DIS - Diseases of the Vasculature IV: Diabetes I - Week 11 Flashcards
What is diabetes mellitus?
Sustained hyperglycaemia
List the two types of diabetes and whether they are insulin dependent or independent.
Type 1 - insulin dependent
Type 2 - insulin independent
What onset do type 1 and 2 diabetes typically have?
1 - juvenile
2 - adult
Can non-insulin dependent diabetes develop into insulin dependent?
Yes
What three things related to insulin can diabetes be due to?
Lack of endogenous insulin
Reduced efficacy of endogenous insulin
Both
What is the typical random blood glucose level with diabetes? What about fasting?
Random - >11mmol/L
Fasting - >7mmol/L
What does the glucose tolerance test measure?
Glucose clearance from the blood
What is HbA1c with diabetes?
> 6.5%
Describe how a glucose tolerance test is carried out and what the prerequisite is.
Prerequisite - eat/drink adequate carbohydrates for 3 days (150g/d)
Fast for 8h before the test
Take fasting blood glucose test
Ingest 75g of glucose (with 2L of fluid)
Blood glucose measured after 1 and 2h
List three early systemic signs of diabetes. What is this related to?
Excessive thirst
Excessive urine production
Loss of appetite and weight
-all related to osmosis
What is a late systemic sign of diabetes? Describe why it occurs.
Ketoacidosis
-insufficient insulin leads to the body burning fat for energy
-ketones accumulate in blood and urine
Describe the association between insulin and nerves and what the evidence is like.
Some evidence suggests insulin is a neurotrophic factor
-neurons need insulin to sustain them
What is the proportion of type 1 and 2 diabetes?
1 - 15%
2 - 85%
List the two classifications of diabetic retinopathy and what they are characterised by (1, 2).
Non-proliferative
-microangiopathy
Proliferative
-formation of new vessels on the vitreo-retinal interface and in the vitreous
-proliferation of fibrovascular tissue on the retina/disc
What two factors correlate strongest with the presence of diabetic retinopathy?
Duration of diabetes
Quality/degree of glycaemic control of diabetes
What is thought to directly link to development and progression of diabetic retinopathy? What are the two major effects of this?
Altered glucose metabolism
-increased blood retinal barrier permeability - leakage
-alterations in retinal blood flow (hypoxia)
Describe how hyperglycaemia can lead to changes in vessels (4). Explain what these changes are (2) and what it can lead to (2) and how (1).
Causes the production of advanced glycation end products and increased diacylglycerol levels
These activate protein kinase C and overexpression of VEGF
PKC activation lead to capillary leakage and neovascularisation
Capillary occlusion leads to increased expression of insulin-like growth factor (IGF-1)
This leads to the development of pre-retinal and iris neovascularisation
What two things do all diabetics need?
Regular retinal examination
Dilated pupil exam
Should newly diagnosed diabetics have a retinal exam?
Yes
What happens to the basement membrane of retinal capillaries with diabetes? What is a consequence of this?
Thickens
-decreased O2
What happens to pericytes and endothelial cells in retinal capillaries with diabetes? What are two consequences of this?
Loss of pericytes
Endothelial enlargement
-microaneurysm formation
-capillary leakage and eventual drop out
What are three early signs of non-proliferative diabetic retinopathy?
Microaneurysms
Dot/blot haemorrhages
Lipid exudates
What are five signs of more advanced non-proliferative diabetic retinopathy?
More of the three early signs plus
Cotton wool spots
Intraretinal microvascular abnormalities
Flame haemorrhages
Venous beading
What are four signs of proliferative diabetic retinopathy?
Signs of non-proliferative DR (usually more advanced) plus
New vessels - NVI, NVE, NVD
Vitreous haemorrhage
Tractional retinal detachment
How do microaneurysms appear? What about with angiography? Are they isolated or clustered?
Tiny red dots like dot haemorrhages
Hyperfluorescent on FA
Sometimes isolated, sometimes clustered
What retinal layer do dot/blot haemorrhages occur (non-specific)?
From middle retinal layers
-from microaneurysms/deep capillaries
What colour and shape are intra-retinal lipids?
Yellow - often circinate - circular
What two things are generally used for staging diabetic retinopathy?
Number of microaneurysms and haemorrhages
What is a cotton wool spot?
Ischaemia of the RNFL
What is a flame haemorrhage?
Haemorrhage of the superficial capillary layer supplying the RNFL
What is venous beading? What can be seen on fluorescein angiography?
Sacular bulges, dilation
Capillary dropout on both sides of the vein on angiography
What are intraretinal microvascular abnormalities? What do they bypass and what do they mimic? What are they often seen with?
Dilated abnormal capillaries
Bypass capillaries
Mimic new vessels
Often with venous loops and cotton wool spots