Diabetes Complications Flashcards
List the major complications of Diabetes?
Short Term:
Diabetic Ketoacidosis (DKA)
Hyperglycaemic Hyperosmolar State (HHS)
Hypoglycaemia
Long Term:
Macrovascular –> CAD/PAD/Stroke
Microvascular –> Retinopathy, Nephropathy, Neuropathy & PAD
Explain the macrovascular effects of diabetes?
DM accelerates Atherosclerosis
The Excess Glc bind to LDL preventing it from being cleared by liver cells –> Hyperlipidaemia
What is the major consequence of DM’s macrovascular effect?
Increased risk of athermatous diseases including CAD, MI, PAD & stroke
Explain DM’s microvascular effects?
DM triggers the Hyaline Change in areterioles/capillaries by:
- Glycosylating collagen in the subendothelial space allowing it bind albumin from the plasma
- Glycosylating basal lamina proteins allowing them to bind and cross-link
These mechanisms cause a build up of proteins in the vessel wall causing narrowing
What are the consequences of DM’s microvascular effects?
Neuropathies
Retinopathy
Nephropathy
Peripheral Arterial Disease
What are the forms of Diabetic retinopathy?
- Background Retinopathy
- Proliferative Retinopathy (occurs after background retinopathy
- Maculopathy (exudate/haemorrhage specfically at the macula)
What events occur causing diabetic retinopathy?
Background (Pre-proliferative):
- Microaneurysms
- Hard Exudates
- Cotton wool spots (damaged nerves)
PRoliferative:
- VEGF from damaged vessels –> Proliferation
- Vitreous hemorrhage (potential complication of proliferation)
How do we treat proliferative retinopathy?
We can do a vitrectomy if theres a vitreous haemorrhage
Laser photocoagulation destroys ischaemic retina, reducing Endothelial Growth Factors causing the new vessels to regress
How do we treat maculopathy?
Grid laser therapy
Glc Control
BP control
How does diabetes affect cataracts?
It doubles risk of cataracts due to build up of glucose
What are the main types of diabetic neuropathy?
Peripheral Neuropathies (primarily the feet) including acute senory peripheral neuropathy and proximal motor neuropathy.
Mononeuritis
Autonomic Neuropathy
What is the main danger of peripheral neuropathy?
Foot ulcers that arn’t noticed -> infection -> Amputation
How would you tell if someone has peripheral neuropathy?
Small muscle wasting (e.g. between toes/tendons on foot)
Chronic sensory changes like paraesthesia, burning or numbess
How do we care for a peripheral neuropathy?
Pain relief:
- Capsaisan cream
- Amitriptyline
Protection of feet from ulceration:
- Fitted footwear
- Regular podiatry visits
- Foot screening and risk assessment
What is Acute Sensory Peripheral Neuropathy?
A type of peripheral neuropathy brought on by Diabetes.
Its a rapid onset of neuro symptoms that can be severe followed by a gradual recovery.
Can be caused by rapid tightening of Glc control or acute metabolic upset
What is proximal motor neuropathy?
A type of peripheral neuropathy
Causes weight loss, pain and wasting, mainly in the legs of elderly men
What are the main nerves affected by diabetic mononeuritis
Motor ocular nerves (III, IV, VI) Peroneal Nerve (acute foot drop)
They have acute onset and slow recovery
What are the main features of autonomic neuropathies?
Erectile Dysfunction Postural hypotension Gastric stasis -> Recurrent vomiting Diarrhoea Sweating, peripheral oedema & urinary retention
Erectile dysfunction is a potential diabetic autonomic neuropathy, how do you treat it?
Phosphodiesterase inhibitors e.g. Viagra
Postural Hypotension is a potential diabetic autonomic neuropathy, how do you treat it?
Tell them to stand up slowly, otherwise:
NSAIDS or Fludrocortisone
Gastric stasis and vomiting is a potential diabetic autonomic neuropathy, how do you treat it?
Domperidone.
Dopamine antagonist that acts as an antiemetic and progastrokinetic
Diarrhoea is a potential diabetic autonomic neuropathy, how do you treat it?
Loperamide (i.e. imodium)
How does diabetic nephropathy arise?
Microvascular damage to glomeruli capillaries causing them to leak proteins into the urine and eventually become unable to filter blood
How do we detect Diabetic nephropathy early on?
a 1st morning urine sample or timed over night urine collection to test for albumin in the urine
Important as its still reversible early on
Whats the progression of Diabetic Nephropathy?
Microalbuminuria
Proteinuria
Impaired renal function (+/- nephrotic syndrome)
End stage renal disease
How do we manage diabetic nephropathy?
- Glycaemic control
- BP control
- ACE inhibitor slows progression & treats BP
- CVD risk factor control
What is Diabetic Ketoacidosis?
A large number of Ketone bodies produced from FAs by the liver, turning the blood acidic
What causes DKA?
Low levels of insulin allow glucagon to rise, causing FAs to be released from adipose and broken down for energy.
Period of extra energy need can trigger DKA such as stress, infection or insulin omission
Its far more common in Type 1
How does DKA present?
- N&V
- Thirst & Dehydration
- Kussmauls Respiration (Deep, rapid & sighing)
- Polyuria
- Tachycardia & Hypotension
- Weakness, confusion and coma
- Sweet Ketotic Breath
What is the hyper Glycaemic Hyperosmolar state (HHS)?
A state of high osmolarity due to blood sugar without significant ketoacidosis.
More likely in Type 2
How does HHS present?
Dehydration Weakness Leg Cramps Visual Problems Altered consciousness
DKA itself has complications, what are they?
Hyper/hypokalemia Cerebral oedema (the cause of confusion, coma and death) Aspiration & pneumonia Thromboembolism ARDS Hypoglycaemia
How do we test for DKA?
Inititial Investigations:
- ABCs
- Vital Signs
- IV access
- Clinical Assessment
- Glucose fingerprick test
First Investigations:
- Lab Blood Glucose to confirm
- ABGs (Low CO2 from hyperventilation & acidosis)
- Urinalysis and blood ketones
- U&E + FBC
Other:
- Blood/urine cultures (rules out infection as a trigger/complication)
- ECG
- Consider CXR
How do we manage DKA?
o IV saline o IV Insulin -- Drives glucose into cells o ~Abx o ~Heparin (prevents thromboembolism) o ~NG tube
