macrovascular & microvascular complications

Question 1

What are the microvascular complications?

Answer 1

Retinopathy, nephropathy, neuropathy

Question 2

What are the macrovascular complications?

Answer 2

Ischaemic heart disease, cerebrovascular disease, peripheral vascular disease

Question 3

Relationship between glycaemic control and risk of vascular complications? What is target HbA1c to reduce these complications?

Answer 3

Worse glycaemic control worse risk. Target HbA1C is 53mmol/L to reduce complications

Question 4

what other factors are linked to vascular complications?

Answer 4

Duration of diabetes, dyslipidaemia, hypertension, hyperglycaemic memory, smoking

Question 5

What is the mechanism of microvascular complications?

Answer 5

Combination of hyperglycaemia and tendency towards high cholesterol paired with hypoxia to the vessels leads to pro-inflammatory state - inflammation causes damage of small vessels. Leads to hypoxia of tissues and leaky vessels.

Question 6

What does diabetic retinopathy cause? Early stages? What do we need to do?

Answer 6

Causes vision loss. Early stages asymptomatic. Annual retinal screening.

Question 7

what is seen in background retinopathy?

Answer 7

Hard exudates. Microaneurysms and blot haemorrhages.

Question 8

what is seen in pre-proliferative retinopathy?

Answer 8

More extensive haemorrhages and increased white spots (cotton wool spots/soft exudates) that represent ischaemia

Question 9

what is seen in proliferative retinopathy?

Answer 9

New vessels formed that are easily friable and bleed easily. Haemorrhages too.

Question 10

what is seen in diabetic maculopathy?

Answer 10

Hard exudates/oedema near macula. Same as background retinopathy but near macula, this can threaten vision

Question 11

What is treatment for each stage of retinopathy?

Answer 11

1. Background retinopathy no treatment but annual retinal screening.
2. Pre-proliferative retinopathy early pan-retinal photocoagulation (burns through retinal haemorrhages to prevent further damage and new vessel formation).
3. Proliferative retinopathy - pan-retinal photocoagulation. 4. maculopathy - for oedema - anti VEGF injections into eye to stop inflammatory cascade. Grid photocoagulation

Question 12

What is diabetic nephropathy associated with?

Answer 12

End-stage renal disease requiring dialysis and CV disease

Question 13

How is diagnosis of diabetic nephropathy made?

Answer 13

Urine test for proteinuria - ACR albumin creatinine ratio. Microalbuminuria >2.5 ACR, proteinuria >30, nephrotic range losing 3000mg/24 hours (huge amounts of proteinuria).
-Diagnosis needs progressive albuminuria, hypertension, deranged renal function (eGFR)> in advanced stage will see peripheral oedema.

Question 14

What is the mechanism underpinning diabetic nephropathy?

Answer 14

Combination of hyperglycaemia and hypertension damages the glomerulus leading to reduction in eGFR. Renin-angiotensin system driving vasoconstriction is in overdrive (thus need ACE inhibitors or ARBS)

Question 15

What to do when microalbuminuria?

Answer 15

Start ACE inhibitor or ARB

Question 16

Why not give ARBS and ACEi together?

Answer 16

no extra benefit. can interfere with potassium

Question 17

Effects of microalbuminuria?

Answer 17

Increased risk of stroke, MI, CV disease

Question 18

Management of diabetic nephropathy?

Answer 18

Tighter glycaemic control, stop smoking, aim for blood pressure (130/80), consider starting SGLT-2 inhibitor. Ace/arb if microalbuminuria

Question 19

What is diabetic neuropathy (peripheral)? Why can it cause damage?

Answer 19

Damage of the peripheral nerves. Supplied by small blood vessels - vasa nevorum - get blocked during neuropathy. Can lead to loss of sensation peripherally especially at legs, leading to damage

Question 20

Risk factors of diabetic neuropathy?

Answer 20

Hyperglycaemia, dyslipidaemia, smoking, height (longer nerves) presence of diabetic retinopathy

Question 21

Why feet more commonly? What distribution?

Answer 21

Longer nerves in legs. Glove and stocking distribution

Question 22

Why diabetic foot ulceration?

Answer 22

Reduced sensation in the feet predisposes them to damage - get hurt and cannot feel it

Question 23

What is checked at annual foot check?

Answer 23

Deformity, ulceration, sensation and foot pulses

Question 24

Management of diabetic neuropathy?

Answer 24

Regular inspection, good footwear, avoid being barefoot. If ulcer, foot clinic, offloading period for rest, often cant heal because of peripheral vascular disease so vascular surgeon can do re-vascularisation, antibiotics if infected, amputation

Question 25

What is mononeuropathy? Examples?

Answer 25

Isolated palsy, sudden motor loss eg. Wrist drop, foot drop, oculomotor palsy double vision

Question 26

What is autonomic neuropathy? What can be the consequences?

Answer 26

Neuropathy affecting PNS and SNS. Affect abdomen, heart, can cause abdominal issues, cardiac problems, postural hypotension, sudden cardiac death, nocturnal diarrhoea

Question 27

Risk factors for macrovascular complications?

Answer 27

Smoking, diabetes, dyslipidaemia, hypertension, sex, age, BMI

Question 28

How to manage CV risk in T2D?

Answer 28

1. quit smoking 2. dyslipidaemia total cholesterol and LDL 3. weight loss 4. hypertension - 140/80 or 130/80 if microvascular complications, drugs + annual microalbuminuria screen