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Stage 2: Inflammation > Diabetes Complications > Flashcards

Diabetes Complications Flashcards

1
Q

What causes a lot of diabetes complications and why?

A

Damage to the blood vessels - diabetes is a vascular disease

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2
Q

What are the two types of diabetes complications?

A

Microvascular and macrovascular

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3
Q

Which type of complication is unique to diabetes?

A

Microvascular

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4
Q

What increases the risk of all diabetes complications?

A

Smoking

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5
Q

What is the most common cause of death in patients with diabetes?

A

Macrovascular complications

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6
Q

What are the macrovascular complications of diabetes?

A
  • Coronary heart disease
  • Ischaemic stroke
  • Congestive heart failure
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7
Q

What are the microvascular complications of diabetes?

A

1) Diabetic retinopathy (leading cause of blindness in < 65)
2) Diabetic nephropathy (leading cause of ESRD)
3) Diabetic neuropathy
(4) Limb amputation)

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8
Q

Why does limb amputation occur in diabetes patients?

A
  • Higher risk of infection (glucose)
  • Neuropathy (reduced sensation)
  • Macrovascular complications
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9
Q

When do diabetes complications occur?

A

1) Macrovascular - can develop before diagnosis

2) Microvascular - 5-20 years to develop and become serious

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10
Q

What % of T2D patients have retinopathy at diagnosis?

A

21%

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11
Q

Which type diabetes patients get retinopathy?

A

Both (90-95% of T1D 20 years after diagnosis and 60% of T2D)

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12
Q

What happens in diabetic retinopathy?

A
  • Blood vessels in retina are damaged, creating microaneurysms
  • These can bleed and leak out exudate (protein and lipid) creating a ring
  • High pressure haemorrhage can occur from an artery
  • Areas of the retina can become ischaemic
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13
Q

What is important about the location of a haemorrhage in retinopathy?

A
  • If the haemorrhage occurs on the macula (circle on right of optic nerve) this causes blindness - no detailed vision, no colour
  • If the haemorrhage occurs in an area of the retina that isn’t used much, the person would be unaware
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14
Q

What happens after blood vessels burst in retinopathy?

A
  • New blood vessels grow but they are fragile and useless, going in all directions, not in the plane of the eye (uncontrolled)
  • These new blood vessels can bleed very quickly and bc they go forward, they can bleed into the vitreous
  • Can be lasered
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15
Q

What happens when blood vessels bleed into the vitreous?

A
  • Vitreal haemorrhage
  • A little bit of blood spreads everywhere bc it is fluid
  • Causes blindness
  • If it clears can treat this with laser
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16
Q

How is diabetic retinopathy treated?

A

1) Laser therapy to seal off microaneurysms and areas of ischaemia to prevent new blood vessels growing
2) Photocoagulation - if pan-retina, lose night and peripheral vision but can still use macula

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17
Q

What happens if you laser the macula?

A

Blind

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18
Q

What happens in end stage eye disease?

A
  • Many haemorrhages
  • Scarred retina and vitreous
  • When there is bleeding and scarring, the vitreous contracts and detaches the retina
  • This leads to retinal detachment
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19
Q

Why is it important for diabetic patients to get eye checks?

A

By the time you get symptoms, the damage is advanced

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20
Q

What happens in background/pre-proliferative retinopathy?

A
  • BM thickening (due to decrease in ECM breakdown)
  • Microaneurysm formation
  • Microaneurysm complication (haemorrhage or leakage and accumulation of exudate)
  • Vascular occlusions (ischaemic lesions)
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21
Q

What happens in proliferative retinopathy?

A
  • New vessel formation (from pre-existing vessels) anterior to the retina on its inner surface within the vitreous
  • Traction of the new vessels with haemorrhage formation
  • Maculopathy
  • Retinal detachment due to vitreous
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22
Q

What happens in the haemorrhages from the new vessels in retinopathy doesn’t go into the vitreous and stays behind the lining?

A

The person would not have symptoms

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23
Q

What happens in diabetic nephropathy?

A
  • ECM deposition
  • Cytokine production (transforming growth factor beta 1)
  • Microalbuminuria or proteinuria
  • End stage renal failure
  • Increase risk of CV disease
  • 30-40% incidence
24
Q

How many stages of kidney disease are there?

A

5

25
Q

What happens in stage 1 kidney disease?

A
  • Increase in GFR due to hyperfiltration
  • Kidneys increase in size
  • Kidney damage e.g. microalbuminuria
  • Worse in people with higher sugars
26
Q

What happens in stage 2 kidney disease?

A
  • Glomeruli begin to show damage (kidney damage)
  • Microalbuminuria occurs
  • GFR 60-89
27
Q

What happens in stage 3 kidney disease (moderate)?

A
  • Albumin excretion rate (AER) > 200 micrograms/min
  • Blood creatinine and urea-nitrogen rise
  • BP may rise
  • GFR 30-59
28
Q

What happens in stage 4 kidney disease (severe)?

A
  • GFR < 75 ml/min (15-29)
  • High proteinuria
  • High BP
  • Higher levels of blood creatinine and urea-nitrogen
29
Q

What happens in stage 5 kidney disease?

