Complications of Diabetes Flashcards
1
Q
List two types of complications of diabetes
A
- Microvascular
- Macrovascular
2
Q
How much does diabetes shorten the life span by
A
7 years
3
Q
How much does diabetes increase morality by
A
2-2.5 fold predominately due to cardiovascular complication
4
Q
what does long term hyperglycaemia lead to
A
- vessel closure (parietal or full) - reduction in the supple of oxygen and nutrients)
- vessel permeability - damaged vessels dilate and leak undated substances
5
Q
What is the big killer in diabetes
A
Cardiovascular disease
6
Q
How much does healthcare cost diabetes
A
- Accounts for around 9% of total healthcare expenditure
- around 65% of this cost is for in patient care - care of complication
7
Q
Name the chronic complications of diabetes
A
Macrovascular (atherosclerosis)
- coronary heart disease = MI, CCF
- Cerebrovascular disease = Stroke
- Periphreal vascular disease = Ulceration, gangrene, amputation
Microvascular
- Nephropathy
- retinopathy
- Neuropathy
Other
- skin
- rheumatological
- hepatic
8
Q
How does perisperhal vascular disease present
A
- Ulceration
- gangrene
- amputation
9
Q
What are the risk factors that increase the risk of complications
A
- Smoking – the most potent risk factor
- Hypertension
- Dyslipidaemia
- Hyperglycaemia – the least potent risk factor
10
Q
What is an important mediator factor in increasing complications in diabetes
A
VEGF - in eye disease and retinopathy
TGBF - nephropathy
11
Q
what are the microvascular complications of diabetes
A
Retinopathy
Nephropathy
Neuropathy
▪ Peripheral sensorimotor
▪ Autonomic
12
Q
what are the macrovascular complications of diabetes
A
Coronary Heart Disease
Cerebrovascular Disease
Peripheral Vascular Disease
13
Q
Name other diabetes complications
A
Skin
Rheumatological
Liver
14
Q
How common is diabetic retinopathy
A
- very common - 50% of people with diabetes longer than 10 years have some form of retinopathy
15
Q
What is the most commonest cause of blindness in people of working age
A
diabetic retinopathy
16
Q
How can diabetic retinopathy be prevented
A
Good blood pressure control
Good glycaemic control
Regular eye screening - photo of there eye by digital retinal screening
17
Q
What is a major risk factor for retinopathy
A
hypertension
18
Q
Name the types of diabetic retinopathy
A
Non-proliferative retinoapthy (background retinopathy)
Proliferative retinopathy
Maculopathy
19
Q
What is non proliferative retinopathy
A
- retinopathy not involving the macula
20
Q
What is non proliferative retinopathy charactered by
A
• microaneurysms
• dot and blot haemorrhages
• hard exudates (lipid deposits)
- soft exudates (cotton wool spots = retinal ischaemia but only in severe cases)
- macular oedema - leakage of macular blood vessels - main loss of vision
21
Q
What is non proliferative retinopathy differentiated into
A
- Mild
- Moderate
- Severe - where there may also be cotton wool spots (called soft exudates)
22
Q
What are cotton wool spots (soft exudates)
A
areas of retinal ischaemia
- also called soft exudates
23
Q
what are hard excudates made out of
A
lipid deposits
24
Q
what does the macula have in it
A
photoreceptor signs
25
What is proliferative retinopathy
Ischaemic retina leads to production of growth factors (such as VEGF) and to new vessel formation (neovascularisation)
- caused by VEGF
26
what are the two difference characteristics of proliferative retinopathy
- new vessels on disc (NVD)
| - new vessels elsewhere (NVE)
27
What is the problem with the new vessels in proliferative retinopathy and how do you treat it
- these vessels are prone to haemorrhage
- over time they can lead to fibrosis and scarring which leads to loss of vision
- refer to laser treatment
28
What is maculopathy
is the presence of any retinopathy within 1 disc diameter around macula.
