DM - Complications Flashcards
For every 1% decrease in HbA, there is a ___% decrease in mortality and ____% decrease in microvascular complications
21%, 37%
1 cause of chronic kidney disease (CKD),
ESRD, & CKD requiring renal replacement
therapy (aka Dialysis)
Diabetic Nephropathy
Most common cause of Nephrotic Syndrome
40% of DM II
30% of DM I
Nephrotic Syndrome
- Loss of protein from plasma into urine
2° ↑ glomerular permeability - Leads to generalized edema,
hypoalbuminemia, hyperlipidemia, &
frank proteinuria (detectable with urine
dipstick)
Etiology/Pathogenesis of Diabetic nephropathy
Glomerular Damage
↓
leaking protein into urine
↓
Hypoalbuminemia
Hypoalbuminemia process
↓osmotic pressure
↑ edema
↓ vascular volume
↓ blood pressure
↑ kidney renin production
↑ aldosterone
↑ sodium & water retention
↑ intravascular fluid
↑ edema
40% of patients with diabetes develop diabetic ____
nephropathy
T/F Smoking accelerates the decline in renal function
T
Annual assessments for Diabetic nephropathy
- Serum Creatinine (Cr) to determine eGFR
- Urine Albumin & Cr to determine
Albumin/Cr ratio - Begin annual screening 5 years after diagnosis of DM I or At diagnosis of DM II or DM I
When Management of Diabetic Nephropathy requires Nephrologist referral
✅ Atypical presentation
✅ Rapid decline in eGFR OR albuminuria progression
✅ Stage 4 CKD
Management of Diabetic Nephropathy
- Smoking cessation
- RAAS blockade for albuminuria
- Nephrologist referral
1 cause of preventable blindness in adults
Diabetic Retinopathy
Epidemiology of Diabetic Retinopathy
- 86% of DM I
- 40% of DM II
Risk Factors of Diabetic Retinopathy
- African-American, Hispanic, South Asian
- ↓ age at Dx of DM
- HTN
- Dyslipidemia
- Pregnancy
- Puberty
- Cataract surgery
Clinical Presentation of Diabetic Retinopathy
- *Often Asymptomatic!
- Blurred or double vision
- ↓ field of vision
- Seeing dark spots
- Pressure or pain in eyes
- ↓ vision in dim light
- Sudden blindness (rare)
Clinical features on funduscopic exam vary by disease severity
- Neovascularization
- Ischemia
- Microaneurysms: Earliest clinical sign
Diabetic Neuropathy in multiple systems
- Cardiovascular → resting tachycardia & orthostatic hypotension
- Genitourinary → Gastroparesis & bladder-emptying abnormalities
- Skin → Hyperhidrosis of the upper extremities & anhidrosis of the lower
extremities result from sympathetic nervous system dysfunction
Anhidrosis of the feet → dry skin → cracking → ↑ risk of foot ulcers - Endocrine → Autonomic neuropathy may ↓ counter-regulatory
hormone release (esp. catecholamines) → ↓ sensation of hypoglycemia
Assessment of Diabetic Neuropathy
Begin assessment
5 years after diagnosis of DM I
At diagnosis of DM II
Complete neurologic examination
annually
Assess for Heart Rate Variability
Deep inspiration
Valsalva maneuver
Change in position from supine
to standing
FDA approved for Diabetic Neuropathy
duloxetine (Cymbalta®)
amitriptyline (Elavil®)
pregabalin (Lyrica®)
Capsaicin 8% patch
Management of Large-fiber neuropathies
↓ joint position, vibration sensation & sensory ataxia
Management of Small-fiber neuropathies
↓ pain, temperature & autonomic function
Treatment of Diabetic Neuropathy
Improved glycemic control
Hydrate
Chew your food
Small meals low in fat/fiber
Prevent bezoar
Liquid nutritional supplements
E.g. Glucerna®
Otherwise tx are inadequate
____ Study showed ↑ in PAD, CAD, MI, & CHF
Framingham Heart
American Heart Association has designated DM as a
“_______” & DM II patients without a prior MI
have a similar risk for coronary artery–related events as nondiabetic individuals who have had a prior MI.
CHD risk equivalent
DM is the ___ cause of nontraumatic lower
extremity amputation in the US
1
___% of all lower limb amputations in patients with DM are preceded by a foot ulcer
85
Management of lower extremity complications in DM patients
Educate high-risk patients on ulcer prevention, every visit
Screen for asymptomatic PAD
↓ risk factors for vascular disease in Lower extremity complications of DM patients
Smoking cessation
Dyslipidemia
Hypertension
Tight glycemic control
When to refer lower extremity complications to Podiatry
Protracted wound healing & skin
ulceration
Callus deformities
Nail deformities
Annual Exam
Orthotic shoes, inserts, & devices
Education about off the shelf
footwear
Most common skin manifestations of DM are
Xerosis and Pruritus
DERMATOLOGIC MANIFESTATIONS in DM
Bullosa Diabeticorum: DM related bullae
Vitiligo: ↑ frequency in T1 DM
Acanthosis Nigricans: Hyperpigmented velvety plaques, signals severe insulin resistance
Lipoatrophy & lipohypertrophy: insulin injection sites
