Long Term Complications - Micro and Macro

Question 1

How does the risk of complications change with worsening glycaemic state?

Answer 1

it increases

Question 2

what are some macro and micro vascular complications of diabetes?

Answer 2

Question 3

does diabetes increase the risk of cardiovascular disease?

Answer 3

yes

Question 4

what is atherosclerosis?

Answer 4

● Macrophages and foam cells

● Intracellular lipids

● Extracellular lipid accumulation

● Fibrotic and calcific layers

● Damage to surface, exposure to platelets and clotting

Question 5

how does diabetes affect atherosclerosis?

Answer 5

accelerates atherosclerosis

Question 6

Dyslipidaemia is present in nearly all people with diabetes, what dislipidaemia occurs?

(disturbances in fat metabolism lead to changes in the concentrations of lipids in the blood)

Answer 6

HDL Cholesterol is lower

Triglycerides are higher

LDL cholesterol is in the form of small dense particles which are worse - Oxidisation of these particles promotes the features that lead to plaque formation (and glycation of the particles worsens the effect)

Question 7

hwo does diabetes affect atherosclerosis?

Answer 7

Dyslipidaemia is present in nearly all people with diabetes

Endothelial dysfunction

Hypercoagulability

Question 8

what are the effects of atherosclerosis in diabetes?

Answer 8

Ischaemic cerebrovascular disease - strokes

Ischaemic Heart Disease - angina, myocardial infarctions

Heart Failure - related to coronary disease and abnormal cardiac myocyte glucose handling

Peripheral vascular disease - Causes lower limb ischaemia, leading to ulcers and poor healing of these ulcers. Amputations are a potential outcome

Question 9

how do you prevent macrovascular disease?

Answer 9

Good diabetes control

Blood pressure control

Lipid control

Smoking cessation, weight, exercise

Question 10

Case A:

57M

Admitted with a non-healing foot ulcer needing investigations and IV antibiotics.

Type 2 diabetes diagnosed 8 years ago

On gliclazide 160mg BD and metformin 1gm BD.

HbA1c 87 mmol/mol (ideally <58)

Hypertension

Previous NSTEMI

On clopidogrel, ramipril, amlodipine, atorvastatin (irregularly taken)

Current smoker

BMI = 42.5 kg/m2

BP 150/95 mmHg

Total cholesterol 6.8 mmol/L (ideally <4), HDL 0.8 mmol/L (ideally >1.0), LDL cholesterol 4.0, Triglycerides 7.6 mmol/L

Poor circulation from atherosclerotic disease of femoropopliteal vessels

Impaired sensation from neuropathy

Inappropriate footwear

Poor ongoing foot care

What management is required?

Answer 10

Foot ulcer care – debridement, specialist podiatry

IV antibiotics

Xrays – to check for osteomyelitis? May use MRI for more subtle changes

Rest and avoidance of pressure on ulcer.

Slow healing process!

Improve glycaemic status

Optimise lipid levels – was not taking atorvastatin regularly

Review cardiac status

Smoking cessation

Education, support

Question 11

Microvascular Disease: Retinopathy

what are the 2 different types?

Answer 11

Non Proliferative Diabetic Retinopathy

Proliferative Diabetic Retinopathy

Question 12

What is Non Proliferative Diabetic Retinopathy?

Answer 12

Retinal capillary dysfunction, platelet dysfunction, blood viscosity abnormality

Question 13

What is Proliferative Diabetic Retinopathy?

Answer 13

Retinal ischaemia, new blood vessel formation, vitreous haemorrhage, retinal tears/detachment

Treatment with laser photocoagulation

Question 14

what is the impact of diabetic retinopathy?

Answer 14

Over a period of 20 years after diagnosis, 100% of people with Type 1 diabetes and 60% of those with Type 2 diabetes will have some form of retinopathy (mild-to-severe)

7% of people who are registered blind have advanced diabetic retinopathy (EnglandWales figure)

[Other eye effects of diabetes include a 50% increase in glaucoma, and a 3-fold increase in cataracts]

Question 15

what is the treatment of diabetic retinopathy?

Answer 15

Improve glycaemic control

Laser photocoagulation

Question 16

what is Nephropathy?

Answer 16

Nephropathy is a general term for the deterioration of proper functioning in the kidneys

Question 17

what does nephropathy cause?