- suspect if visual acuity is reduced
- leads to oedema and significant visual loss
29
What are the types of maculopathy
Focal or exudative maculopathy – hard exudates around macula which leads to macular oedema and visual loss
Diffuse
Ischaemic – due to retinal vessel closure
30
How do you prevent diabetic retinopathy
Every person with diabetes in the UK should undergo a yearly digital retinal screen
Aim to achieve tight glycaemic control (HbA1c < 53 mmol/mol)
consider BP, Cholesterol and glycemic control
31
How do you treat proliferative or maculopathy diabetic retinopathy
Proliferative
- Laser photocoagulation
Maculopathy
- laser photocoagulation
- intravitreal steroids
- anti-angiogenic agents
32
What can maculopathy do
- loose visual acuity and production of oedema which results in sight loss
33
What are the types of diabetic neuropathy
Peripheral sensory neuropathy
Autonomic neuropathy
Proximal motor neuropathy
- (Amyotrophy)
- severe pain in anterior thigh and can lead to quadriceps wasting
Mononeuropathy
- Cranial nerve palsies
- Median nerve (Carpal Tunnel syndrome) is more common in long standing diabetes
34
What are the symptoms of peripheral sensory neuropathy
```
- Glove and stocking distribution
▪ Numbness
▪ Pins and needles
▪ Burning
- sensory loss may be patchy
▪ Shooting
- median neuropathy/carpal tunnel syndrome
```
35
What are people with peripheral sensory neuropathy at high risk of
High risk of ulceration and amputation
36
How do you screen for high risk of peripheral sensory neuropathy
```
Vibration sense
Fine touch sense (using a Semmes
Weinstein Monofilament – see photo) - at the point of bending it is 10 grams of fine touch
Ankle reflexes
Evidence of muscle wasting
```
37
how often should patients with diabetes have a foot check
- Should have a foot check every year
38
what systems in the body are effected by autonomic neuropathy
- genito-urinary
- gastrointestinal
- cardiovascular
39
Describe the symptoms of autonomic neuropathy in
- genitourinary symptoms
- gastrointestinal symptoms
- cardiovascular symptoms
Genito-urinary:
▪ Erectile dysfunction
▪ Atonic bladder – leading to difficulty voiding or urinary incontinence
Gastrointestinal:
▪ Gastroparesis – recurrent vomiting and early satiety due to gastric outflow
problems - stop doesn't empty due to problems with the autonomic nervous system
▪ Chronic constipation or diarrhoea
▪ Gustatory sweating – severe sweating on eating
Cardiovascular
▪ Postural hypotension
- reduced verb-vascular auto regulation
- loss of respiratory sinus arrhythmia
40
What is the most common cause of end stage renal failure in the UK
Diabetic nephropathy
41
how many people with diabetes have diabetic nephropathy
25-30% of people with type 2 diabetes have some degree of nephropathy
42
Who has a higher risk of diabetic nephropathy
South Asians / Afro-Caribbeans have higher risk
43
What is nephropathy associated with
Nephropathy is associated with a greatly increased incidence of atherosclerotic vascular disease
44
What are the risk factors for diabetic nephropathy
```
Duration of diabetes
Hypertension
Poor glycaemic control
Smoking
Gender – male preponderance
Ethnicity – South Asian / Afro-Caribbean
Having a relative with hypertension
```
45
What is the clinical triad of nephropathy
Hypertension
Albuminuria (preceded by microalbuminuria)
Declining renal function
- on renal biopsy: Kimmelstein-wilson lesion
46
what does diabetic nephropathy look like on renal biopsy
On renal biopsy, the pathological lesion is the “Kimmelstein-Wilson lesion”
47
what is the screening test for diabetic nephropathy
Void urine in the morning and measure urine albumin:creatinine ratio (ACR)
48
What Is the normal levels of microalbuminuria (albumin: creatine ration) (screening for diabetic nephropahty)
- do the urine sample as you wake up
Normal is < 2.5 mg/mmol in men or < 3.5 mg/mmol in women
If elevated, repeat x2
If 2 out of 3 positive – microalbuminuria present
49
What is the management for diabetic nephropathy
Most important to maintain blood pressure < 130/80 mmHg
- ACEI first line (ACEI is given even if BP normal)
- Consider angiotensin receptor blocker if ACEI not tolerated
- Often more than one anti-hypertensive is needed to achieve this BP
glycemic control = (HbA1c < 53 mmol/mol)
