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Year 3 - Met3b > Complications of Diabetes > Flashcards

Complications of Diabetes Flashcards

1
Q

List two types of complications of diabetes

A
  • Microvascular

- Macrovascular

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2
Q

How much does diabetes shorten the life span by

A

7 years

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3
Q

How much does diabetes increase morality by

A

2-2.5 fold predominately due to cardiovascular complication

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4
Q

what does long term hyperglycaemia lead to

A
  1. vessel closure (parietal or full) - reduction in the supple of oxygen and nutrients)
  2. vessel permeability - damaged vessels dilate and leak undated substances
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5
Q

What is the big killer in diabetes

A

Cardiovascular disease

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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

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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
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8
Q

How does perisperhal vascular disease present

A
  • Ulceration
  • gangrene
  • amputation
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9
Q

What are the risk factors that increase the risk of complications

A
  1. Smoking – the most potent risk factor
  2. Hypertension
  3. Dyslipidaemia
  4. Hyperglycaemia – the least potent risk factor
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10
Q

What is an important mediator factor in increasing complications in diabetes

A

VEGF - in eye disease and retinopathy

TGBF - nephropathy

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11
Q

what are the microvascular complications of diabetes

A

 Retinopathy

 Nephropathy

 Neuropathy
▪ Peripheral sensorimotor
▪ Autonomic

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12
Q

what are the macrovascular complications of diabetes

A

 Coronary Heart Disease
 Cerebrovascular Disease
 Peripheral Vascular Disease

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13
Q

Name other diabetes complications

A

 Skin
 Rheumatological
 Liver

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14
Q

How common is diabetic retinopathy

A
  • very common - 50% of people with diabetes longer than 10 years have some form of retinopathy
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15
Q

What is the most commonest cause of blindness in people of working age

A

diabetic retinopathy

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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

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17
Q

What is a major risk factor for retinopathy

A

hypertension

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18
Q

Name the types of diabetic retinopathy

A

Non-proliferative retinoapthy (background retinopathy)

Proliferative retinopathy

Maculopathy

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19
Q

What is non proliferative retinopathy

A
  • retinopathy not involving the macula
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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

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21
Q

What is non proliferative retinopathy differentiated into

A
  • Mild
  • Moderate
  • Severe - where there may also be cotton wool spots (called soft exudates)
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22
Q

What are cotton wool spots (soft exudates)

A

areas of retinal ischaemia

- also called soft exudates

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23
Q

what are hard excudates made out of

A

lipid deposits

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24
Q

what does the macula have in it

A

photoreceptor signs

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25
Q

What is proliferative retinopathy

A

Ischaemic retina leads to production of growth factors (such as VEGF) and to new vessel formation (neovascularisation)
- caused by VEGF

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26
Q

what are the two difference characteristics of proliferative retinopathy

A
  • new vessels on disc (NVD)

- new vessels elsewhere (NVE)

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27
Q

What is the problem with the new vessels in proliferative retinopathy and how do you treat it

A
  • 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
Q

What is maculopathy

A

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
Q

What are the types of maculopathy

A

 Focal or exudative maculopathy – hard exudates around macula which leads to macular oedema and visual loss

 Diffuse

Ischaemic – due to retinal vessel closure

30
Q

How do you prevent diabetic retinopathy

A

 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
Q

How do you treat proliferative or maculopathy diabetic retinopathy

A

Proliferative
- Laser photocoagulation

Maculopathy

  • laser photocoagulation
  • intravitreal steroids
  • anti-angiogenic agents
32
Q

What can maculopathy do

A
  • loose visual acuity and production of oedema which results in sight loss
33
Q

What are the types of diabetic neuropathy

A

 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
Q

What are the symptoms of peripheral sensory neuropathy

A 
- Glove and stocking distribution 
▪ Numbness
▪ Pins and needles
▪ Burning
- sensory loss may be patchy
▪ Shooting
- median neuropathy/carpal tunnel syndrome
35
Q

