Diabetes complications

Question 1

What is the difference between microvascular and microvascular complications?

Answer 1

Microvascular is damage to small blood vessels e.g. capillaries
Microvascular is damage to large blood vessels e.g. arteries and veins

Question 2

What is the difference between microvascular and microvascular complications?

Answer 2

Microvascular is damage to small blood vessels e.g. capillaries
Microvascular is damage to large blood vessels e.g. arteries and veins

Question 3

What are examples of microvascular complications?

Answer 3

Retinopathy
Nephropathy
Neuropathy

Question 4

What are examples of macrovascular complications?

Answer 4

Atherosclerotic cardiovascular disease (CVD)

Question 5

What is the effect of a 1% higher Hba1c than recommended?

Answer 5

• 21% increase in diabetes-related deaths
• 14% increase in myocardial infarction
• 43% increase in peripheral vascular disease

Question 6

Why are eye, kidney and nerve cells vulnerable to damage (hence the complications of diabetes)?

Answer 6

The endothelial cells of the retina, peripheral NS and kidney allow glucose to enter the cell even in the absence of insulin.
- All other cells require insulin to bind to a GLUT-4 transporter on their membrane to allow glucose uptake.
These 3 don’t and are permeable to glucose- this leads to lack of control

Question 7

What is diabetic retinopathy?

Answer 7

• This is damage to the retina (back of the eye) caused by high sugar levels that damage the blood vessels supplying the back of the eye.
  it is the most common cause of blindness in ages 30-65

Question 8

What are the 3 stages of retinopathy causing damage to the blood vessels?

Answer 8

background retinopathy – tiny bulges develop in the blood vessels, which may bleed slightly but do not usually affect your vision

pre-proliferative retinopathy – more severe and widespread changes affect the blood vessels, including more significant bleeding into the eye

proliferative retinopathy – scar tissue and new blood vessels, which are weak and bleed easily, develop on the retina; this can result in some loss of vision

Question 9

What are the risk factors for retinopathy?

Answer 9

• Having had diabetes for a long time
• Hypertension
• Consistent hyperglycaemia
• Pregnancy
• High cholesterol
• Of asian or Afro-carribean background

Question 10

What is the treatment/prevention of diabetic retinopathy?

Answer 10

• keep blood glucose levels under control
• keep blood pressure and cholesterol within threshold
• avoid smoking
• Keep a healthy lifestyle
• Attend yearly diabetic eye screening appointments- from age 12- where eye drops dilate the pupil and hen pictures are taken
• only if vision is at risk will treatment (except lifestyle changes) be offered:
• laser treatment- seal off leaky vessels
• injections into the eyes- anti-VEGF injections to prevent the formation of new blood vessels e.g. ranibizumab (Lucentis) or Alflibercept (Eylea)- given once a month and then may decrease
• operation to remove blood or scar tissue from the eye- vitreoretinal surgery

Question 11

What are the symptoms of diabetic retinopathy?

Answer 11

• Originally, doesn’t usually present any symptoms- hence the importance of eye screening to detect problems before vision is effected.
  However, if you have the following symptoms you should seek medical intervention:
• Gradual worsening of vision
• sudden loss of vision
• shapes floating in field of vision
• blurred/patchy vision
• eye pain or redness
• difficulty seeing in the dark

Question 12

What is proteinuria?

Answer 12

The presence of albumin (protein) in the urine and is a common sign of renal disease
- detected using combur-3 tests
if patient has a repeated positive need a 24 hour urine collection to quantify amount present

Question 13

What is microalbuminuria?

Answer 13

• The abnormal presence of small amounts of albumin in the urine detected using Microalbustix dipsticks
• Often an early indicator of nephropathy

Question 14

What is ‘ACR’ ?

Answer 14

Albumin:Creatinine ratio
Measured routinely in diabetes to looks at protein in the urine
if levels:
>2.5 mg/mmol in men
>3.5 mg/mmol in women
it is indicating nephropathy and will start treatment

Question 15

What are the likelihood of patients developing microalbuminuria or proteinuria in type 1 and the 2 DM?

Answer 15

Type 1:
- 40% of patients with diabetes for 30 years develop microalbuminuria
- 20% of patients with diabetes for 25 years develop proteinuria

Type 2:
- Approximately 25-30% develop some type of nephropathy
- 20^ of patients with microalbuminuria who survive for 10 years will develop proteinuria

Question 16

What is the treatment for nephropathy?

Answer 16

• Improve diabetes control- aim for Hba1c of >7%
• Agressive control of blood pressure:
  Type 1: NICE target <130/80 mm/Hg
  Type 2: NICE target <140/90 if under 80 years and <150/90 if over 80 (same as non diabetics)
• Would give an ACE inhibitor e.g. ramipril as it has reno-protective properties (slow progression of renal failure and nephropathy)
  may add a calcium-channel blocker e.g. amlodipine or felodipine as these also have Reno-protective abilities
• Restrict dietary sodium intake to less than 100 mmol e.g cut foods such as cold meats, bacon, nuts, soy sauce (high in salts)
• in type 2 treat and other risk factors for coronary heart disease e.g. smoking cessation
• healthy lifestyle

Question 17

What are the symptoms of kidney disease?

