DM complications Flashcards
microvascular complications
-eye:
-retinopathy
-cataracts
-glaucoma
-> blindness
-kidney:
-nephropathy- microalbuminuria and gross albuminuria
-> kidney failure
-nerves:
-neuropathy- peripheral and autonomic
-> amputation
-all can lead to death and/or disability
diabetic retinopathy
-Diabetic retinopathy is MC cause of new cases of blindness among adults 20-74 years of age.
-Each year, between 12,000-24,000 people lose their sight because of diabetes.
-During the first 2 decades of disease, nearly all patients with type 1 diabetes and over 60% of patients with type 2 diabetes have retinopathy
-develops in some degree in nearly all pts
-MC cause of new cases of blindness in adults
-most predominant cause of vision loss are clinically significant macular edema and proliferative diabetic retinopathy
-proper ophthalmic care and exam to identify retinopathy in early stages
screening for diabetic retinopathy
-type 2- initial dilated and comprehensive eye exam by ophthalmologist at time of diabetes dx
-If no evidence of diabetic retinopathy (DR) for 1 or more annual eye exams and glycemia is well controlled, then screening every 1–2 years may be considered
-If any level of DR is present -> dilated retinal exam should be repeated at least annually
-If DR is progressing or sight-threatening, then exam required more frequently
-Programs that use retinal photography (with remote reading or use of a validated assessment tool) to improve access to DR screening can be appropriate screening strategies for DR
-Such programs need to provide pathways for timely referral for a comprehensive eye examination when indicated
risk of diabetic retinopathy related vision loss
-Duration of diabetes disease
-Type 1 patients experience a 25% rate of retinopathy after 5 years of disease, and 80% at 15 years of disease
-Up to 21% of newly diagnosed type 2 patients have some degree of retinopathy at time of diagnosis
-Puberty
-Pregnancy- GDM doesnt tend to have eye problems -> dont need to fu as often
-Lack of appropriate ophthalmic examination
retinopathy
-Diabetes accounts for 8% of all legal blindness in the US
-Tight control – delays onset and progression of retinopathy
-Proteinuria, elevated blood urea nitrogen, and elevated blood creatinine
-Cataract: 5x more common among people with diabetes
-Glaucoma- Glaucoma occurs with increased frequency in people with diabetes
natural hx of diabetic retinopathy
-from most mild to severe
-Mild nonproliferative diabetic retinopathy (NPDR)
-Moderate NPDR
-Severe NPDR
-Very Severe NPDR
-Proliferative diabetic retinopathy (PDR)- new vessels are being formed bc less O2 -> fragile and bleed easily
mild NPDR
-Clinical Findings
-Increased vascular permeability
-Microaneurysms
-Intraretinal hemorrhages
-Clinically Significant Macular Edema (CSME) possible
-Management/Treatment
-Annual follow-up
-If CSME present: color fundus photography, fluorescein angiography, and photocoagulation
moderate NPDR
-Clinical Findings
-Venous caliber changes
-Intraretinal Microvascular Abnormalities (IRMAs)
-CSME possible
-Management/Treatment
-6-12 month follow-up without CSME
-Color fundus photography
-CSME present: color fundus photography, fluorescein angiography, focal photocoagulation*, 3-4 month follow-up
severe/very sever NPDR
-Clinical Findings
-Retinal ischemia
-IRMAs
-Extensive hemorrhage and microaneurysms
-CSME possible
-Management/Treatment
-3-4 month follow-up
-Color fundus photography
-Possible panretinal photocoagulation
-CSME present: color fundus photography, fluorescein angiography, focal photocoagulation* (clotting off the blood vessels), 3-4 month follow-up
proliferative diabetic retinopathy
-Clinical Findings
-Ischemia induced neovascularization
-at the optic disk (NVD)
-elsewhere in the retina (NVE)
-Vitreous hemorrhage
-Retinal traction, tears, and detachment
-CSME possible
normal retinopathy
-Color yellowish orange to creamy pink
-Disc vessels tiny
-Disc margins sharp (except perhaps nasally)
-The physiologic cup is located centrally or somewhat temporally.
-It may be conspicuous
-or absent. Its diameter from side to side is usually less than half that of the disc.
micoaneurysms
-Tiny, round, red spots seen commonly but not exclusively in and around the macular area.
