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Year2 Endo > Micro and macrovascular complications of DM > Flashcards

Micro and macrovascular complications of DM Flashcards

1
Q

What are the microvascular complication of Dm

A

1) retinopathy
2) nephropathy
3) Neuropathy

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2
Q

What are teh macrovascular complications of DM

A

1) cerebrovascular disease
2) Ischaemia heart disease
3) peripheral vascular disease

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3
Q

how does increase HbA1c link to microvascular conditions

A

Extent of hyperglycaemia (as judged by HbA1c) is strongly associated with the risk of developing microvascular complications
Target HbA1c to reduce risk of microvascular complications
= 53 mmol/mol (<7%)

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4
Q

how does hypertensions cause complications of microvascular disesase

A

Clear relationship between rising systolic BP and risk of MI and microvascular complications in people with T1DM and T2DM

Therefore, prevention of complications requires reduction in HbA1c and BP control

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5
Q

name the risk factors that could lead to microvascular complications

A

Duration of diabetes
Smoking – endothelial dysfunction
Genetic factors – some people develop complications despite reasonable glycaemic control
Hyperlipidaemia
Hyperglycaemic memory – inadequate glucose control early on can result in higher risk of complications LATER, even if HbA1c improved

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6
Q

what is the mechanism of damage of hyperglycaemia and hyperlipidaemia leading to how they cause microvascular complications

A

1) hyperglycaemia and hyperlipidaemia cause:
a) Age - Rage:
Generation of glycated plasma proteins to form advanced glycation end products (AGEs)

b) Oxidative stress ; Increased formation of mitochondrial superoxide free radicals in the endothelium
c) hypoxia
2) leads to inflammatory signalling cascades
3) activation of pro inflammatory cytokines
4) inflammation –> damaged endothelium results in leaky capillaries + ischaemia
4) This causes nephropathy , retinopathy , neuropathy

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7
Q

What is diabetic retinopathy and what does it cause

A

Main cause of
visual loss in people with diabetes
blindness in people of working age

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8
Q

why is a screening programme needed for diabetic retinopathy

A

The early stages of retinopathy are all asymptomatic, therefore screening is needed
Aim of screening - to detect retinopathy EARLY when it can be treated before it causes visual disturbance / loss
Annual retinal screening in the UK for all diabetes patients

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9
Q

what does a normal retina look like

A

Can see optic disk ,
macula - central , high res, colour vision
see docs for images

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10
Q

what is background retinopathy

A 
Hard exudates ( cheese colour , lipid) 
Microaneurysms ( dot) 
Blot haemorrhages
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11
Q

What are reproliferate retinopathies + features

A

Cotton wool spots called soft exudates represent retinal ischemia

present with haemorrhage of eye and cotton wool spots

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12
Q

How do proliferative retinopathies present

A

Visible new vessels on disc or elsewhere in retina

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13
Q

How do maculopathies present

A

heard exudates / oedema near the macula
same disease as background but happens to be near macula
this can threaten vision

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14
Q

what are the different types of retinopathy

A

1) background
2) reproliferate
3) proliferative
4) maculopathies

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15
Q

How can you treat retinopathies and maculopathies

A

for all
Improve HbA1c, stop smoking, lipid lowering,
good blood pressure control <130/80 mmHg

1) background –> Continued annual surveillance

2) reproliferative –. If left alone will progress to new vessel growth
So, early panretinal photocoagulation

3) Proliferative –>panretinal photocoagulation

4) Diabetic maculopathy
–> Oedema: Anti-VEGF injections directly into the eye (VEGF: vascular endothelial growth factor)
Grid photocoagulation

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16
Q

What is pan- retinal photocoagulation

A

wt

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17
Q

What other diseases is diabetic nephropathy associated with

A

Associated with progression to end-stage renal failure requiring haemodialysis
Associated with progression to end-stage renal failure requiring haemodialysis

Healthcare burden

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18
Q

whit is diagnosis of diabetic nephropathy

A

Progressive proteinuria (urine albumin:creatinine ratio - ACR)

Increased blood pressure

Deranged renal function (eGFR)

