Diabetes Complications

Question 1

Explain the macrovascular effects of diabetes?

Answer 1

DM accelerates Atherosclerosis

The Excess Glc bind to LDL preventing it from being cleared by liver cells –> Hyperlipidaemia

Question 2

Pathophysiology of Microvascular complications in Diabetes

Answer 2

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

Question 3

Types DM’s microvascular effects?

Answer 3

Neuropathies
Retinopathy
Nephropathy
Peripheral Arterial Disease

Question 4

What are the forms of Diabetic retinopathy?

Answer 4

• Background Retinopathy
• Proliferative Retinopathy (occurs after background retinopathy
• Maculopathy (exudate/haemorrhage specfically at the macula)

Question 5

What events occur causing diabetic retinopathy?

Answer 5

Background (Pre-proliferative):

• Microaneurysms
• Hard Exudates
• Cotton wool spots (damaged nerves)

PRoliferative:

• VEGF from damaged vessels –> Proliferation
• Vitreous hemorrhage (potential complication of proliferation)

Question 6

How do we treat proliferative retinopathy?

Answer 6

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

Question 7

How do we treat maculopathy?

Answer 7

Grid laser therapy
Glc Control
BP control

Question 8

How does diabetes affect cataracts?

Answer 8

It doubles risk of cataracts due to build up of glucose

Question 9

What are the main types of diabetic neuropathy?

Answer 9

Peripheral Neuropathies (primarily the feet) including acute senory peripheral neuropathy and proximal motor neuropathy.

Mononeuritis

Autonomic Neuropathy

Question 10

What is the main danger of peripheral neuropathy?

Answer 10

Foot ulcers that arn’t noticed -> infection -> Amputation

Question 11

How would you tell if someone has peripheral neuropathy?

Answer 11

Small muscle wasting (e.g. between toes/tendons on foot)

Chronic sensory changes like paraesthesia, burning or numbess

Question 12

How do we care for a peripheral neuropathy?

Answer 12

Pain relief:

• Capsaisan cream
• Amitriptyline

Protection of feet from ulceration:

• Fitted footwear
• Regular podiatry visits
• Foot screening and risk assessment

Question 13

What is Acute Sensory Peripheral Neuropathy?

Answer 13

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

Question 14

What is proximal motor neuropathy?

Answer 14

A type of peripheral neuropathy

Causes weight loss, pain and wasting, mainly in the legs of elderly men

Question 15

What are the main nerves affected by diabetic mononeuritis

Answer 15

Motor ocular nerves (III, IV, VI)
Peroneal Nerve (acute foot drop)

They have acute onset and slow recovery

Question 16

What are the main features of autonomic neuropathies?

Answer 16

Erectile Dysfunction
Postural hypotension
Gastric stasis -> Recurrent vomiting
Diarrhoea
Sweating, peripheral oedema & urinary retention

Question 17

Erectile dysfunction is a potential diabetic autonomic neuropathy, how do you treat it?

Answer 17

Phosphodiesterase inhibitors e.g. Viagra

Question 18

Postural Hypotension is a potential diabetic autonomic neuropathy, how do you treat it?

Answer 18

Tell them to stand up slowly, otherwise:

NSAIDS or Fludrocortisone

Question 19

Gastric stasis and vomiting is a potential diabetic autonomic neuropathy, how do you treat it?

Answer 19

Domperidone.

Dopamine antagonist that acts as an antiemetic and progastrokinetic

Question 20

Diarrhoea is a potential diabetic autonomic neuropathy, how do you treat it?

Answer 20

Loperamide (i.e. imodium)

Question 21

How does diabetic nephropathy arise?

Answer 21

Microvascular damage to glomeruli capillaries causing them to leak proteins into the urine and eventually become unable to filter blood

Question 22

How do we detect Diabetic nephropathy early on?

Answer 22

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

Question 23

Complications of diabetic nephropathy

Answer 23

Microalbuminuria
Proteinuria
Impaired renal function (+/- nephrotic syndrome)
End stage renal disease

Question 24

How do we manage diabetic nephropathy?

Answer 24

• Glycaemic control
• BP control
• ACE inhibitor slows progression & treats BP
• CVD risk factor control

Question 25

Presentation of hyperosmolar hyperglycaemic state

Answer 25

Dehydration
Weakness
Leg Cramps
Visual Problems
Altered consciousness

Question 26

DKA itself has complications, what are they?

Answer 26

Hyper/hypokalemia
Cerebral oedema (the cause of confusion, coma and death)
Aspiration & pneumonia
Thromboembolism
Acute respiratory distress syndrome
Hypoglycaemia

Question 27

How do we test for DKA?

Answer 27

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

Question 28

How do we manage DKA?

Answer 28

o	IV saline
o	IV Insulin -- Drives glucose into cells
o	~Abx
o	~Heparin (prevents thromboembolism)
o	~NG tube