Long Term Complications of Diabetes Flashcards
Microvascular complications of Diabetes
- R…pathy
- N…pathy
- N…apathy
- Retinopathy
- Neuropathy
- Nephropathy
Macrovascular complications of Diabetes
- I..
- C..
- P..
- IHD
- CVD
- PVD
Microvascular Complications
- Most cells are able to reduce glucose transport in response to extracellular hyperglycaemia (ones below are not able to)
- … endothelial cells
- Mesangial cells of …
- … cells and peripheral … cells
- Most cells are able to reduce glucose transport in response to extracellular hyperglycaemia (ones below are not able to)
- Retinal endothelial cells
- Mesangial cells of glomerulus
- Schwann cells and peripheral nerve cells
Microvascular Complications
- Take … … to develop
- Rare before … years of T1 diabetes
- May be detected at presentation of …
- Take many years to develop
- Rare before 5 years of T1 diabetes
- May be detected at presentation of T2 diabetes
What disease is shown?
Retinopathy
Retinopathy
- … commonest cause of blindness in those of working age
- …+ in England blind from diabetic retinopathy
- Risk of blindness increased 1..-.. fold by DM
- (G… and c… increased)
- Second commonest cause of blindness in those of working age
- 4000+ in England blind from diabetic retinopathy
- Risk of blindness increased 10-20 fold by DM
- (Glaucoma and .. increased)
The Retinal Microcirculation
- … density of capillaries
- … functional reserve
- Flow needs to respond to … needs
- … key to local regulation of flow
-
Low density of capillaries
- Little functional reserve
- Flow needs to respond to local needs
- Pericytes key to local regulation of flow
Pericytes
- Pericytes are present around blood vessels in the normal ….
- Pericyte dropout is one of the major hallmarks of diabetic ….
- Pericytes are present around blood vessels in the normal retina.
- Pericyte dropout is one of the major hallmarks of diabetic retinopathy.
Pathological Findings of Diabetic Retinopathy
- Loss of …
- Basement membrane …
- Capillary …
- Is…
- … production
- Increased capillary …
- Loss of pericytes
- Basement membrane thickening
- Capillary closure
-
Ischaemia
- VEGF production
- Increased capillary permeability
Normal retina?
Yes
Normal retina?
No - small dot - early sign of diabetic eye disease (dot haemorrhage or a microaneurysm)
Normal retina?
No - developing hard exudates - leaking vessels - cholesterol and protein rich fluid
Normal retina?
No - lots of hard exudates - leaking fluid out full of cholesterol and protein rich
Normal retina?
No - circinate exudates
Normal retina?
No - cotton wool spots
Normal retina?
No - cotton wool spots
Normal retina?
No - retina ischaemia - produce growth factors - new vessels developed - weaker than original vessels
Normal retina?
No - very advanced diabetic eye disease - hard exudate, haemorrhages, cloud of new vessels growing out
Normal retina?
No - new vessels - blood leaking out (rupture)
Normal retina?
No - catastrophic blood leakage out of vessels - see red out of the eye
Normal retina?
No - fibrous band (scar on back of retina) can cause retinal detachment - vision will go
Normal eye?
No - very advanced diabetic eye disease - very rare - new vessels over iris - rubeosis iridis - advanced form of eye disease associated with glaucoma
It is important that people are screened for diabetic eye disease - why?
- Possible to have extensive damage and not know about it - perfect vision but devestating sight threatening disease
- Most of UK have retinal photography - high res digital camera - temporal and nasal field - after dilation of eye with eye drops - highly trained screeners - refer to eye specialist if an issue
Clinical Stages of Retinopathy
- Non-proliferative
- Background - examples? (3)
- Pre-proliferative (changes due to … - leave it for long - new … develop - … wool spots)
- Proliferative (new … already developed - risk of …)
- Macular Oedema
- Sight threatening
- Non sight threatening
- Non-proliferative
- Background (little dot haemorrhages, microaneurysms, hard exudates)
- Pre-proliferative (changes due to retinal ischaemia - leave it for long - new vessels develop - cotton wool spots)
- Proliferative (new vessels already developed - risk of bleeding)
- Macular Oedema
- Sight threatening
- Non sight threatening
Diabetic Retinopathy
- Diabetic … important
- … control important
- … treatment
- Can be Pan …
- Can be F…
- Intra-vitreal anti … Ab
- Diabetic control important
- Blood pressure control important
-
Laser treatment
- Pan retinal
- Focal
- Intra-vitreal anti VEGF Ab
What is shown here?
Laser burns - leave macula spaired - leaking vessels cauterised, oedema fluid reabsorbed - new vessels that were liable to blled have regressed - reduced risk of threat to sight - slight peripheral night vision - usually unimpaired - can drive
Neuropathy
- Affects up to …% of diabetic patients
- …% have painful neuropathy (cf ..% non-diabetic population)
- Affects up to 50% of diabetic patients
- 15% have painful neuropathy (cf 5% non-diabetic population)
Neuropathy Types
- What are the 3 ‘main’ types?
- (Entrapment neuropathy increased)
- Peripheral neuropathy
- Mononeuropathy
- Autonomic neuropathy
Peripheral Neuropathy
- Peripheral neuropathy is nerve damage caused by chronically high blood sugar and diabetes.
