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Hormones > Endo 18: Microvascular complications of diabetes > Flashcards

Endo 18: Microvascular complications of diabetes Flashcards

1
Q

3 sites of microvascular complication

A

Retinal arteries

Glomerular arterioles (kidney)

Vasa nervorum (tiny blood vessels that supply nerves)

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2
Q

What determines microvascular complications

A
  1. Severity of hyperglycaemia
    - Affects retinopathy the most, then nephropathy then neuropathy
  2. HTN
  3. Genetic
  4. Hyperglycaemia memory
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3
Q

What causes microvascular complications, generally

A

Tissue damage through originally reversible and later irreversible alterations in proteins

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4
Q

What is hyperglycaemia memory

A

The fact that previous glucose control affects microvascular outcomes at a given time

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5
Q

How does hyperglycaemia cause microvascular damage?

A

High glucose levels cause many changes in the inflammatory cascades.

This then leads to inflammation, causing problems in the eyes, kidneys and nerves.

There are pathways that make this damage worse:

  • Polyol pathway
  • AGEs
  • Protein kinase C
  • Hexosamine
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6
Q

What is the main cause of blindness in people of working age

A

Diabetic retinopathy is the main cause of visual loss in people with diabetes and the main cause of blindness in people of working age

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7
Q

Outline the cause of proliferative diabetic retinopathy

A

Hyperglycaemia leads to inflammation (polyol, AGEs, PKC, hexosamine etc)

This leads to vascular endothelial dysfunction. Hypertension also leads to this.

This all leads to retinal ischaemia, promoting VEGF and erythropoietin.

There is increased vascular permeability, leading to diabetic macular oedema, and RETINAL NEOVASCULARISATION, leading to PDR compliations

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8
Q

What will be see in background diabetic retinopathy

A

Hard exudates (cheese colour, lipid)

Microaneurysms (“dots”)

Blot haemorrhages

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9
Q

What is seen in pre-proliferative diabetic retinopathy

A

Cotton wool spots also called soft exudates

Represent retinal ischaemia

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10
Q

What is seen in proliferative retinopathy

A

Visible new vessels

On disk or elsewhere in retina

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11
Q

What is maculopathy

A

Hard exudates near the macula

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12
Q

T/F maculopathy has a distinct pathological process to background diabetic retinopathy

A

NO!

It’s background diabetic retinopathy, but happens to be near macula

Can threaten direct vision

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13
Q

Management of background diabetic retinopathy

A

Background:

  • improve control of blood glucose
  • warn patient that warning signs are present
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14
Q

Management of pre-proliferative diabetic retinopathy

A

If left alone, new vessels WILL grow

Needs: Pan retinal photocoagulation

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15
Q

Management of proliferative diabetic retinopathy

A

Also needs:

-Pan retinal photocoagulation

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16
Q

In which case would you need to use photocoagulation when you only have background retinopathy

A

Maculopathy

Only have problem around macula
Needs only a GRID of photocoagulation

(NOT pan retinal photocoagulation)

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17
Q

What is diabetic nephropathy

A

Hypertension
Progressively increasing proteinuria
Progressively deteriorating kidney function
Classic histological features

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18
Q

T/f diabetic nephropathy is associated with morbidity not mortality

A

F… both

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19
Q

What is the most significant set of risk factors for cardiovascular disease

A

Diabetes and CKD

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20
Q

Histological features at the glomerulus in nephropathy

A

Mesangial expansion
Basement membrane thickening
Glomerulosclerosis

21
Q

What might indicate that a patient’s kidney problems are not due to diabetes

A

If retinopathy has not already been detected

22
Q

What is the proportion of diabetics getting nephropathy

A

Type 1 DM: 20-40% will have nephropathy after 30-40 years

• Type 2 DM: Probably equivalent – BUT there are a few caveats

23
Q

What affects the likelihood of a T2DM patient getting nephropathy

A

Age at development of disease
Racial Factors
Age at presentation
Loss due to cardiovascular morbidity

