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BRS Flashcards (Y2) > Micro- And Macrovascular Complication Of Diabetes > Flashcards

Micro- And Macrovascular Complication Of Diabetes Flashcards

1
Q

What are the microvascular complication of Diabetes?

A

Retinopathy
Nephropathy
Neuropathy

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2
Q

What are the macrovascular complications of Diabetes?

A

Cerebrovascular disease
Ischaemic heart disease
Peripheral vascular disease

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3
Q

What is the relationship between risk of microvascular complications and HbA1c levels?

A

Extent of hyperglycaemia, measured by HbA1c, is strongly associated with the risk of developing microvascular complications

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4
Q

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

A

53 mmol/mol (<7%)

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5
Q

Is glycaemic control the only factor that should be monitored in prevention of microvascular complications?

A

No systolic BP must also be monitored as there is a relationship between rising systolic BP and risk of MI and microvascular complications in people with T1 and T2DM

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6
Q

What other factors are related to the development of microvascular complications in people with T1 and T2DM?

A

Duration of diabetes
Smoking - endothelial dysfunction
Genetic factors - development of complications despite reasonable glycaemic control
Hyperlipidaemia
Hyperglycaemic memory - inadequate glycaemic control early on may increase risk of complications later on despite improved HbA1c

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7
Q

What is the mechanism of damage in microvascular disease?

A
  • Hyperglycaemia and hyperlipidaemia lead to increased formation of mitochondrial superoxide free radicals in the endothelium
  • Generates glycated plasma proteins that form advanced glycation end products (AGEs)
  • Activates inflammatory pathways that damage endothelium (exacerbated by smoking)
  • Causes leaky capillaries (proteins flows out) and ischaemia (impaired blood flow)
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8
Q

What is the main cause of visual loss in people with diabetes?

A

Diabetic retinopathy

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9
Q

What is the main cause of blindness in people of working age?

A

Diabetic retinopathy

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10
Q

Why is screening necessary for diabetic retinopathy and what are the aims of screening?

A

Diabetic retinopathy is asymptomatic in early stages
Aim is to detect retinopathy early when it can be treated - before it causes visual disturbance/loss

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11
Q

What type of retinal screening is offered for patients with diabetes in the UK?

A

Annual retinal screening for all diabetes patients

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12
Q

What condition does this image show and what are the abnormalities?

A

Background retinopathy (early stage)
Hard exudates (cheese colour - lipids/protein)
Microaneurysms (dots)
Blot haemorrhages

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13
Q

Label the abnormalities on this image. What condition does it show?

A

Pre-proliferative retinopathy
‘Cotton wool spots’ - soft exudates

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14
Q

What do cotton wool spots represent?

A

Retinal ischaemia

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15
Q

What stage of retinopathy is shown in this image?

A

Pre-proliferative retinopathy

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16
Q

What condition does this image show and what are the abnormalities?

A

Proliferative retinopathy
Visible new vessels on disc or elsewhere in retina - response to ischaemia, susceptible to damage

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17
Q

How is maculopathy different from retinopathy?

A

Same disease as background retinopathy but happens to be around the macula
Threatens vision - macula is important for fine, detailed colour vision
Hard exudates/oedema near the macula

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18
Q

What is the first step of management for all stages of diabetic retinopathy/maculopathy?

A

Lifestyle:
Improve HbA1c
Stop smoking
Lipid lowering
Good BP control <130/80 mmHg

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19
Q

After lifestyle, what is the treatment for background retinopathy?

A

Continued annual surveillance

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20
Q

After lifestyle, what is the treatment for pre-proliferative retinopathy?

A

If left alone, will progress to new vessel growth
Early panretinal photocoagulation treatment - burning of new vessels to prevent haemorrhages

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21
Q

After lifestyle, what is the treatment for proliferative retinopathy?

A

Panretinal photocoagulation

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22
Q

After lifestyle, what is the treatment for diabetic maculopathy?

A

Anti-VEGF (vascular endothelial growth factor) injections directly into the eye
Grid photocoagulation

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23
Q

What is a consequence of pan-retinal photocoagulation?

A

Reduced peripheral vision (as you’ve burned a hole in the retina)

24
Q

What does this image show?

A

Retina after pan-retinal photocoagulation (laser treatment)

25
Q

Why is diabetic nephropathy important?

A

Associated with progression to end-stage renal failure requiring haemodialysis
Healthcare burden
Associated with increased risk of cardiovascular events

26
Q

How is diabetic nephropathy diagnosed?

A

Progressive proteinuria (measured by urine albumin:creatinine ratio - ACR)
Increased BP
Deranged renal function (eGFR)
Advanced - peripheral oedema

27
Q

How are microalbuminuria, proteinuria and the nephrotic range classified?

A

Microalbuminuria - ACR >2.5 mg/mmol
Proteinuria - ACR >30 mg/mmol
Nephrotic range - ACR >3000 mg/24hr (frothy urine, low blood albumin)

28
Q

Is one urine sample test enough for a diagnosis of microalbuminuria?

