Long Term Complications Flashcards
What are the 2 classifications of complications?
- Macrovascular affecting large vessels
- Microvascular affecting small vessels
What are the complication risk factors?
- Duration of diabetes
- Metabolic control
- Smoking
- Hypertension
- Hyperlipidaemia
- Genetics
What is the main cause of death in diabetes?
Cardiovascular macrovascular disease
How does diabetes affect your risk of MI?
Increases by 2-5x with higher mortality and morbidity post MI
How does diabetes affect your risk of stroke?
Increases by 3x
How does diabetes affect your risk of peripheral arterial disease?
Increase by 5x
Describe peripheral arterial disease..
- A diffuse distal disease
- x40 fold increased risk of amputation
What are the cardiovascular risk factors?
- Glucose control
- Blood pressure
- Smoking
- Lipids
- Proteinuria
- Family history
- Gender
What primary prevention is there to reduce CV risk?
- Target HbA1c 53mmols/mol
- Control BP to <130/80
- Smoking cessation
- Statin therapy
- Lifestyle choices
Give examples of microvascular diseases.
- Retinopathy
- Neuropathy
- Nephropathy
What is microvascular disease?
Disease of the arterioles and capillaries
What is diabetic the commonest cause of?
Blindness in working age population
How can diabetic retinopathy be prevented?
- Good glucose control
- Tight BP control
- Early detection and intervention
Give examples of types of diabetic retinopathy.
- Background retinopathy
- Proliferative retinopathy
- Maculopathy
Give examples of retinal abnormalities in diabetes.
- Microaneurysms (dots)
- Blot haemorrhages
- Hard exudates
- Cotton wool spots
- New vessel formation
- Vitreous haemorrhage
- Advanced eye disease
How is proliferative retinopathy treated?
- Laser photocoagulation (destruction of peripheral ischaemic retina leads to reduction of endothelial growth factors and regression of new vessels)
- Vitrectomy
What are the features of diabetic maculopathy?
- Exudates and blot haemorrhages at macula
- Macular ischaemia
- Macular oedema deforms the macula
- Decrease in visual acuity is common in type 2 diabetes
What is the treatment for diabetic maculopathy?
- Grid laser therapy
- Tight control of blood glucose
- Tight control of BP
Who re cataracts common in?
- Elderly
- 2 fold increase in diabetes
- Those with poor glycaemic control
What dictates when surgery is carried out for cataracts?
Visual acuity
What types of diabetic neuropathy are there?
- Peripheral neuropathy (diffuse nerve disease)
- Mononeuritis (single nerve palsy)
- Autonomic neuropathy
What percentage of diabetics suffer from peripheral neuropathy?
Up to 40%
Where does peripheral neuropathy affect?
Mainly the feet but also classic ‘glove and stocking’ distribution
What are the clinical features of peripheral neuropathy?
- Feet insensitive to trauma
- Unpleasant chronic symptoms (paraesthesia, burning pain, numbness)
- May be asymptomatic
- Small muscle wasting
What is the management of peripheral neuropathy?
- Early detection
- Self-care education
- Protection of feet
- Pain relief (capsaisin cream, amitriptyline, gabapentin, duloxetine)
How are ulcers prevented?
- Foot screening and risk scoring
- Patient education on foot care
- Regular podiatry for those at high risk
- Trauma avoidance/fitted footwear
- Huge morbidity from ulcers
What skeletal abnormality may occur in diabetes?
Charcot foot caused by charcot neuro-arthropathy
What risk factors makes someone’s feet more at risk?
- Impaired circulation
- Impaired sensation
- Impaired vision
- Foot shape changes
- Abnormal pressures
What is acute sensory peripheral neuropathy?
Rapid onset of neuropathic symptoms
What are the precipitating factors for acute sensory peripheral neuropathy?
- Rapid tightening of glycaemic control
- Acute metabolic upset
Describe the progression of acute sensory peripheral neuropathy.
- May be very severe
- Gradual recovery
What is another name for proximal moto neuropathy?
Diabetic amyotrophy
Who is mainly affected by proximal motor neuropathy?
Elderly men with T2DM
Where does proximal motor neuropathy affect mainly?
-Legs mostly
What are the clinical features of proximal motor neuropathy?
- Wasting of thigh muscles
- Weight loss
- Painful
What is the prognosis of proximal motor neuropathy?
Good
What does mononeuritis mainly affect?
Ocular cranial nerves
- III
- IV
- VI
Other than the ocular cranial nerves, what other nerve does mononeuritis affect?
Peroneal nerve causing acute foot drop
How does mononeuritis progress?
Presents like a vascular event:
- Acute onset
- Gradual recovery
Give 7examples of presentations of autonomic neuropathy.
- Erectile dysfunction
- Postural hypotension
- Gastric stasis and recurrent vomiting
- Diarrhoea
- Abnormal sweating
- Peripheral oedema
- Urinary retention
What interventions are there for erectile dysfunction?
- Phosphodiasterase inhibitors e.g. Viagra and Cialis
- Prostaglandins
- Mechanical devices
- Implants
How can postural hypotension be managed?
- NSAIDs
- Fludrocortisone
What is the treatment for gastric stasis and recurrent vomiting?
Domperidone
What is the treatment for diarrhoea?
- Loperamide
- Codeine phosphate
How is autonomic neuropathy diagnosed?
- Based on symptom pattern and exclusion of other causes
- Abnormal ECG rhythm e.g. no variation of rate on deep breathing
What is diabetic nephropathy?
Damage to the structure and function of the meshwork of capillaries which make up the glomerulus
What happens to the glomeruli in diabetic nephropathy?
Glomeruli become leaky to larger molecules and eventual reduction in ability to filtrate blood
What percentage of T1DM patients will develop diabetic nephropathy after 30 years?
25%
What are the stages in kidney disease?
- Normal
- Microalbuminaemia
- Proteinuria
- Impaired renal function +/- nephrotic syndrome
- End stage renal disease
What stage kidney disease is reversible?
Microalbuminaemia
What is the screening test for microalbuminuria?
First morning urine sample
-Normal albumin/creatinine ratio
Male <2.5 mg/mmol; Female <3.5
What is the definitive test for microalbuminuria?
Timed over night urine collection for albumin excretion rate (AER)
- Normal < 20μg/min
- Microalbuminuria 20-200μg/min
How is early kidney disease managed?
- Optimise glycaemic control
- Tight BP control - aim for <125/75 in type 1 diabetes
- Ace inhibitor therapy slows progression
- Cardiovascular risk factor management
