ERS Case 4: Diabetes Flashcards
Different types of DM
See lecture
Understanding of pathogenesis of different types of diabetes
See lecture
Understanding of pathophysiology of diabetic complications
See lecture
Acute complication:
1. Diabetic ketoacidosis
- Isotonic saline infusion
- Low-dose IV insulin
- Correction of hypokalaemia
- Correction of acidosis by HCO3
Chronic complication:
- Microvascular
1. Retinopathy
2. Nephropathy
3. Neuropathy
- Macrovascular
1. Atherosclerosis
Knowledge of pharmacology of anti-diabetic drugs
See lecture
***Natural history and progression of diabetic nephropathy
First changes
- **Microalbuminuria
- **Glomerular BM thickening —> Microangiopathy
- Accumulation of matrix material in mesangium
Subsequent changes
- **Heavy proteinuria
- Nodular deposits
- **Glomerulosclerosis
Pathogenesis:
1. Chronic hyperglycaemia
—> ***↑ Mesangial Cell matrix production + apoptosis —> Mesangial cell expansion + injury
- Glomerular hypertrophy (↑ Renal size)
—> ↑ shear stress on glomerular capillary wall - Glomerular hyperfiltration (↑ GFR)
—> dilatation of afferent arteriole by ***AGEs, Sorbitol, IGF-1
—> ↑ Renal blood flow
—> ↑ Intra-glomerular pressure (Intra-glomerular hypertension) - Glomerulosclerosis
—> ∵ Intra-glomerular hypertension
—> ∵ Hyaline narrowing of vessels supplying the glomeruli (Hyaline deposition induced by ischaemic injury)
Histology:
1. Diabetic **Glomerulosclerosis —> ECM deposition in glomeruli
2. **Mesangial expansion
3. **GBM thickening
4. **Arteriolar Hyalinosis / Arteriolosclerosis
Consequence:
Microalbuminuria
Management:
1. Protein restriction
2. Antihypertensive
3. Glycaemic control
Diabetic retinopathy
Pathogenesis:
1. Chronic hyperglycaemia
—> ↑ Retinal blood flow
—> ↑ Shear stress on retinal blood vessels
—> Stimulate production of Vasoactive substances + Vascular leakage + Fluid accumulation in retina
—> Macula edema
- Accumulation of sorbitol
—> ↑ intracellular osmotic pressure
—> alteration of crystalline structure of lens proteins
—> Cataract - Formation of AGEs
—> accumulation of AGEs —> Cataract
—> interact with RAGE
—> ROS formation
—> Vascular inflammation - Growth factors
—> interaction between IGF-1 and VEGF
—> promote growth of new blood vessels from adjacent vessels to revascularise diseased tissue
—> ↑ Vascular permeability
Types:
1. Non-proliferative (Absence of abnormal new blood vessels)
- Dot / Blot haemorrhage
- Hard (protein leakage) / Soft exudates (microinfarcts)
- Microaneurysm
- Macular edema —> breakdown of retinal-capillary barrier —> leakage of plasma contents into retina
- Proliferative (Abnormal new blood vessels from retina)
Management:
1. BP control
2. Glycaemic + Lipid control
3. Vitrectomy
Conditions and drugs that may cause deterioration of glycaemic control
Side effects of steroid therapy
See lecture
***Metformin CI use with Steroid
—> Steroid cause hepatic steatosis / steatohepatitis
—> liver more susceptible to Metformin-induced lactate production
—> Lactic acidosis
SE of steroid:
1. Hyperglycaemia
2. Truncal obesity (Buffalo hump)
3. Hypertension
4. Osteoporosis
5. Immunosuppression
Interpret laboratory results
Glucose
- ↑ Fasting glucose
- ↑ HbA1c
Lipid
- Hypertriglyceridaemia
- ↑ LDL
- ↑ Non-HDL Cholesterol
- ↓ HDL
—> Dyslipidaemia
Metabolic syndrome:
1. Obesity
2. DM
3. Hypertension
4. Hypertriglyceridaemia
5. Low HDL-Cholesterol
—> High risk of CVS disease
Problems of maintaining treatment compliance in chronic illness
LO omitted
Treatment targeting multiple risk factors
- Weight reduction
- Diet
- Exercise - Smoking cessation
- BP, Lipid control
- Psychosocial
- Screening of complications
Burden of diabetic complications on individual and on health care system
LO omitted
Discuss psychosocial aspects of chronic diseases
- Life-long disease
- Drug compliance
- Continued motivation required
- Long-term complications of DM —> emotional / behavioural disturbance
- Adaptation to acute symptoms of metabolic decompensation
Psychosocial problems influence metabolic control by
1. Hormonal stress reaction
2. Poor drug compliance
Waist-Hip ratio
Waist circumference / Hip circumference
Normal
Male: <0.9
Female: <0.7
