Long term complications of diabetes Flashcards
Micro and macrovascular (aren't I lucky?)
What systems are affected by long term complications of diabetes?
○ Large vessels (macrovascular) - Cardiovascular system ○ Small vessels (microvascular) - eyes - nerves - kidneys
What are the risk factors for developing complications of diabetes?
○ Duration of diabetes ○ Metabolic control ○ Smoking ○ Hypertension ○ Hyperlipidaemia ○ Genetics
Explain cardiovascular disease as a complication of diabetes
○ Main cause of death in diabetes
○ Myocardial infarction: risk increases 2-5 x
○ with higher mortality and morbidity post MI
○ Stroke: risk increases 3 x
○ Peripheral arterial disease: risk increases 5 x
- diffuse disease
- more distal disease
- x 40 fold increased risk of amputation
What are the risk factors of developing cardiovascular disease as a complication of diabetes?
- Glucose control
- Blood pressure
- Smoking
- Lipids
- Proteinuria
- Family history
- Gender
How does one reduce the risk of developing cardiovascular disease as a complication of diabetes?
- Target HbA1c 53 mmol/mol (7%)
- Control BP to < 130/80
□ (UKPDS trial evidence that can reduce death from cardiovascular disease by 1/3) - Smoking cessation: support, nicotine replacement or drug therapy (Zyban, Champix)
- Statin therapy e.g. simvastatin for patients over 40 and in younger patients with significant complications
- Lifestyle choices
What are the microvascular complications that a diabetic can develop?
- Diabetic retinopathy
- Diabetic maculopathy
- Cataracts
- Diabetic neuropathy
- Proximal motor neuropathy (diabetic amyotrophy)
- Mononeuritis
- Autonomic neuropathy
- Diabetic nephropathy
- Microalbuminuria
Explain diabetic retinopathy
- Commonest cause of blindness in working age population
- Much is preventable
□ Good glucose control
□ Tight BP control
□ Early detection & intervention - Background retinopathy
□ mild - moderate – severe - Proliferative retinopathy
- Maculopathy
What types of retinal abnormalities can you get in diabetes?
□ Microaneurysms (dots) □ Blot haemorrhages □ Hard exudates □ Cotton wool spots □ New vessel formation □ Vitreous haemorrhage □ Advanced eye disease
How do you treat proliferative retinopathy?
□ Laser photocoagulation
® Destruction of peripheral ischaemic retina leads to reduction of endothelial growth factors and regression of new vessels
□ Vitrectomy
Explain diabetic maculopathy as a complication of diabetes
- Exudates and blot haemorrhages at macula
- Macular ischaemia
- Macular oedema deforms the macula
- decreased visual acuity - common in type 2 diabetes
- Treatment
□ Grid laser therapy
□ Tight control of blood glucose and BP
Explain cataracts as a complication of diabetes
- Common in elderly
- Two fold increase in diabetes
- Poor glycaemic control increases risk
- High success of surgery
- Visual acuity dictates timing
Explain peripheral neuropathy as a complication of diabetes
□ Common presentation (up to 40% patients)
□ Affecting the feet mainly but classic ‘glove & stocking’ distribution
□ Feet insensitive to trauma
□ Unpleasant chronic symptoms (paraesthesia, burning pain, numbness)
□ May be asymptomatic
□ Small muscle wasting
□ AT RISK FEET
What is the management of peripheral neuropathy?
® Early detection ® Self-care education ® Protection of feet ® Pain relief ® Capsaicin cream ® Amitriptyline, gabapentin, duloxetine ® Ulcer prevention - 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
Explain acute sensory peripheral neuropathy as a complication of diabetes
® Rapid onset of neuropathic symptoms ® Precipitating factors ◊ Rapid tightening of control ◊ Acute metabolic upset ® May be very severe – gradual recovery
Explain proximal motor neuropathy as a complication of diabetes
□ Elderly men; type 2 DM □ Legs mostly □ Wasting of thigh muscles □ Weight loss □ Painful □ Good prognosis □ Now seen rarely
Explain mononeuritis as a complication of diabetes
□ Mainly ocular cranial nerves ® III ® IV ® VI □ Acute foot drop –peroneal nerve □ Vascular event - acute onset and gradual recovery
Explain autonomic neuropathy as a complication of diabets
□ Erectile dysfunction is common
□ Phosphodiesterase inhibitors are effective
® e.g. Viagra, Cialis
□ Prostaglandins, mechanical devices, implants
□ Postural hypotension
® NSAIDs
® Fludrocortisone
□ Gastric stasis and recurrent vomiting
® Rx Domperidone
□ Diarrhoea
® Rx Loperamide, Codeine phosphate
® Bowel overgrowth?
□ Abnormal sweating, peripheral oedema, urinary retention
□ Diagnosis based on symptom pattern and exclusion of other causes
□ Abnormal ECG rhythm responses e.g. no variation of rate on deep breathing
Explain diabetic nephropathy
- 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
- 25% of type 1 patients may develop nephropathy after 30 years disease duration
- Detecting early kidney disease
- normal -> + Proteinuria -> Impaired renal function
What are the tests for microalbuminuria?
□ SCREENING TEST - first morning urine sample
® Normal albumin/creatinine ratio
® Male <2.5 mg/mmol; Female <3.5
□ DEFINITIVE TEST- timed overnight urine collection for albumin excretion rate (AER)
® Normal < 20μg/min
® Microalbuminuria 20-200μg/min
What is the management for 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