What are people with peripheral sensory neuropathy at high risk of

A

 High risk of ulceration and amputation

36
Q

How do you screen for high risk of peripheral sensory neuropathy

A 
 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
Q

how often should patients with diabetes have a foot check

A
  • Should have a foot check every year
38
Q

what systems in the body are effected by autonomic neuropathy

A
  • genito-urinary
  • gastrointestinal
  • cardiovascular
39
Q

Describe the symptoms of autonomic neuropathy in

  • genitourinary symptoms
  • gastrointestinal symptoms
  • cardiovascular symptoms
A

 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
Q

What is the most common cause of end stage renal failure in the UK

A

Diabetic nephropathy

41
Q

how many people with diabetes have diabetic nephropathy

A

25-30% of people with type 2 diabetes have some degree of nephropathy

42
Q

Who has a higher risk of diabetic nephropathy

A

South Asians / Afro-Caribbeans have higher risk

43
Q

What is nephropathy associated with

A

 Nephropathy is associated with a greatly increased incidence of atherosclerotic vascular disease

44
Q

What are the risk factors for diabetic nephropathy

A 
 Duration of diabetes
 Hypertension
 Poor glycaemic control 
 Smoking
 Gender – male preponderance
 Ethnicity – South Asian / Afro-Caribbean 
 Having a relative with hypertension
45
Q

What is the clinical triad of nephropathy

A

 Hypertension

 Albuminuria (preceded by microalbuminuria)

 Declining renal function
- on renal biopsy: Kimmelstein-wilson lesion

46
Q

what does diabetic nephropathy look like on renal biopsy

A

On renal biopsy, the pathological lesion is the “Kimmelstein-Wilson lesion”

47
Q

what is the screening test for diabetic nephropathy

A

Void urine in the morning and measure urine albumin:creatinine ratio (ACR)

48
Q

What Is the normal levels of microalbuminuria (albumin: creatine ration) (screening for diabetic nephropahty)

A
  • 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
Q

What is the management for diabetic nephropathy

A

 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
Q

What is the treatment to prevent cardiovascular complications

A

 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
Q

what is the risk of tight glucose control

A

hypoglycaemia

52
Q

Therefore due to the risk of hypoglycaemia from tight glucose control what are the latest guidelines

A

 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
Q

describe heart attacks in patients with diabetes

A

 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
Q

What is the treatment o MI with patients with diabetes

A 
 Aspirin
 Primary angioplasty or thrombolysis
 Glucose-insulininfusion
 Secondary prevention - ACE Inhibitors, b-blockers, statins, aspirin, improve glycaemic control
 Cardiac rehabilitation
55
Q

How do you treat stroke with patients with diabetes

A

 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
Q

how many people die with peripheral vascular disease

A

Approx. 20% of people with PVD will die within 2 yrs of symptoms
 Most deaths are from MIs

57
Q

What are the symptoms of peripheral vascular disease

A

 Intermittent claudication
 Rest pain
 Buttock pain

58
Q

What is the management go peripheral vascular disease

A 
 Aspirin
 Vasodilating agents
 Reconstructive surgery
 Angioplasty
 Amputation &amp; rehabilitation &amp; foot care
59
Q

Name different skin manifestations of diabetes

A

 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
Q

Name rheumatogloical manifestations of diabetes

A

 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
Q

How does diabetes lead to cirrhosis

A
  • Non-alcoholic fatty liver disease is very common amongst people with diabetes
  • Can progress to Non alcoholic steato hepatitis (NASH) / fibrosis / cirrhosis
62
Q

when should you investigate liver

A

Raised ALT and AST - greater than 2 x upper limit of normal needs investigation

63
Q

How do you investigate the liver - what tests should you carry out

A

Hepatitis serology
Ultrasound scan
Ferritin (to exclude haemochromatosis which can cause diabetes)

64
Q

What can reduce diabetes progression to liver cirrhosis

A

Possibly a specific role for pioglitazone in reducing progression to cirrhosis
- need a vigorous treatment of diabetes and risk factors

65
Q

How is the kidney damaged by diabetes

A
  • Glomerular damage
  • Ischaemia – resulting from hypertrophy of afferent and efferent arterioles
  • Ascending infection
66
Q

What is done in the annual diabetic screen

A
  1. HbA1c
  2. BP
  3. Cholesterol
  4. Smoking
  5. U&Es
  6. Foot check
  7. Digital retinal screen
  8. BMI
  9. ACR

Year 3 - Met3b (26 decks)

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