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BRS YR2 > Micro- and Macro-vascular Complications of Diabetes Mellitus > Flashcards

Micro- and Macro-vascular Complications of Diabetes Mellitus Flashcards

1
Q

What are examples of microvascular complications of DM?

A
  • retinopathy
  • nephropathy
  • neuropathy
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2
Q

What are examples macrovascular complications of DM?

A
  • Cerebrovascular disease
  • Ischaemic heart disease
  • Peripheral vascular disease
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3
Q

What is strongly associated with the risk of developing microvascular complications?

A

The extent of hyperglycaemia judged by HbA1c

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4
Q

What is the target HbA1c to reduce the risk of microvascular complications?

A

53mmol/mol (<7%)

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5
Q

What is the relationship between rising systolic BP and risk of MI and microvascular complication in people T1DM and T2DM?

A
  • positive relationship
  • high BP leads to higher risk of MI and microvascular complications in those with T1DM and T2DM
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6
Q

What is required for the prevention of complications of DM?

A
  • reduction in HbA1c
  • control blood pressure
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7
Q

What are the factors associated with the development of microvascular complications?

A
  • duration of diabetes
  • smoking (inflammatory endothelial dysfunction)
  • genetic factors (development irrelevant of glycaemic control)
  • hyperlipidaemia
  • hyperglycaemic memory
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8
Q

What is hyperglycaemic memory?

A

inadequate glucose control early on > high risk of later complications (even if HbA1c improves)

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9
Q

What is the general mechanism of damage involved in microvascular complications?

A
  • increased formation of mitochondrial superoxide free radicals in the endothelium
  • generation of glycated plasma proteins to form advanced glycation end products (AGEs)
  • Activation of Inflammation pathways
  • Damaged endothelium leads to: ‘leaky’ capillaries and Ischaemia
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10
Q

What does hyperglycaemia and hyperlipidemia trigger?

A
  • AGE-RAGE
  • Oxidative stress
  • Hypoxia
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11
Q

What does AGE-RAGE, Oxidative stress and Hypoxia trigger?

A
  • Inflammatory Signalling Cascade
  • Local activation of pro-inflammatory cytokines
  • Inflammation
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12
Q

Which conditions are diabetic retinopathy the main cause of?

A
  • visual loss in people with diabetes
  • blindness in people of working age
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13
Q

Why is Diabetic Retinopathy screening needed?

A

early stages are asymptomatic

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14
Q

What is the aim of Diabetic Retinopathy Screening?

A

detect it early before it causes visual disturbance and loss

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15
Q

How often is Diabetic Retinopathy screening for diabetes patients?

A

UK - annual screening

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16
Q

What is the visual presentation of Background Retinopathy?

A
  • Hard exudates (cheese colour, lipid)
  • Microaneurysms (dots)
  • Blot haemorrhages
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17
Q

What is the physical presentation of Pre-Proliferative Retinopathy?

A
  • Soft exudates (cotton wool spots)
  • haemorrhage
  • representative of retinal ischaemia
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18
Q

What characterises Proliferative Retinopathy?

A

visible new vessels on disk or elsewhere in retina

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19
Q

What is Maculopathy?

A
  • same as background retinopathy but near macula
  • hard exudates/oedema near the macula
  • threatens vision
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20
Q

What is the Macula?

A
  • central, high resolution, colour vision
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21
Q

What is the optic disc?

A
  • point of origin of the blood vessels of the eye
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22
Q

What is the first treatment plan for all retinopathys and maculopathys?

A
  • improve HbA1c
  • smoking cessation
  • lipid lowering
  • blood pressure control (good, <130/80mmHg)
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23
Q

What further should be used to treat Background Retinopathy?

A
  • continued annual surveillance
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24
Q

What further should be done to treat Pre-proliferative Retinopathy?

A
  • Early Panretinal Photocoagulation
  • if left alone will lead to new vessel growth
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25
Q

What can be done to further treat Diabetic Maculopathy?

A
  • Anti-VEGF (Vascular Endothelial Growth Factor) injections directly into the eye to treat oedema
  • Grid Photocoagulation
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26
Q

What is Pan-retinal Photocoagulation?

A
  • for: retinal ischemic disease
  • creating thermal burns in the peripheral retina leading to tissue coagulation
  • can lead to permanent loss of peripheral vision
  • improved retinal oxygenation
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27
Q

What is diabetic nephropathy associated with?

A
  • progression to end-stage renal failure requiring haemodialysis
  • increased risk of cardiovascular events
  • healthcare burden
28
Q

How do you diagnose diabetic nephropathy?

A
  • progressive proteinuria (urine albumin:creatinine ratio)
  • Increased BP
  • Deranged Renal Function (eGFR)
  • Advanced: peripheral oedema
29
Q

What values would you see when diagnosing diabetic nephropathy?

A
  • Microalbuminuria, >3 mg/mmol
  • ACR, >30mg/mmol
  • Nephrotic Range, >3000mg/24hr
30
Q

What is the mechanism of diabetic nephropathy?

A
  • hyperglycemia and hypertension
  • glomerular hypertension
  • proteinuria
  • glomerular and interstitial fibrosis
  • glomerular filtration rate decline
  • renal failure
31
Q

Where does Angiotensin II act?

A

via angiotensin receptors

32
Q

What do ACE inhibitors do?

