Complications of Diabetes Flashcards
Why do complications occur?
- long term hyper = vessel closure and permeability
- closure = decreased supply of oxygen and nutrients
- permeability = vessels dilate and leak unwanted substances
RF of complications
- smoking (most potent)
- hypertension
- dyslipidaemia
- hyperglycaemia (least potent)
Name the microvascular complications
Retinopathy
Nephropathy
Neuropathy (peripheral sensorimotor and autonomic)
Name the macrovascular complications
CHD
Cerebrovasc disease
PVD
Other complications
Skin
Rheumatological
Liver
Diabetic retinopathy
- 50% diabetics >10yrs have some form
- commonest cause of blindness in working age
How to prevent retinopathy
- bp control
- reg. eye screening
- glycaemic control
Non-prolif retinopathy
- background
- not involving macula
- microaneurysms
- dot haemorrhages
- hard exudates
- mild, mod, severe
- severe = cotton wool spots may be (retinal ischaemia)
Proliferative retinopathy
- ischaemic retina = GF production and neovascularisation
- NVD = new vessels on disc
- NVE = new vessels everywhere
Diabetic maculopathy
- 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)
How to prevent diabetic retinopathy
- 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
Types of diabetic neuropathy
- peripheral sensory
- autonomic
- proximal motor (amyotrophy)
- mononeuropathy (cranial nerve palsies, median nerve - carpal tunnel)
Peripheral sensory neuropathy
- 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)
Diabetic autonomic neuropathy
Genito-urinary = ED, atonic bladder (difficulty voiding and urinary incontinence) GI = gastroparesis, chronic constipation, diarrhoea, gustatory sweating CV = postural hypotension
What is gastroparesis
- recurrent vomiting and early satiety
- due to gastric outflow problems
RF of diabetic nephropathy
- duration of diabetes
- hypertension
- poor glycaemic control
- smoking
- male
- South Asian/Afro-Caribbean
- relative with hypertension
Clinical features of diabetic nephropathy
TRIAD = hypertension, albuminuria, declining renal function
- Kimmelstein-Wilson pathological lesion on renal biopsy
Screening for microalbuminuria
- diabetic neuropathy sign
- measure ACR
- <2.5mg/mmol men normal
<3.5 women normal - if elevated repeat twice
- 2/3 positive = microalbuminuria
Treatment of nephropathy
- 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)
What is SPK?
Simultaneous pancreas and kidney transplant
Treatment to prevent complications
- smoking cessation
- BP <140/80 and <130/80 if CVD or microalbuminuria
- cholesterol statins so <4
- HbA1c <53
BP treatment to prevent comp
1) ACEi
2) CCB
3) thiazide
4) beta blocker/alpha blocker
Glycaemic control protocol
- 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
Acute MI in diabetes
- 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
