Long Term Complications of Diabetes Flashcards
What tissues are concerned with the problems associated with large vessel and small vessel diabetic disease?
Large vessel - CVS
Small vessel - Eyes (retinopathy), nerves (neuropathy) and kidneys (nephropathy)
What are the risk factors for complications of diabetes?
- Duration of diabetes
- Metabolic control
- Smoking
- Hypertension
- Hyperlipidaemia
- Genetics
What is the main cause of death in diabetes?
Macrovascular
(cardiovscular disease)
What comes under the heading of cardiovascular disease?
MI
Stroke
Peripheral arterial disease
Look
Notice the increase in incidence as age increases
What are you at risk to when there is peripheral arterial disease?
•x 40 fold increased risk of amputation
What are the risk factors for cardiovascular disease?
(these are very similar to the risk factors for complications of diabetes)
- Glucose control
- Blood pressure
- Smoking
- Lipids
- Proteinuria
- Family history
- Gender
What is primary prevention for CV risk reduction?
Target HbA1c 53 mmols/mol (7%)
Control Bp to less than or equal to 130/80
Smoking cessation
Statin therapy
Lifestlye choices
What are the ways we can prevent diabetic retinopathy?
Good glucose control
Tight Bp control
Early detection and intervention
Define what is meant by non-prolifereative diabetic retinopathy
No symptoms or signs
Fundus photography shows microaneurysms
Fluorescein angiography shows retinal ischaemia (narrowed or blocked retinal blood vessels)
Define macular oedema
Blood vessels leak their contents into the macular region
Can occur at any stage of non-proliferative diabetic retinopathy
Optical coherence tomography will show areas of macular thickening (due to fluid accumulation) of macular oedema
What are the symptoms of macular oedema?
Blurred vision and darkened or distorted images that are not the same in both eyes.
What is proliferative diabetic retinopathy?
Abnormal new blood vessels form at the back of the eye - they grow into the vitreous
Can result in scarring and contraction of the vitreous - potential for retinal detatchment
These new blood vessels are fragile and susceptible to bursting and bleeding and therefore blurring the vision
What are the retinal abnormalities in diabetes?
- Microaneurysms (dots)
- Blot haemorrhages
- Hard exudates
- Cotton wool spots
- New vessel formation
- Vitreous haemorrhage
- Advanced eye disease
What is the cause of cotton wool spots?
They are caused by damage to nerve fibers and are a result of accumulations of axoplasmic material within the nerve fiber layer.
What is the treatment of proliferative retinopathy?
Laser photocoagulation
–Destruction of peripheral ischaemic retina leads to reduction of endothelial growth factors and regression of new vessels
Vitrectomy - bubble is inflated within the eye, this pushes the retina back towards the wall of the eye, tears in the retina are sealed using a freezing probe or a laser treatment
What is treatment for macular oedema?
Grid laser therapy
Tight control of blood glucose and blood pressure
What eye condition is common in the elderly and has a two fold increase when diabetes is present?
Cataracts
What are the types of diabetic neuropathy?
Peripheral neuropathy (diffuse nerve disease)
Mononeuritis (single nerve palsy)
Autonomic neuropathy
What are the features of peripheral neuropathy?
Feet insensitive to trauma
Chronic symptoms (paraesthesia, burning pain, numbness)
Small muscle wasting
Charcots foot (small bone fractures cause foot deformations)
Ulcers
What is the management of peripheral neuropathy?
Early detection (foot screening, regular podiatry for high risk patients)
Self care education
Protection of feet (trauma avoidance /fitted footwear)
Pain releif (capsaisin cream, amitriptyline, gabapentin, duloxetine)
What are the factors that result in increase risk to the foot?
Impaired circulation
Impaired sensation
Impaired vision
Foot shape changes
Abnormal pressures
What is acute sensory peripheral neuropathy?
Rapid onset of neuropathic symtoms
May be very severe - gradual recovery
What are the precipitating factors associated with acute sensory peripheral neuropathy?
–Rapid tightening of control
–Acute metabolic upset
What is diabetic amyotrophy also known as?
Proximal motor neuropathy
What are the features of diabetic amyotrophy?
Usually affects elderly men (type 2 diabetes)
Usually affects legs
Wasting of thigh muscles
Weight loss
Painful
Good prognosis
Now rarely seen
What nerves are often affected in mononeuritis?
- Mainly ocular cranial nerves
- III
- IV
- VI
Mononeuritis is the inflammation of a singular nerve and is a result of a vascular event
Acute onset and gradual recovery
What is the sign if the peroneal nerve is affected by mononeuritis?
Acute foot drop
What are the symptoms of diabetic autonomic neuropathy?
Erectile dysfunction
Postural hypotension
Gastric stasis and recurrent vomiting
Diarrhoea
Abnormal sweating, peripheral oedema, urinary retention
How do you diagnose autonomic neuropathy?
Based on symptom pattern and exclusion of other causes
Abnormal ECG rhythm responses (e.g no variation of rate on dep breathing)
What is the disease process of diabetic retinopathy?
Damage to the structure and function of the meshwork of capillaries which make up the glomerulus
Glomeruli become leaky to larger molecules and eventual reduction in ability to filtrate blood.
What is the reversible stage of kidney disease?
MICROALBUMINURIA
•SCREENING TEST - first morning urine sample
Normal albumin/creatinine ratio
Male <2.5 mg/mmol; Female <3.5 (female has more albumin)
•DEFINITIVE TEST- timed over night urine collection for albumin excretion rate (AER)
Normal < 20μg/min
Microalbuminuria 20-200μg/min
What is the management of early kidney disease?
- Optimise glycaemic control
- Tight BP control - aim for <125/75 in type 1 diabetes
- Ace inhibitor therapy slows progression
- Cardiovascular risk factor management
What follows from impaired renal function?
Possible nephrotic syndrome
End stage renal disease
Cardiovascular disease (since end stage renal disease is a risk factor for cardiovascular disease)
Nephrotic syndrome: kidney disease, especially when characterized by oedema and the loss of protein from the plasma into the urine due to increased glomerular permeability (also called nephrotic syndrome ).
