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Endocrinology > Diabetes complications > Flashcards

Diabetes complications Flashcards

1
Q

What are the 3 groups of diabetes complications?

A

Macrovascular
Microvascular
Others

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2
Q

What are some macrovascular complications of diabetes?

A

Ischaemic heart disease
Stroke

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3
Q

What are some microvascular complications of diabetes?

A
  • Neuropathy
  • Nephropathy
  • Retinopathy
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4
Q

What are some other complications of diabetes?

A

psychiatric, cognitive and erectile dysfunctions

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5
Q

What is required in screening for diabetic complications?

A

Digital retinal screening
Foot risk assessment
Urine albumin:creatinin ratio

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6
Q

How does hyperglycaemia cause microvascular complications of diabetes?

A

Mitochondria cant keep up with high demand, and so not all glucose undergoes glycolysis and the Krebs cycle

This means that alternative pathways are used

The polyol pathway uses aldose reductase to form sorbitol

The pentose phosphate pathway forms NADPH oxidase

The hexosamine pathway forms UDP-GlcNAC

Advanced glycation end products can be formed from methyl glyoxal

All of these products cause osmotic damage and inflammatory fibrosis

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7
Q

What are some possible ophthalmic complications of diabetes?

A

Diabetic retinopathy
Diabetic maculopathy
Cataracts
Glaucoma
Visual blurring

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8
Q

What is retinopathy?

A

Damage to the retina

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9
Q

What are the 2 types of diabetic retinopathy?

A

Non-proliferative (Background) retinopathy
Proliferative retinopathy

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10
Q

What is non-proliferative (Background) retinopathy?

A

Early stages of retinopathy, rated from mild-severe (with severe being last stage before proliferative retinopathy)

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11
Q

Describe the pathophysiology of non-proliferative retinopathy

A
  1. Hyperglycaemia damages small vessels
  2. This causes micro aneurysms and intra-retinal haemorrhages (Dot, blot, flame)
  3. Leaked vessels leaves hard exudates (Lipid breakdown products)
  4. Micro-infracts (Ischaemia) due to occluded vessels causes cotton wool spots
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12
Q

What is the management option for non-proliferative diabetic retinopathy?

A

Laser therapy to help prevent long-term visual loss

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13
Q

Describe the pathophysiology of proliferative retinopathy

A
  1. Blockage of blood vessels from NPDR
  2. Causes ischaemia and non-perfusion
  3. Ischaemia causes VEGF release
  4. Formation of new blood vessels
  5. Intra-retinal microvascular abnormality (IRMA) causes vitreous haemorrhage
  6. This causes sudden vision loss
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14
Q

What is the lifetime risk of diabetic patients developing proliferative retinopathy?

A

35%

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15
Q

How is retinopathy graded?

A
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16
Q

Describe the features of fundoscopy

A
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17
Q

What is shown?

A

Microanaeurysms

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18
Q

What is shown?

A

Haemorrhages

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19
Q

What is shown?

A

Hard exudate

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20
Q

What is shown?

A

Cotton wool spot

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21
Q

What is shown?

A

Intra-retinal microvascular abnormalities (IRMA)

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22
Q

What is shown?

A

New vessel formation

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23
Q

How is diabetic maculopathy graded?

A
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24
Q

How can diabetic retinopathy be managed?

A

Laser - Pan retinal photocoagulation
Virectomy can be used in cases of vitreal haemorrhage

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25
Q

How does pan-retinal photocoagulation treat diabetic retinopathy?

A

It reduces the oxygen requirement of the retina and thus reduces ischaemia that is driving retinopathy

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26
Q

What is diabetic macular oedema?

A

A condition involving clinically significant retinal thickening and oedema involving the macula, hard exudates and macula ischaemia

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27
Q

In what conditions can diabetic maculopathy occur?

A

Non-proliferative diabetic retinopathy
Proliferative diabetic retinopathy

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28
Q

What investigation is required in diabetic maculopathy?

A

Optical coherence tomography

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29
Q

What is shown?

A

Referable maculopathy (Hard exudate within 1 disc diameter of the fovea)

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30
Q

What is shown?

A

Retinal thickening on optical coherence tomography in diabetic maculopathy

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31
Q

How is diabetic retinopathy managed?

A

Intravitreal anti-VEGF (anti-vascular endothelial growth factor)

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32
Q

How does cataracts occur in diabetes?

A
  • Increased sugar contents in lens
  • Conversion of glucose to sortbitol
  • Altered osmotic gradients → swelling and fibre disruption
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33
Q

What form of glaucoma occurs in diabetes?