Answer 17

Microalbuminuria - leak of protein (albumin) starts

Glomerular basement membrane changes, mesangial tissue proliferation, “glomerular hypertension” all contribute to renal dysfunction. Progressive renal impairment - note kidneys do not shrink when the disease progresses

Progressive renal failure progresses to end-stage renal disease if unchecked

Question 18

what is the impact of diabetic nephropathy?

Answer 18

75% of people with diabetes have some renal effects, and 20% go on to overt kidney disease that may need treatment

Diabetes is the biggest single cause of end stage renal disease needing renal replacement therapy (dialysis)

Renal failure ultimately leads to death in 21% of people with Type 1 and 11% of people with Type 2 diabetes

Question 19

what is the prevention and treatment of nephropathy?

Answer 19

Screening of urine for albumin is vital!

Diabetes control

Renin-angiotensin system blockade - ACE inhibition, angiotensin receptor blockade, renin inhibition - Very good results in slowing/preventing progression of renal disease (ACE-I, ARB)

Hypertension control

Question 20

what is neuropathy?

Answer 20

Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes

High blood sugar (glucose) can injure nerves throughout your body

Diabetic neuropathy most often damages nerves in your legs and feet

Little blood vessels around the nerves

And the nerves are starved slowly

Question 21

what type of loss and nerves can neuropathy cause?

Answer 21

Sensory, Motor, Autonomic

Sensory - objective loss, particularly in feet & lower legs; subjective symptoms, especially paresthesia

Can be symptomatically troublesome. However, lack of sensation can lead to the development of neuropathic ulcers, which, alongside poor macro-vasculature, leads to severe foot infections

Autonomic neuropathy can cause GI effects (stomach, intestines), or the cardiovascular system (tachycardia, blood pressure fluctuations). Watch out for silent myocardial infarction!

Question 22

what foot care is required in a neuropathy?

Answer 22

Question 23

what is charcot foot?

Answer 23

Charcot foot is a condition causing weakening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy)

The bones are weakened enough to fracture, and with continued walking, the foot eventually changes shape

All blood vessels in the foot under the ankle go haywire and the foot swells up and the bone goes spongy

Poorly understood

Can be triggered by trauma

Nothing you can do that helps it

End up with special moon boot things to alleviate pressure

Something that happens to the vasculature

Question 24

what are other conditions that may be caused by diabetes?

Answer 24

Erectile dysfunction/sexual dysfunction

Depression - possibly twice as common as in the general population

Question 25

Case B:

42F

Admitted with diabetic ketoacidosis (DKA)

Also has problems with severe hypogycaemia, with lack of awareness of low blood glucose levels (among other factors, autonomic neuropathy contributes to the loss of normal autonomic responses to low glucose)

Type 1 diabetes diagnosed at age 14

On insulin: long-acting Lantus once a day (bedtime) and short-acting Novorapid with each meal.

HbA1c 78 mmol/mol (ideally <53)

Nephropathy with significant proteinuria, deteriorating renal function – under monitoring from Renal team with anticipatory planning for dialysis

Retinopathy – laser treatment

Peripheral neuropathy and peripheral vascular disease, non-healing ulcer on L 5th toe with osteomyelitis, leading to amputation of that toe previously

BMI = 22 kg/m2

what management is required?

Answer 25

Acute complication of DKA treated using IV insulin as per standard protocol, with good recovery

Deteriorating renal functions worsening – followup arranged in the pre-dialysis clinic

Attempts to improve glycaemic control while addressing the risk of impaired hypoglycaemia awareness

Newer techniques for glucose monitoring to help improve glycaemic control

Possibility of kidney-pancreas transplantation in the setting of established end-stage renal disease

Question 26

____vascular and ____vascular complications of diabetes are a major problem

Macrovascular disease (coronary, stroke disease and heart failure) can be prevented by controlling ____ factors as well as ________ status

Microvascular disease (nephropathy, retinopathy, neuropathy) must be ________ for, and some preventative measures are good, e.g., for nephropathy, while some treatments are valuable in preventing severe __________, e.g., retinal laser treatment. Good _________ control reduces risk of progression

Answer 26

Macrovascular and microvascular complications of diabetes are a major problem

Macrovascular disease (coronary, stroke disease and heart failure) can be prevented by controlling risk factors as well as glycaemic status

Microvascular disease (nephropathy, retinopathy, neuropathy) must be screened for, and some preventative measures are good, e.g., for nephropathy, while some treatments are valuable in preventing severe dysfunction, e.g., retinal laser treatment. Good glycaemic control reduces risk of progression