A

antihypertensives which block ACE

33
Q

What do ARBs (Angiotensin Receptor Blockers) do?

A

antihypertensives which block angiotensin receptors

34
Q

What is the common suffix of ACE inhibitors?

A

-pril

35
Q

What is the common suffix of ARBs?

A

-sartan

36
Q

What does blocking the Renin-Angiotensin System using ACE/ARB do?

A
  • reduces blood pressure
  • slows the progression of diabetic nephropathy
37
Q

When should diabetes patients have a ACEi/ARB?

A
  • if they have microalbuminuria/proteinuria
  • EVEN, if normotensive
38
Q

When should patients be on both ACEi and ARB?

A
  • never
  • no clinical benefit
39
Q

What is microalbuminuria a risk factor for?

A

cardiovascular disease

40
Q

What is involved in the management of diabetic nephropathy?

A
  • tight glycaemic control (HbA1c <53 mmol/mol)
  • ACEi/ARB with microalbuminuria
  • reduce BP (<130/80 mmHg)
  • Smoking cessation
  • SGLT-2 inhibitor if T2DM?
41
Q

What is neuropathy?

A

When vasa nervorum (small vessels supplying nerves) get blocked

42
Q

What is the most common cause of neuropathy?

A
  • Diabetes Mellitus, most common cause of lower limb amputation
43
Q

What are the risk factors of neuropathy?

A
  • age
  • duration of diabetes
  • poor gylcaemic control
  • height (longer nerves in lower limbs)
  • smoking
  • presence of diabetic retinopathy
44
Q

Where is diabetic neuropathy most common?

A
  • in the feet (longest nerves in the feet)
  • commonly presents with a glove and stocking distribution (peripheral neuropathy)
45
Q

What is the danger of diabetic neuropathy?

A

Patients may not be able to detect injuries in feet (although DN can be painful)

46
Q

What is included in the annual foot check (for those with diabetes)?

A
  • foot deformity?
  • ulceration?
  • sensation? (monofilament, ankle jerks)
  • foot pulses? (dorsalis pedis, posterior tibial)
47
Q

Why is there a risk of foot ulceration?

A
  • reduced foot sensation (peripheral neuropathy)
  • poor vascular foot supply
    (peripheral vascular disease)
48
Q

What is involved in the management of peripheral neuropathy?

A
  • regular foot inspection (self)
  • good footwear
  • avoid barefoot walking
  • IF needed: podiatry and chiropody
49
Q

What is involved in the management of peripheral neuropathy with ulceration?

A
  • multidisciplinary diabetes foot clinic
  • offloading
  • revascularisation if concomitant PVD
  • antibiotics if infected
  • orthotic footwear
  • LAST RESORT: amputation
50
Q

What is mononeuropathy?

A
  • single nerve is damaged
  • sudden motor loss (eg: wrist and foot drop)
  • cranial nerve palsy - double vision due to oculomotor nerve palsy
51
Q

How to visually confirm 3rd (oculomotor) nerve palsy?

A

eye looks DOWN and OUT, pupil is dilated

52
Q

What is autonomic neuropathy?

A

damage to the sympathetic and parasympathetic nerves innervating: GI tract, bladder and cardiovascular system

53
Q

What is the impact of autonomic neuropathy on the GI tract?

A
  • delayed gastric emptying: nausea vomiting (problematic for prandial SA insulin)
  • constipation
  • noturnal diarrhoea
54
Q

What is the impact of autonomic neuropathy on the cardiovascular system?

A
  • postural hypotension (possibly disabling, collapsing on standing)
  • cardiac autonomic supply > sudden cardiac death
55
Q

What does the treatment/prevention of macro-vascular complications of DM involve?

A
  • treatment aimed at hyperglycaemia has a minor effect on the increased risk of CVD
  • prevention of macro-vascular disease requires aggressive, multifactorial management
56
Q

What are the modifiable risk factors of macro-vascular disease?

A
  • dyslipidaemia
  • hypertension
  • smoking
  • DM
  • central obesity
57
Q

What are the non-modifiable risk factors of macro-vascular disease?

A
  • age
  • sex
  • birth weight
  • Genes
58
Q

How do you manage cardiovascular risk in DM?

A
  • smoking cessation
  • weight loss (lifestyle changes or pharmacological options)
  • annual urine microalbuminuria screen
  • lipids: total cholesterol <4, LDL <2
  • blood pressure, <140/80 or <130/80 with microvascular complications (multiple agents often required)
59
Q

What does inflammation caused by hyperglycaemia and hyperlipidemia cause?

A
  • nephropathy
  • retinopathy
  • neuropathy
60
Q

What does this image show?

A

Normal retina

61
Q

What are the stages of retinopathy?

A
  1. Background retinopathy
  2. Pre-proliferative retinopathy
  3. Proliferative retinopathy
  4. Maculopathy
62
Q

What do the black dots in this image show?

A

Thermal burns

63
Q

What is the surveillance for diabetic nephropathy?

A

Every patient with diabetes mellitus should have an annual urine sample to quantify the urine albumin:creatinine ratio - ACR

64
Q

What is the early sign of diabetic nephropathy which won’t be detected on a urine dipstick?

A

Microalbuminuria

65
Q

Why do you need a repeated positive UACR to confirm microalbuminuria?

A

False positives are quite common

BRS YR2 (67 decks)

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