24
Q

Clinical features of diabetic nephropathy

A

Progressive proteinuria

Increased BP

Deranged renal function

25
Q

What are the ranges of proteinuria

A

Normal Range <30mg/24hrs

Microalbuminuric Range 30 - 300mg/24hrs

Assymptomatic Range 300 - 3000mg/24hrs

Nephrotic Range >3000mg/24hr

26
Q

Strategies for control of diabetic nephropathy

A
  1. Diabetic control (37% decrease in risk of microvascular complications per 1% decrement in HbA1c)
  2. BP control
  3. Control of the RAS
  4. Smoking cessation
27
Q

How does BP control affect GFR

A

It reduces the rate of deterioration of GFR in patients with diabetic nephropathy

28
Q

Which antihypertensive is used in diabetic retinopathy

A

ACEi

29
Q

Effects of angiotensin II

A 
Vasoactive effects
Mediation of glomerular hyperfiltration
Increased tubular uptake of proteins
Induction of pro fibrotic cytokines
Stimulation of glomerular and tubular growth
Podocyte effects
Induction of pro inflammatory cytokines
Generation of ROS &amp; NF-kB
Stimulates fibroblast proliferation
Up regulation of adhesion molecules on endothelial cells
Up regulation of lipoprotein receptors
30
Q

Which parts of the RAS are targets in diabetic nephropathy

A

Renin
ACE
AT1

31
Q

What is the name of small arteries supplying nerves

A

Vasa nervorum

32
Q

What is the problem with the nerves in diabetes

A

The small blood vessels to the nerves (vasa nervorum) are blocked= neuropathy

33
Q

What is the most common cause of limb amputation

A

Diabetes

34
Q

What types of neuropathy can you get in diabetic neuropathy

A 
Peripheral polyneuropathy
Mononeuropathy
Mononeuritis multiplex
Radiculopathy
Autonomic neuropathy
Diabetic amyotrophy
35
Q

Which peripheral nerves are longest

A

Longest nerves supply feet

36
Q

What does peripheral nephropathy result in and who is it most common in

A

Loss of sensation

More common in tall people and patients with poor glucose control

37
Q

What is the danger with peripherla neuropathy

A

Danger is that patients will not sense an injury to the foot (eg. Stepping on a nail)

38
Q

What signs can be seen on peripheral neuropathy

A

Loss of ankle jerks

loss of vibration sense (using tuning fork)

multiple fractures on foot X-ray (Charcot’s joint)

39
Q

What signs are seen in mononeuropahty

A

Usually sudden motor loss

wrist drop, foot drop

Cranial nerve palsy:
double vision due to 3rd nerve palsy

40
Q

What eye sign is seen in mononeuropathy

A

Eye is usually “down and out”.
(6th nerve pulls eye out and 4th nerve pulls it down).

Pupil DOES respond to light.

41
Q

Why does mononeuropathy not involve the pupil

A

parasympathetic fibres on outside.

Thus they do not easily lose blood supply in diabetes

42
Q

Signs of aneurysm causing 3rd nerve palsy

A

Will press on parasympathetic fibres first causing fixed dilated pupil

In diabetes this is NOT the case

43
Q

What is mononeuritis multiplex

A

A random combination of peripheral nerve lesions

44
Q

What is radiculopathy

A

Pain over spinal nerves, usually affecting a dermatome on the abdomen or chest wall.

45
Q

What is autonomic neuropathy

A

Loss of sympathetic and parasympathetic nerves to GI tract, bladder, cardiovascular system.

46
Q

How might autonomic neuropathy affect GI tract

A 
GI tract:
difficulty swallowing
delayed gastric emptying
constipation / nocturnal diarrhoea
Bladder dysfunction
47
Q

What is worrying with autonomic neuroapathy

A

Postural hypotension
can be disabling: collapsing on standing.

Cardiac autonomic supply
case reports of sudden cardiac death

48
Q

How can autonomic neuropathy be detected

A

Measure changes in heart rate in response to Valsalva manoevre

Normally there is a change in heart rate

Look at ECG and compare R-R intervals

Hormones (23 decks)

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