A

No, require at least two
False positives - high temp, UTI

29
Q

What is microalbuminuria an early sign of and how is renal function affected?

A

Diabetic kidney damage
Indicator for increased cardiovascular risk
Often have normal renal function

30
Q

What is the proposed mechanism of diabetic nephropathy?

A
31
Q

Should a patient with two confirmed tests of microalbuminuria be started on treatment and if so, what treatment?

A

Yes, all diabetes patients with microalbuminuria/proteinuria should have an ACEi/ARB even if they are normotensive

32
Q

When else should diabetes patients be started on an ACEi/ARB?

A

If they are hypertensive - BP over 130/80

33
Q

What are the benefits of taking ACEi/ARB if there is confirmed microalbuminuria/proteinuria?

A

Reduces blood pressure and progression of diabetic nephropathy

34
Q

What are the suffixes for ACEi and ARBs?

A

ACEi -> ‘-pril’
ARB -> ‘-sartan’

35
Q

Microalbuminuria is a risk factor for what disease?

A

Cardiovascular disease

36
Q

How is diabetic nephropathy managed?

A

Aim for tighter glycaemic control
ACEi/ARB for microalbuminuria even if normotensive
Reduce BP (aim for <130/80) usually through ACEi/ARB
Stop smoking
Can start SGLT2 inhibitor for T2DM

37
Q

What is the most common cause of neuropathy and therefore lower limb amputation?

A

Diabetes Mellitus

38
Q

What are the small vessels supplying nerves called?

A

Vasa nervorum

39
Q

When does neuropathy occur?

A

When the vasa nervorum get blocked

40
Q

What are the risk factors for diabetic neuropathy?

A

Age
Duration of diabetes
Poor glycaemic control
Height (longer nerves in lower limbs - tall people)
Smoking
Presence of diabetic retinopathy

41
Q

Why is diabetic neuropathy more common in your feet and what other distributions are common?

A

Longest nerves supply feet
Also commonly glove and stocking distribution - peripheral neuropathy
Can be painful

42
Q

What is the danger of diabetic neuropathy?

A

Patients may not sense an injury to the foot (e,g, stepping on a nail)
More susceptible to foot ulceration - diabetic foot

43
Q

What does the annual diabetic foot check involve?

A

Looking for foot deformity/ulceration
Assessing sensation (monofilament, ankle jerks)
Assessing foot pulses (dorsalis pedis and posterior tibial)

44
Q

What are risk factors for foot ulceration?

A

Reduced sensation to feet (peripheral neuropathy)
Poor vascular supply to feet (peripheral vascular disease)

45
Q

How is peripheral neuropathy managed?

A

Regular inspection of feet by affected individual
Good footwear
Avoid barefoot walking
Podiatry and chiropody if needed

46
Q

How is peripheral neuropathy with ulceration managed?

A

Multidisciplinary diabetes foot clinic
Offloading
Revascularisation with concomitant PVD
Antibiotics if needed
Orthotic footwear
Amputation - last resort

47
Q

Give examples of mononeuropathy due to diabetes

A

Single nerve damage
Usually sudden motor loss, e.g, foot drop or wrist drop
Cranial nerve palsy - double vision due to 3rd nerve palsy (down and out)

48
Q

Describe diabetic autonomic neuropathy

A

Damage to sympathetic and parasympathetic nerves innervating GI tract, bladder and cardiovascular system

49
Q

What effects can autonomic neuropathy have on the GI tract?

A

Delayed gastric emptying causing nausea and vomiting (can make prandial short-acting insulin challenging - no digested food for insulin to act on, hypoglycaemia risk)
Constipation/nocturnal diarrhoea

50
Q

What effects can autonomic neuropathy have on the cardiovascular system?

A

Postural hypotension - collapsing on standing
Cardiac autonomic supply - sudden cardiac death

51
Q

Is HbA1c linked with cardiovascular risk?

A

Not really - implicated in microvascular complications
Management of BP and cholesterol are key in mitigating cardiovascular risk

52
Q

Is focusing on cardiovascular risk in T2DM more important than in T1DM?

A

No, equally as important!

53
Q

What are the non-modifiable risk factors of macrovascular disease?

A

Age
Sex
Brith weight
Family history/genetics

54
Q

What are the modifiable risk factors of macrovascular disease?

A

Dyslipidaemia
Hypertension
Smoking
Diabetes Mellitus
Central obesity

55
Q

How is cardiovascular disease managed in Diabetes Mellitus?

A

Smoking status - support to quit
BP - <140/80 mmHg, <130/80 mmHg if microvascular complications (may need multiple agents)
Lipid profile - total chol <4, LDL <2
Weight - lifestyle +/- pharmacological
Annual urine microalbuminuria screen - risk factor for CVD

BRS Flashcards (Y2) (79 decks)

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