- It is the … …. complication of diabetes.
- Longest nerves are affected (therefore worse in what areas?)
- Does it follow a dermatomal pattern?
- Peripheral neuropathy is nerve damage caused by chronically high blood sugar and diabetes.
- It is the most common complication of diabetes.
- Longest nerves are affected (therefore worse in what areas?) - worse in distal areas e.g. hands, feet (usually legs more so as they are longer)
- Does it follow a dermatomal pattern? - NO
Peripheral Neuropathy - Symptoms
- You can get w…, … pains, n…, b…/ti…
- You can get weakness, sharp pains, numbness, burning/tingling
What type of ulcer?
Neuropathic ulcer - nerve damage will do this
- Lots of callus build up
What is shown?
Callus - build up of hard skin - keep walking on it - painful - may start before neuropathic ulcer if you have impaired sensation and leave it and continue to walk on it
What is shown here? (Caused by …)
- Charcot foot (Caused by peripheral neuropathy)
- Inflammatory process - dense nerve damage - unable to feel much - very good blood supply usually - redness, swelling of foot
- Usually misdiagnosed
Diabetes - what has happened here?
Mononeuropathy - third nerve palsy - A complete third nerve palsy causes a completely closed eyelid and deviation of the eye outward and downward. The eye cannot move inward or up, and the pupil is typically enlarged and does not react normally to light
Autonomic Neuropathy
- Gastro…
- … hypotension
- … dysfunction
- … sweating
- Dia..
- Gastroparesis
- Postural hypotension
- Erectile dysfunction
- Gustatory sweating
- Diarrhoea
Nephropathy
- Commonest cause of … in Western World
- Accounts for deaths of …% of type 1 and …% of type 2 patients
- Commonest cause of ESRD (End Stage Renal Disease) in Western World
- Accounts for deaths of 21% of type 1 and 11% of type 2 patients
Renal Microcirculation
- … glomerular capillaries
- … membrane
- Highly specialised …
- Fenestrated glomerular capillaries
- Basement membrane
- Highly specialised podocytes
Pathological Findings of Diabetic Nephropathy
- Basement membrane …
- Loss of … charge
- P… loss
- Loss of integrity of … barrier
- Glomerular s…
- M… expansion
- Basement membrane thickening
- Loss of negative charge
-
Podocyte loss
- Loss of integrity of filtration barrier
- Glomerular sclerosis
- Mesangial expansion
This is showing Clinical stages of…
Diabetic Nephropathy
Diabetic Nephropathy
- … … control important
- Blockers of … system preferred
- Glucose control important but less so once overt …
- Associated with increased … risk
- Ultimately … replacement / transplantation
- Blood pressure control important
- Blockers of RAS system preferred
- Glucose control important but less so once overt proteinuria
- Associated with increased CVD risk
- Ultimately renal replacement / transplantation
What is this?
Section of an artery - macrovascular disease - atheromatous disease
Macrovascular Disease
- Dramatic increase in risk with …
- Patients with … have multiple RF
- Dramatic increase in risk with diabetes
- Patients with type 2 diabetes have multiple RF
Many people with T2 diabetes have …
Metabolic syndrome
Study below - investigating risk factors for what?
CVS disease - number over 1 suggests increased risk - diabetes increases, smoking increases risk etc
Macrovascular Disease
- Patients with type … diabetes have long disease duration
- Presentation depends upon … bed affected
- A…/MI
- S…
- PVD - what is this?
- Patients with type 1 diabetes have long disease duration
- Presentation depends upon vascular bed affected
- Angina/MI
- Stroke
- PVD (peripheral vascular disease)
Macrovascular Disease - attention to all modifiable risk factors
- … p…
- L…
- S…
- (… control)
- Blood pressure
- Lipids
- Smoking
- (Glucose control)
Diabetic Foot
- Diabetes is the … cause of non-traumatic lower limb amputation
- P..
- N… (… ulcer, … change)
- Impaired … function
- •Diabetes is the commonest cause of non-traumatic lower limb amputation
- PVD
- Neuropathy (neuropathic ulcer, Charcot change)
- Imapaired leucocyte function
- What study is this? (Diabetes)
- What type of Diabetes?
- Results?
UKPDS study - Microvascular Endpoints
- UK Prospective Diabetes Study
- Results = 25% relative risk reduction in microvascular endpoints - statistical significance - first evidence that trying to control blood glucose was relevant in terms of end points
- Also looked at Blood pressure control (Shown) microvascular endpoints - can see that lower BP better in terms of eye complications and renal complications
- Exclusively T2 patients
- What study is this? (Diabetes)
- What type of Diabetes?
- Results?
- DCCT
- T1 Diabetes patients
- Managed intensively or conventionally
- Intensive = multiple daily injfections or insulin pump therapy
- Non intensive - twice a day mixed insulins
- Results = glucose control worsens = increased risk of developing microalbuminuria, increased risk of nerve damage, increased risk of overt proteinuria, increased risk of eye damage
- Glucose control was important in terms of risk of microvascular complications in T1 Diabetes