A

Rubeotic glaucoma - new vessel formation forming angle (rare and late complication)

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34
Q

What is diabetic nephropathy?

A

Progressive kidney disease caused by damage to the capillaries in the glomeruli

35
Q

What are some other names for diabetic nephropathy?

A

Kimmelsteil-Wilson Syndrome
Nodular Glomerulosclerosis

36
Q

What are some features of diabetic nephropathy?

A

Proteinuria
Diffuse scarring of the glomeruli

37
Q

What is ACR?

A

Albumin:Creatinine ratio

38
Q

What is PCR?

A

Protein:Creatinine ratio

39
Q

What is determined by PCR?

A

PCR is any protein that you urinate out compared to the amount of creatinine urinated out

40
Q

Why is ACR always a fraction of PCR?

A

Albumin is one of the proteins counted in PCR

41
Q

How much protein is normally urinated out?

A

None

42
Q

What ACR or PCR level is classified as microalbuminuria?

A

ACR < 30
PCR < 50

43
Q

What investigations are required in initial positive test of microalbuminuria?

A
  1. Repeat twice as false positive readings are common
  2. Established microalbuminuria if 2/3 positive
  3. Microalbuminuria will not show up as protein++ on urine dipstick
44
Q

What ACR or PCR level is classified as proteinuria?

A

ACR >30
PCR >50

45
Q

What investigations are required in initial diagnosis of proteinuria?

A
  1. Repeat on EMU
  2. Proteinuria will show up on a urine dipstick
46
Q

How is microalbuminuria managed?

A

ACEi or ARB
Dilate renal arterioles so decrease filtration pressure → decrease proteinuria (also decreases GFR - allow up to 20% deterioration in GFR)

47
Q

How should diabetic patients with microalbuminuria be managed?

A

SGLT2i

48
Q

What is the target BP for people with diabetes?

A

<140/80 mmHg

49
Q

How can the risk of diabetic nephropathy be decreased?

A

Good glycaemic control (<53mmol/mol) in those with T2DM

50
Q

What are some complications of diabetic retinopathy?

A
  • Development of hypertension
  • Relentless decline in renal function
    • Reduction in GFR of 1ml/min/month if untreated
  • Accelerated vascular disease
  • Microalbuminuria is a sign of damage to the glomeruli causing protein leak
    • Marker of ‘high risk’ of other vascular problems
51
Q

What is diabetic neuropathy?

A

Damage to the peripheral nervous tissue

52
Q

What are some risk factors for developing diabetic neuropathy?

A
  • Increased length of diabetes
  • Poor glycaemic control
  • More common in T1DM
  • High cholesterol/lipids
  • Smoking
  • Alcohol
  • Genetics
  • Mechanical injury
53
Q

What are the main types of neuropathy?

A

Peripheral neuropathy
Autonomic neuropathy
Proximal neuropathy
Focal neuropathy

54
Q

What is peripheral neuropathy?

A

Pain/loss of feeling in feet and hands caused by distal symmetrical or sensorimotor neuropathy

55
Q

What are some symptoms of peripheral neuropathy?

A
  • Glove and stocking distribution
  • Numbness/insensitivity
  • Tingling/burning
  • Sharp pains or cramps
  • Sensitivity to touch
  • Loss of balace and coordination
56
Q

What are some complications of peripheral neuropathy?

A

Painless trauma
Charcot foot
Foot ulcer
Claw foot
Callus formation
Argyll Robertson pupil

57
Q

What is painless trauma?

A

Patient may continue to walk on a wounded foot - worsens injury and may lead to infection

58
Q

What is Charcot foot?

A

Complication of severe neuropathy that occurs in a well-perfused foot

59
Q

What are some features of Charcot foot?

A
  1. Acute onset of a hot, swollen foot +/- pain
  2. Bony destruction - if treatment is delayed, the foot can become deformed as bone is destroyed
  3. Radiological consolidation and stabilisation - after 6-12 months
60
Q

What investigation is required in investigation?

A

MRI can differentiate between Charcot foot and infection

61
Q

How is Charcot foot managed?

A
  • Aim is to prevent/minimise bony destruction by keeping pressure off the foot - non-weight bearing, total contact cast or aircast boot
  • Any resulting deformity can alter the pressure distribution across the foot and predisposes the foot to future ulceration
62
Q

How does peripheral neuropathy cause claw foot?

A

Interosseous wasting results in unbalanced traction by the long flexor muscles → high arch and clawing of toes

63
Q

How does peripheral neuropath cause callus formation?