Answer 17

Unlikely to have symptoms at start hence routine tests
Symptoms may develop:
- Swollen feet, ankles, hands
- Blood in urine
- Tiredness
- Shortness of breath
- Feeling nauseas

Question 18

What is diabetic neuropathy?

Answer 18

Nerve damage/disease that causes progressive loss of peripheral nerve function
Over time, high blood glucose damages the small blood vessels that supply the nerves in your body. This stops essential nutrients reaching the nerves. As a result, the nerve fibres can become damaged, and they may disappear. 

Question 19

Can diabetic neuropathy be reversed?

Answer 19

No- once the nerves have been damaged they cant be reversed but the symptoms can be treated.
This is why diabetes control is so important and can prevent further damage

Question 20

What are the symptoms of diabetic neuropathy?

Answer 20

• numbness in both legs
• pain
• tingling, itching (paresthesia)
• impaired sense of position- uneasy on feet
• decreased vibration sense

Question 21

Where does diabetic neuropathy effect?

Answer 21

Most commonly the legs and feet (as described in other revision cards)
- but can also effect other areas e.g. Motor neuropathy occurs in the automatic nervous system and can lead to:
- erectile dysfunction
- low bp on standing- orthostatic hypertension
- delayed emptying of the stomach- bloating, nausea, vomiting = gastroporesis
- diabetic diarrhoea- neuropathy affects the anal sphincter

Question 22

What is the treatment for diabetic neuropathy?

Answer 22

• Optimise blood sugar control
• can give pain relief
  - Simple analgesics e.g. paracetamol
  - Anelgesics specialised for nerve pain e.g. gabapentin, carbamazepine, Amitriptyline

Question 23

What are the 2 underlying causes of diabetic foot disease?

Answer 23

• neuropathy
• vascular disease

Question 24

What are the complications of diabetic foot disease?

Answer 24

• Gangrene
• Amputation
• cellulitis
• deep ulceration
• uncontrollable infection
• premature mortality

Question 25

What causes diabetic foot disease?

Answer 25

Caused by a combination of microvascular and microvascular complications
- Peripheral vascular disease (macro): causes poor circulation and ischaemia of lower limb (restricted blood flow)
leads to problems healing infection
problems getting antibiotics to the site of infection in sufficient concentrations as blood supply is bad

• Peripheral neuropathy (Micro): Reduced sensation of pain- can lead to severe problems and ulcers without being aware

Question 26

What are the risk factors for diabetic foot disease?

Answer 26

• Previous foot ulcers/amputation
• callus or enormity in joint/foot/nail
• orthopaedic problems e.g. arthiritis
• visual impairment/motility problems- limiting self care
• Increased duration of diabetes
• poor control of blood glucose and blood pressure
• poorly fitting footwear

Question 27

What is the management/prevention/treatment for diabetic foot disease?

Answer 27

• Wound management- cleaning and dressings
• Reduce reoccurrence- check footwear,
  regular feet checks,
  no foot products containing acids e.g. salicylic acid corn plasters,
  no abrasive foot products e.g. foot files
  optimisation of blood pressure and glucose control
• Referral- urgent if patient has ulceration, swelling, cellulitis, discolouration of skin
• Systemic antibiotics if infected- cellulitis/bone infection
  bacteria that can cause these is broad so need antibiotics that target gram positive and negative and anaerobic bacteria- at a high dose, possibly iv to ensure penetration
• check blood Flow to the area- if restricted:
  surgery- blod vessel graft to bypass affected area of the artery
  drug treatment to dissolve blood clots e.g. Alteplase

patient education:
- Seek medical help immediatelt
- no OTC chiropody products e.g. verruca treatment
- regular review- see chiropodist on diagnosis and then annually

Question 28

What is the microvascular complication of diabetes?

Answer 28

• Cardiovascular disease- causes 60% of diabetic deaths
  risk of CVD is 2-4 x more likely than non-diabetics

Question 29

What is the treatment for reducing cardiovascular risk?

Answer 29

Type 1 and 2 diabetics aged 40 and over should be put on a statin.
NICE guidelines: Atorvastatin 20 mg

and if patient aged 18-39 years and has:
- retinopathy
- poor glycemic control (Hba1c >9%/ 75mmol/mol)
- high blood pressure
- total serum cholesterol >6 mmol/L
- premature CVD in first degree relative
- features of metabolic syndrome- central obesity, fasting triglycerides >1.7 mmol/l, HDL cholesterol greater than 1 mmol/l in men and 1.2 mmol/l in women

Anti-hypertensive therapy- 1st line is an ACE inhibitor

• Aspirin- ONLY if have established cardiovascular disease

Question 30

What are the three As of treatment/prevention of cardiovascular disease?

Answer 30

• Atorvastatin 20mg
• ACE inhibitor- e.g. ramipril
• Aspirin (ONLY in established cvd)

Question 31

What causes nephropathy?

Answer 31

High blood sugar levels and high blood pressure can both cause damage to blood vessels in the kidneys. This can damage the filters that prevent protein from entering the urine from the blood. When these are damage, high concentrations of protein enter the urine.

Question 32

What is EGFR?

Answer 32

The estimated glomerular filtration rate. This is a test that that measure how well the kidneys are functioning by measuring quantities of the waste product, creatinine.