diabetes assoc conditions

Question 1

commonest cause of end stage renal disease

Answer 1

diabetic nephropathy!

1/3 with T1DM have diabetic nephropathy by 40

Question 2

histology of diabetic nephropathy

Answer 2

basement membrane thickening
capillary obliteration
mesengial widening

Kimmelstiel-Wilson nodules - nodulular hyaline areas

non-enzymatic glycosylation of basement membrane plays a key role

Question 3

risk factors for developing diabetic nephropathy

Answer 3

modifiable
- hypertension, hyperlipidaemia
- smoking
- poor glycaemic control
- raised dietary protein

non-mod
- males
- duration of diabetes
- genetic predispos - ACE gene polymorphs

Question 4

screening for diabetic nephropathy

Answer 4

albumin:creatinine ratio (ACR)
- ACR >2.5 = microalbuminuria

all patients screened annually

Question 5

management of diabetic nephropathy

Answer 5

dietary protein restriction, tight glycaemic control
BP control - aim for <130/80

statins
ACEi or ARB
- start if urinary ACR >=3
- never give together

Question 6

peripheral neuropathy

Answer 6

sensory loss NOT motor
–> glove + stocking distribution

lower legs affected first (due to length of sensory neurons supplying this area)

Question 7

managment of diabetic neuropathy

Answer 7

1st line = amitriptyline, duloxetine, gabapentin or pregabalin
- if one doesnt work, try another

pain mx clinics if resistant
tramadol may be used as “rescue therapy”

Question 8

gastrointestinal neuropathy

Answer 8

1. gastroparesis
   - sx erratic BMs, bloating, vomiting
   - mx = metoclopromide, domperidone, erythromicin (prokinetic agents)
2. chronic diarrhoea - often at night
3. GORD
   - caused by decreased lower oesphageal sphincter pressure

Question 9

why does diabetic foot disease occur

Answer 9

neuropathy + peripheral arterial disease

Question 10

diabetic foot disease presentation

Answer 10

neuropathy - loss of sensation
ischaemia - absent foot pulses, reduced ABPI, intermittent claudication

complications - calluses, ulceration, Charcot’s arthropathy, cellulitis, osteomyelitis, gangrene

Question 11

screening of diabetic foot disease

Answer 11

ischaemia - palpate pulses: dorsalis pedis + posterior tibial artery

neuropathy - 10g monofilament used in various parts of sole of foot

annual basis

Question 12

key features of diabetic retinopathy

Answer 12

non-proliferative
- microaneurysms
- blot haemorrhages
- hard exudates
- cotton wool spots
- venous beading

proliferative = retinal neovascularisation - may lead to vitreous haemorrhage

Question 13

what is meant by “cotton wool spots”

Answer 13

soft exudates - represents areas of retinal infarction

Question 14

management of maculopathy

Answer 14

if change in visual acuity - intravitreal VEGF inhibitors

Question 15

management of proliferative retinopathy

Answer 15

panretinal laser photocoag
cx = reduction in visual fields, decrease night vision - due to scaring of retinal tissue + rod damage

intravitreal VEGF inhibitors (ranibizumab)
- used in combo with pan photocoag

Question 16

when can amitriptyline not be used to manage neuropathic pain

Answer 16

BPH - risk of urinary retention