A
  • Kidney failure/ESRD

- GFR < 10-15 ml/min or dialysis

30
Q

What is the average length of time for someone with T1D to progress from stage 1 to stage 4 kidney disease?

A

17 years (23 for stage 5)

31
Q

How is nephropathy detected?

A

Testing for urinary protein

32
Q

What can conventional bedside testing detect in nephropathy?

A

Albumin concentration > 200 mg/l (stage 4 nephropathy)

33
Q

How can earlier detection of nephropathy be achieved?

A
  • More sensitive assays detecting microalbuminuria (albumin 20-200 mg/l)
34
Q

What is the difference between proteinuria and microalbuminuria?

A
  • Proteinuria = microalbuminuria > 200 mg/l
35
Q

What is the prognosis of diabetic nephropathy?

A

10-15 years before dialysis, only get symptoms at very end

36
Q

Why is GFR not used to detect diabetic nephropathy?

A

Bc this would pick it up 13 years into the disease when the GFR becomes < 90 (normal) and need to pick it up much sooner

37
Q

Describe diabetic neuropathy

A
  • Most common complication
  • Variable presentation and severity
  • Blood vessels that supply nerves are affected
38
Q

What does diabetic neuropathy result in?

A

1) Neuropathic pain
2) Autonomic failure
3) Contribution to diabetic food ulceration

39
Q

Describe generalised symmetric polyneuropathies in diabetic neuropathy

A
  • Nearly always starts in feet with the longest nerves (in legs), rarely hands
  • Affects sensation first and most profoundly but does affect both
40
Q

What are the 3 types of diabetic neuropathy?

A

1) Acute sensory
2) Chronic sensorimotor
3) Autonomic

41
Q

What are the types of focal and multifocal diabetic neuropathies?

A

1) Cranial
2) Truncal
3) Focal limb
4) Proximal motor (amyotrophy)

42
Q

Are most generalised sensory neuropathies chronic or acute?

A

Chronic

43
Q

Describe presentation of painful chronic generalised sensory neuropathies

A
  • Distal, burning, shooting pain esp. at night

- Parasthesia or hyperasthesia

44
Q

Describe presentation of painless chronic generalised sensory neuropathies

A
  • Asymptomatic sensory loss
  • Impaired light touch, vibration, temperature sensation
  • Absent reflexes
  • Autonomic dysregulation - warm skin, bounding pulses
  • Injuries, infections and trauma to foot
45
Q

Describe presentation of focal/multifocal neuropathies

A
  • Diabetic amyotrophy - painful wasting of the proximal leg muscles esp. quads
  • Median and ulnar nerves commonly affected
  • May present with unilateral cranial nerve III, IV or VI palsy
46
Q

What causes diabetic foot?

A
  • Loss of pain sensation
  • Unrecognised trauma
  • Loss of joint position sense
  • Abnormal foot posture (foot gradually changes shape bc walk differently due to lack of sensation)
  • Wasting of small intrinsic muscles
  • Foot deformity
47
Q

What happens in cardiovascular autonomic neuropathy?

A
  • Resting tachycardia
  • Postural hypotension
  • Risk of cardiac arrhythmias/sudden death
48
Q

What happens in gastrointestinal autonomic neuropathy?

A
  • Gastroparesis
  • Autonomic diarrhoea
  • Abnormal gustatory sweating e.g. sweating in response to sandwich somewhere else, unlike just in response to spicy food which is normal
49
Q

What happens in genitourinary autonomic neuropathy?

A
  • Bladder dysfunction

- Erectile dysfunction (vascular and nerve problem - viagra treats vascular problem)

50
Q

What does good glycaemic control reduce development of?

A

Retinopathy and nephropathy

51
Q

What are the parts of diabetic screening for complications done once a year (more frequently for high risk patients)?

A

1) Urine tests
2) Microalbuminuria
3) BP
4) eGFR
5) Cholesterol
6) Smoking status
7) Retina photography
8) Foot check
(Don’t screen for autonomic problems)

52
Q

What is glomerulosclerosis?

A

Dead glomerulus with no blood supply

53
Q

What causes glomerulosclerosis (diabetic nephropathy)?

A

1) Metabolic insult - glucose and lipids

2) Haemodynamic insult - vascular problems

54
Q

What are possible reasons that glucose/diabetes causes complications?

A

1) Advanced glycation - glucose binding to aa forming AGEs which accumulate leading to tissue and protein dysfunction
2) Sorbitol generation from excess glucose forming ROS
3) Oxidative stress leading to endothelial damage and vasoconstriction
4) Excess cytokines and growth factors (TGFbeta and VEGF)
5) Glucose leads to increase in PKC and VEGF (new blood vessels in eye) - can block VEGF in eye instead of laser therapy

55
Q

What is the main treatment for prevention of diabetic nephropathy?

A

ACE-inhibitors which dilate the efferent arteriole to reduce intra-glomerular pressure (bc afferent arteriole dilates but efferent remains the same, excess pressure leads to excess growth factors)

Stage 2: Inflammation (39 decks)

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