Stop metformin when eGFR < 30 mls/min
Refer to specialist if eGFR below 45 mls/min and falling
Renal replacement therapy may be needed
- e.g Peritoneal Dialysis / Haemodialysis / Transplant
- In type 1 diabetes consider simultaneous pancreas and kidney (SPK) transplant
50
What is the treatment to prevent cardiovascular complications
Smoking Cessation – “1 cigarette in a diabetic = 5 cigarettes in a non-diabetic”
```
Blood pressure
- NICE guidelines suggest optimal BP < 140/80 mmHg (< 130/80 if known
CVD or microalbuminuria)
Often needs more than one treatment, in this order:
1. ACEI
2. Calcium channel blocker
3. Thiazide
4. Alpha Blocker or Beta Blocker
```
Cholesterol
- Aiming for total cholesterol <4.0mmol/l
- NICE guidelines states patients should be on a statin if:
- > all diabetic >40yrs, or diabetic
- diabetic and <40years + 1 other
risk factor
should be on a statin
Improve HbA1c
- < 53 mmol/mol (7.0%), but individualised to the patient
51
what is the risk of tight glucose control
hypoglycaemia
52
Therefore due to the risk of hypoglycaemia from tight glucose control what are the latest guidelines
Glycaemic control early in type 2 diabetes is probably important (aim for < 53
mmol/mol [7.0%] in first 10 years)
Later (>10 years) – less important and more risky (perhaps aim for < 58 mmol/mol [7.5%] or higher)
NICE suggests individualised glycaemic target
53
describe heart attacks in patients with diabetes
Immediate and later mortality rates following MI are high in people with Type 2 diabetes
- 4 x increased risk
MI may be “silent” (ie no chest pain) in people with diabetes due to autonomic neuropathy e.g. no chest pain or atypical symptoms
54
What is the treatment o MI with patients with diabetes
```
Aspirin
Primary angioplasty or thrombolysis
Glucose-insulininfusion
Secondary prevention - ACE Inhibitors, b-blockers, statins, aspirin, improve glycaemic control
Cardiac rehabilitation
```
55
How do you treat stroke with patients with diabetes
If within 3 hours – consider thrombolysis
General consensus is to treat all vascular risk factors aggressively
- ACEi
- Statins
- Aspirin
- Glucose / insulin infusion during acute phase
56
how many people die with peripheral vascular disease
Approx. 20% of people with PVD will die within 2 yrs of symptoms
Most deaths are from MIs
57
What are the symptoms of peripheral vascular disease
Intermittent claudication
Rest pain
Buttock pain
58
What is the management go peripheral vascular disease
```
Aspirin
Vasodilating agents
Reconstructive surgery
Angioplasty
Amputation & rehabilitation & foot care
```
59
Name different skin manifestations of diabetes
Oral / Genital Candidiasis – common presenting symptom
Skin abcesses – especially perianal / axillary
Diabetic dermopathy
Necrobiosis Lipoidica Diabeticorum – seen in type 1 diabetes
Bullosis Diabeticorum
Granuloma Annulare
Acanthosis nigricans – a sign of insulin resistance
Fungal nail infections
60
Name rheumatogloical manifestations of diabetes
Charcot neuroarthropathy – a “neuropathic” joint leads to severe deformity and high risk of ulcers
Diabetic cheiroarthropathy – due to limited joint mobility
Adhesive Capsulitis – “frozen shoulder” much more common amongst
people with diabetes
Diffuse idiopathic skeletal hyperostosis
Flexor tendinopathy
Diabetic osteoarthropathy
61
How does diabetes lead to cirrhosis
- Non-alcoholic fatty liver disease is very common amongst people with diabetes
- Can progress to Non alcoholic steato hepatitis (NASH) / fibrosis / cirrhosis
62
when should you investigate liver
Raised ALT and AST - greater than 2 x upper limit of normal needs investigation
63
How do you investigate the liver - what tests should you carry out
Hepatitis serology
Ultrasound scan
Ferritin (to exclude haemochromatosis which can cause diabetes)
64
What can reduce diabetes progression to liver cirrhosis
Possibly a specific role for pioglitazone in reducing progression to cirrhosis
- need a vigorous treatment of diabetes and risk factors
65
How is the kidney damaged by diabetes
- Glomerular damage
- Ischaemia – resulting from hypertrophy of afferent and efferent arterioles
- Ascending infection
66
What is done in the annual diabetic screen
1. HbA1c
2. BP
3. Cholesterol
4. Smoking
5. U&Es
6. Foot check
7. Digital retinal screen
8. BMI
9. ACR
