Long Term Complications

Question 1

What is the natural history of T2D?

Answer 1

• Insulin resistance due to increased adipose tissue = increased FA’s
• Creates inflam. reaction = cytokines = blocks secondary mechanism system necessary for transport of glucose into cell
  = Increase glucose outside cell so B cells start to produce more & more insulin to compensate
• After long period of time = hyperinsulinemia
• B cells eventually burn out & insulin production decreases so fasting glucose increases

Question 2

What are the risk factors for diabetes?

Answer 2

1. Duration
2. Age of onset
3. High HbA1c
4. Hypertension
5. Micro albuminuria
6. Dyslipidaemia
7. Obesity
8. Smoking

Question 3

What is the pathophysiology of chronic glycaemia?

Answer 3

Increased glucose = toxic to endothelial cells = inflammatory cascade = increased permeability of endothelial = atheroma = cholesterol deposition in basement membrane = thickening + narrowing of BV + stiffening = ischemia = thrombus formation = infarction

Proximal to blockage vessels can widen = aneurysms

Question 4

What are the signs of peripheral vascular disease?

Answer 4

• Claudication
• Rest pain
• Tissue lost
• Gangrene
• High risk amputations

PVD = if femoral arteries involved

Question 5

What is seen in non proliferative diabetic retinopathy?

Answer 5

• Cotton wool spots
• Intra retinal haemorrhages
• Hard exudates
• Micro aneurysms
• Visual loss due to macular oedema

Question 6

What is seen in proliferative diabetic retinopathy?

Answer 6

Neovascularization

Pre retinal + vitreous haemorrhages = fibrosis = traction retinal detachment

Question 7

What is diabetic nephropathy?

Answer 7

• Defined as proteinuria/ micro albuminuria = leaking of protein (albumin) through nephrons
• BM thickening in glomerular capillaries = reduces blood flow = sclerosis = ischemia

Question 8

How is diabetes managed?

Answer 8

• Annual albumin/creatinine ratio screening
• ACE inhibitor/angiotensin receptor blocker (blocks breakdown of bradykinin = vessel dilator so reduced protein leak)
• Intense glycemic control
• Control of other RF’s

Question 9

What is diabetic neuropathy?

Answer 9

Decreased sensation + reduction/loss of vibration due to degeneration of schwann cells

Question 10

What are the types of diabetic nephropathy?

Answer 10

• Distal symmetrical polyneuropathy
• Autonomic neuropathy
• Diabetic amyotrophy
• Mononeuropathy
• Mononeuropathy multiplex
• Treatment induced neuropathy

Question 11

What are the types of diabetic nephropathy?

Answer 11

• Distal symmetrical polyneuropathy: progressive loss of distal sensation followed by motor weakness
• Autonomic neuropathy: postural hypotension, gastro paresis, enteropathy with constipation or diarrhoea
• Diabetic amyotrophy: acute asymmetric focal pain followed by weakness in proximal leg, onset of muscle weakness followed by pain
• Mononeuropathy: median nerve
• Mononeuropathy multiplex: more than 1 nerve involved in different places
• Treatment induced neuropathy: metformin (can interfere with B12 absorption)

Question 12

How do you perform examination of feet?

Answer 12

• Inspection - cracks, deformities, callus formation
• palpate - dorsalis + posterior tibial artery
• Vibration sense
• Monofilament - touch sensation

Question 13

Why is there a risk of developing infection in diabetes?

Answer 13

Reduced blood supply + neuropathy = risk of developing ulcer = inlam. response = reduces in diabetes & phagocytes in diabetics have reduces mobility = infection gets worse = sepsis + amputations