A

Causes abnormal distribution of pressure on walking → callus formation

64
Q

What is meant by Argyll Robertson pupil?

A
  • Small bilateral pupils that do not constrict when exposed to bright light but do constrict when focused on a nearby object
  • Highly specific sign of neurosyphilis but may also be a sign of diabetic neuropathy
65
Q

What are the 4 stages of risk in foot assessment for diabetic neuropathy?

A

Low risk
Moderate risk
High risk
Active

66
Q

What are some features on foot assessment that classify as low risk?

A
  • Sensation unimpaired, foot pulses present
  • Requires annual screening by health-care professional
67
Q

What are some features on foot assessment that classify as moderate risk?

A
  • Sensation unimpaired, foot pulses present OR
  • Inability to self-care for feet
  • Requires annual assessment by podiatrist
68
Q

What are some features on foot assessment that classify as high risk?

A
  • Sensation unimpaired, foot pulses present with skin callus or foot deformity OR
  • Sensation impaired, foot pulses absent OR
  • Previous foot ulcer/amputation
  • Requires annual assessment by podiatrist
69
Q

What are some features on foot assessment that classify as active?

A
  • Current foot ulcer, gangrene, critical ischamia, infection, or unexplained red, hot swollen foot
  • Requires urgent referral to specialist team
70
Q

How is painful neuropathy managed?

A
  • Amitriptyline, duloxetine, gabapentin or pregabalin
  • Topical capsaicin cream can be used for localised neuropathic pain in patients who do not want or can’t tolerate oral treatments
71
Q

What is autonomic neuropathy?

A

Neuropathy that affects the nerves regulating heart rate and blood pressure as well as control of internal organs such as those involved in GI motility, respiratory function, urination, sexual function and vision

72
Q

Who is most at risk of autonomic neuropathy?

A

Usually in those with a long history of very poor diabetes control

73
Q

How can autonomic neuropathy affect the digestive system?

A
  • Gastric slowing/frequency - constipation/diarrhoea (sometimes both)
  • Gastroparesis (slow stomach emptying) - persistent N+V, bloating, loss of appetite
    • Can make blood glucose levels fluctuate widely, due to abnormal food digestion
  • Oesophagus nerve damage - may make swallowing difficult
74
Q

How should gastroparesis be managed in autonomic neuropathy in diabetes?

A
  • Improved glycaemic control
  • Diet - smaller more frequent meals, low fat, low in fiber, if severe may need liquid meals
  • Promotility dugs e.g. metoclopramide
  • Anti-nausea medications e.g. prochlorperazine, and serotonin antagonists e.g. ondansetron
  • Analgeisia: NSAIDs, low dose tricyclic antidepressants, gabapentin, tramadol and fentanyl for abdominal pain
  • Severe cases: consider botulinum toxin, gastric pacemaker
75
Q

How can autonomic neuropathy affect the sweat glands?

A
  • Can affect the nerves that control sweating - prevents the sweat glands from working properly
  • The body cannot regulate its temperature as it should
  • Nerve damage can also cause profuse sweating at night or while eating - gustatory sweating
76
Q

What is the management for sweat gland dysfunction in autonomic neuropathy?

A

Topical glycopyrolate
Clonidine
Botulium toxin

77
Q

How does autonomic neuropathy affect the heart and blood vessels?

A
  • BP may drop sharply after sitting or standing, causing a person to feel light-headed/faint (postural hypertension)
  • Heart rate may stay high, instead of rising and falling in response to normal bodily functions and physical activity
78
Q

What will ECG show in heart dysfunction in autonomic neuropathy?

A

Loss of R-R variability with respiration indicates patient has lost autonomic control of cardiac function

79
Q

What causes proximal neuropathy?

A

Damage to the nerves of the lumbosacral plexus

80
Q

How will proximal neuropathy present?

A

Involves pain in the buttocks, hips, thighs or legs which is then followed by variable weakness in the proximal muscles of the lower limbs and then muscle wasting

81
Q

Who is most at risk of proximal neuropathy?

A

Elderly with T2DM
Associated with weight loss

82
Q

What is focal neuropathy?

A

Sudden weakness in one nerve or a group of nerves causing muscle weakness or pain e.g. carpal tunnel syndrome, cranial nerve palsy

83
Q

What are some possible complications of gestational diabetes on the baby?

A
  • Macrosomia (Increased size)
  • Polyhydramnios
  • Intrauterine death
84
Q
A

Endocrinology (42 decks)

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