Long term complications of diabetes

Question 1

Microvascular complications

Answer 1

e.g retinopathy, nephropathy, neuropathy

Most cells are able to reduce glucose transport in response to extracellular hyperglycaemia

• retinal endothelial cells
• mesangial cells of glomerulus
• schwann cells and peripheral nerve cells

Question 2

Macrovascular complications

Answer 2

IHD

CVD

PVD

Question 3

Retinopathy

Answer 3

Second commonest cause of blindess in those of working age

4000+ in England from diabetic retinopathy

Risk of blindness increased 10-20 fold by DM

Question 4

The retinal microcirculation

Answer 4

Low density of capillaries

Little functional reserve

Flow needs to respond to local needs

Pericytes key to local regulation of flow

Question 5

Pathological finding of diabetic retinopathy

Answer 5

Loss of pericytes

basement membrane thickening

Capillary closure

Ischaemia

• VEGF production
• increased capillary permeability

Question 6

Clinical stages of retinopathy

Answer 6

Non-proliferative

• background
• pre-proliferative

Proliferative

Macular oedema

• sight threatening
• non sight threatening

Question 7

Diabetic retinopathy

Answer 7

Diabetic control important

Blood pressure control important

Laser treatment

• pan retinal
• focal

Intra-vitreal anti VEGF Ab

Question 8

Neuropathy

Answer 8

Affects up to 50% of diabetic patients

15% have painful neuropathy (cf 5% non-diabetic population)

Question 9

Neuropathy types

Answer 9

Peripheral neuropathy

Mononeuropathy

Autonomic neuropathy

Question 10

Autonomic neuropathy

Answer 10

Gastroparesis

Postural hypotension

Erectile dysfunction

Gustatory sweating

Diarrhoea

Question 11

Nephropathy

Answer 11

Commonest cause of ESRD in western world

Accounts for death of 21% of type 1 and 11% of type 2 patients

Question 12

The renal microcirculation

Answer 12

Fenestrated glomerular capillaries

Basement membrane

Highly specialised podocytes

Question 13

Pathological findings od diabetic nephropathy

Answer 13

Basement membrane thickening
- loss of negative charge

Podocyte loss
- loss of integrity of filtration barrier

Glomerular sclerosis

Mesangial expansion

Question 14

Clinical stages of diabetic nephropathy

Answer 14

Normoalbuminuria (dipstick negative)

Microalbuminurea (dipstick negative)

Albuminurea (dipstick postive)

Question 15

Diabetic nephropathy

Answer 15

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

Question 16

Macrovascular disease

Answer 16

Dramatic increase in risk with diabetes

Patients with type 2 diabetes have multiple RF

Patients with type 1 diabetes have long disease duration

Presentation depends on vascular bed affected

• angina/ MI
• stroke
• PVD

Question 17

Modifiable risks of macrovascular disease

Answer 17

Blood pressure

Lipids

Smoking

(glucose control)

Question 18

Diabetic foot

Answer 18

Diabetes is the commonest cause of non-traumatic lower limb amputation

• PVD
• neuropathy
• impaired leucocyte function