant/SPK)

Question 20

What is SPK?

Answer 20

Simultaneous pancreas and kidney transplant

Question 21

Treatment to prevent complications

Answer 21

• smoking cessation
• BP <140/80 and <130/80 if CVD or microalbuminuria
• cholesterol statins so <4
• HbA1c <53

Question 22

BP treatment to prevent comp

Answer 22

1) ACEi
2) CCB
3) thiazide
4) beta blocker/alpha blocker

Question 23

Glycaemic control protocol

Answer 23

• very tight control = hypo esp in elderly
• early control in T2D important <53 in first 10 years
• later >10 years less important <58
• individualised patient targets

Question 24

Acute MI in diabetes

Answer 24

• high mortality rates in T2D
• may be silent in diabetics and atypical symptoms
• aspirin
• primary angioplasty/thrombolysis
• glucose insulin infusion
• ACEi, Beta blockers, statins, aspirin, improve glycaemic control for 2ndry prevention
• cardiac rehab

Question 25

Cerebrovascular events

Answer 25

• thrombolysis within 3 hours
• treat all vascular RF
• ACEi, statins, aspirin, glucose/insulin acutely

Question 26

Peripheral Vasc Disease

Answer 26

• 20% die within 2 years of symptoms mostly by MI
• intermittent claudication
• rest pain
• buttock pain

Question 27

Management of PVD

Answer 27

• aspirin, vasodilating agents, reconstructive surgery, angioplasty, amputation & rehab & foot care

Question 28

Skin manifestations of diabetes

Answer 28

• oral/genital candidiasis
• skin abcesses
• diabetic dermopathy
• necrobiosis lioidica diabeticorum
• bullosis diabeticorum
• granuloma annulare
• acanthosis nigricans
• fungal nail infections

Question 29

Rheumatological manifestations of diabetes

Answer 29

• charcot neuroarthropathy
• diabetic cheiroarthropathy
• adhesive capsulitis (frozen shoulder)
• DISH
• flexor tendinopathy
• diabetic osteoarthropathy

Question 30

Liver problems

Answer 30

• non alcohol fatty liver disease
• progress to non alcoholic steato hepatitis/fibrosis/cirrhosis
• raised ALT and AST >2x upper limit = hepatitis serology, US, ferritin to exclude haemochromatosis
• diabetes and RF vigorous treatment