-They are minute dilatations of very small retinal vessels, but the vascular connections are too small to be seen ophthalmoscopically.
deep retinal hemorrhages
-Small, rounded, slightly irregular red spots that are
sometimes called dot or blot hemorrhages.
-They occur in a deeper layer of the retina than flame shaped hemorrhages.
-Diabetes is a common cause
neovascularization
-Refers to the formation of new blood vessels.
-They are more numerous, more tortuous, and narrower than other blood vessels in the area and form disorderly looking red arcades.
-A common cause is the late, proliferative stage of diabetic retinopathy.
-The vessels may grow into the vitreous, where retinal detachment or hemorrhage may cause loss of vision
-Neovascularization with fibrous proliferations,
distortion of the macula, and reduced visual acuity
PDR management and tx
-2-4 month follow-up
-Color fundus photography
-Panretinal photocoagulation (3-4 month follow-up)
-Vitrectomy
-CSME present: focal photocoagulation, fluorescein angiography
diabetic neuropathy
-About 60-70% of people with diabetes have mild to severe forms of nervous system damage, including:
-Impaired sensation or pain in the feet or hands -> check feet at every visit
-Slowed digestion of food in the stomach
-Carpal tunnel syndrome
-Other nerve problems
-More than 60% of nontraumatic lower-limb amputations in the United States occur among people with diabetes
risk factors of neuropathy
-Glucose control
-Duration of diabetes
-Damage to blood vessels
-Mechanical injury to nerves
-Autoimmune factors
-Genetic susceptibility
-Lifestyle factors
-Smoking
-Diet
pathogenesis of diabetic neuropathy
-Linked to duration of diabetes and level of glucose control
-May affect any part of the nervous system - cranial, peripheral, and autonomic
-Mainly starts at and affects lower limbs
-Often causes paresthesias of extremities
-Symptoms are symmetric and associated with intense burning
-Metabolic factors
-High blood glucose
-Advanced glycation end products
-Sorbitol - breakdown product
-Abnormal blood fat levels
-Ischemia
-Nerve fiber repair mechanisms
screening for diabetic neuropathy
-may not have neuropathy in type 1 because they present much earlier
-All people with diabetes should be assessed for diabetic peripheral neuropathy (DPN) starting at dx of type 2 diabetes and 5 years after dx of type 1 diabetes and every visit after
-check every visit after and with evidence of other microvascular complications, particularly kidney disease and DPN
-Screening can include asking about orthostatic dizziness, syncope, or dry cracked skin in the extremities.
-Signs of autonomic neuropathy include orthostatic hypotension, a resting tachycardia, or evidence of peripheral dryness or cracking of skin
dx test for neuropathy
-Assess symptoms - muscle weakness, muscle cramps, prickling, numbness or pain, vomiting, diarrhea, poor bladder control and sexual dysfunction
-Comprehensive foot exam:
-Skin sensation and skin integrity:
-Temperature/pinprick sensation [small fibers]
-Vibration with 128Hz tuning fork [large fibers]
-Quantitative Sensory Testing (QST)
-Monofilaments [10-g] for risk for ulceration and amputation
-Nerve conduction studies
-Electromyographic examination (EMG)
-Ultrasound
tx of neuropathy pain
-Gabapentinoids, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers are recommended as initial pharmacologic treatments for neuropathic pain in diabetes.
-Refer to neurologist or pain specialist
classification of diabetic neuropathy
-Symmetric polyneuropathy
-Autonomic neuropathy
-Polyradiculopathy
-Mononeuropathy
longest nerves are most affected
-stocking
symmetric polyneuropathy
-MC form of diabetic neuropathy
-Affects distal lower extremities and hands (“stocking-glove” sensory loss)
-Symptoms/Signs
-Pain
-Paresthesia/dysesthesia
-Loss of vibratory sensation
-Symptoms generally begin distally in the toes and feet and move upward toward the calf
-not uncommon for symptoms to also begin to appear in the hands, and the patient develops what is known as “stocking-glove” sensory loss.
-Symptoms include pain, abnormal sensation in the affected areas, and loss of vibratory sensation. Thermal sensation is also affected.
