Long term complications of diabetes

Question 1

What systems are affected by long term complications of diabetes?

Answer 1

○ Large vessels (macrovascular)
- Cardiovascular system
○ Small vessels (microvascular)
- eyes
- nerves
- kidneys

Question 2

What are the risk factors for developing complications of diabetes?

Answer 2

○ Duration of diabetes
○ Metabolic control 
○ Smoking 
○ Hypertension
○ Hyperlipidaemia
○ Genetics

Question 3

Explain cardiovascular disease as a complication of diabetes

Answer 3

○ 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

Question 4

What are the risk factors of developing cardiovascular disease as a complication of diabetes?

Answer 4

• Glucose control
• Blood pressure
• Smoking
• Lipids
• Proteinuria
• Family history
• Gender

Question 5

How does one reduce the risk of developing cardiovascular disease as a complication of diabetes?

Answer 5

• 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

Question 6

What are the microvascular complications that a diabetic can develop?

Answer 6

• Diabetic retinopathy
• Diabetic maculopathy
• Cataracts
• Diabetic neuropathy
• Proximal motor neuropathy (diabetic amyotrophy)
• Mononeuritis
• Autonomic neuropathy
• Diabetic nephropathy
• Microalbuminuria

Question 7

Explain diabetic retinopathy

Answer 7

• 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

Question 8

What types of retinal abnormalities can you get in diabetes?

Answer 8

□ Microaneurysms (dots)
□ Blot haemorrhages
□ Hard exudates
□ Cotton wool spots
□ New vessel formation
□ Vitreous haemorrhage
□ Advanced eye disease

Question 9

How do you treat proliferative retinopathy?

Answer 9

□ Laser photocoagulation
® Destruction of peripheral ischaemic retina leads to reduction of endothelial growth factors and regression of new vessels
□ Vitrectomy

Question 10

Explain diabetic maculopathy as a complication of diabetes

Answer 10

• 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

Question 11

Explain cataracts as a complication of diabetes

Answer 11

• Common in elderly
• Two fold increase in diabetes
• Poor glycaemic control increases risk
• High success of surgery
• Visual acuity dictates timing

Question 12

Explain peripheral neuropathy as a complication of diabetes

Answer 12

□ 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

Question 13

What is the management of peripheral neuropathy?

Answer 13

® 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

Question 14

Explain acute sensory peripheral neuropathy as a complication of diabetes

Answer 14

® Rapid onset of neuropathic symptoms 
® Precipitating factors
◊ Rapid tightening of control
◊ Acute metabolic upset
® May be very severe – gradual recovery

Question 15

Explain proximal motor neuropathy as a complication of diabetes

Answer 15

□ Elderly men; type 2 DM
□ Legs mostly
□ Wasting of thigh muscles
□ Weight loss
□ Painful
□ Good prognosis
□ Now seen rarely

Question 16

Explain mononeuritis as a complication of diabetes

Answer 16

□ Mainly ocular cranial nerves
® III
® IV
® VI
□ Acute foot drop –peroneal nerve 
□ Vascular event - acute onset and gradual recovery

Question 17

Explain autonomic neuropathy as a complication of diabets

Answer 17

□ 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

Question 18

Explain diabetic nephropathy

Answer 18

• 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

Question 19

What are the tests for microalbuminuria?

Answer 19

□ 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

Question 20

What is the management for early kidney disease?

Answer 20

□ Optimise glycaemic control
□ Tight BP control - aim for <125/75 in type 1 diabetes
□ Ace inhibitor therapy slows progression
□ Cardiovascular risk factor management