Advanced: peripheral oedema

Progressive proteinuria (urine albumin:creatinine ratio - ACR)

Increased blood pressure

Deranged renal function (eGFR)

Advanced: peripheral oedema

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19
Q

what is the mechanism of diabetic nephropathy

A

Diabetes –> hyperglycaemia + hypertension

increases glomerular hypertension –> proteinuria –> glomerular and interstitial fibrosis –> glomerular filtration rate decline –> renal failure

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20
Q

what is the renin angiotensin system

A

Angiotensinogen made in liver –> combined with renin from kidney –> angiotensin I
Angiotensin I + ACE ( from lungs) –> angiotensin II
Angiotensin II acts via angiotensin receptors ( to cause vaso constriction and aldosterone production in zonal glomerulosa )

ACE inhibitors (ACEi) are antihypertensives which block ACE
( prevents angiotensin I –> angiotensin II)
Angiotensin receptor blockers (ARBs) are antihypertensives which block angiotensin receptors

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21
Q

what are the mechanism of action of ACE inhibitors

A 
ACE inhibitors (ACEi) are antihypertensives which block ACE
( prevents angiotensin I --> angiotensin II)
22
Q

what are the mechanism of action of Angiotensin receptor blockers

A

Angiotensin receptor blockers (ARBs) are antihypertensives which block angiotensin receptors

23
Q

what does blocking Renin angiotensin system do to diabetic nephropathy

A

Blocking RAS with an ACE inhibitor (‘-pril) or angiotensin 2 receptor blocker (ARB, ‘-sartan’) reduces blood pressure & progression of diabetic nephropathy

24
Q

when should ACE / ARB be givin

A

All diabetes patients with microalbuminuria/proteinuria should have an ACEi/ARB even if normotensive
No benefit to having both ACEi/ARB simultaneously

25
Q

what is microalbuminuria a risk factor of

A

CVD

26
Q

what is the management of diabetic nephropathy

A

All diabetes patients with microalbuminuria/proteinuria should have an ACEi/ARB even if normotensive
No benefit to having both ACEi/ARB simultaneously

27
Q

what is diabetic neuropathy

A

Diabetes mellitus is the most common cause of neuropathy and therefore lower limb amputation

Small vessels supplying nerves are called vasa nervorum

Neuropathy results when vasa nervorum get blocked

28
Q

what is vasa nervorum

A

Small vessels supplying nerves are called vasa nervorum

29
Q

what are the risk factors for diabetic neuropathy

A

Risk factors include

- Age
- Duration of diabetes
- Poor glycaemic control
- Height (longer nerves in lower 	limbs of tall people)
- Smoking
- Presence of diabetic retinopathy
30
Q

what region of teh body does diabetic neuropathy commonly occur in and why is this dangerous

A

Longest nerves supply feet – so more common in feet
Commonly glove & stocking distribution – peripheral neuropathy
Can be painful
Danger is that patients will not sense an injury to the foot (eg. stepping on a nail)
can cause foot ulceration

31
Q

what is checked for in pateints with diabetic foot ulceration + how often must they be check for this

A

All people with diabetes: annual foot check

- Look for foot deformity, ulceration
- Assess sensation (monofilament, ankle jerks) 
- Assess foot pulses (dorsalis pedis and 	posterior tibial)
32
Q

What are the risk factors for foot ulceration

A

All people with diabetes: annual foot check

- Look for foot deformity, ulceration
- Assess sensation (monofilament, ankle jerks) 
- Assess foot pulses (dorsalis pedis and 	posterior tibial)
33
Q

what is the management of diabetic foot disease caused by peripheral neuropathy

A

All people with diabetes: annual foot check

- Look for foot deformity, ulceration
- Assess sensation (monofilament, ankle jerks) 
- Assess foot pulses (dorsalis pedis and 	posterior tibial)
34
Q

what is the management of diabetic foot disease caused by peripheral neuropathy with ulceration

A 
Multidisciplinary diabetes foot clinic
Offloading
Revascularisation if concomitant PVD
Antibiotics if infected
Orthotic footwear
Amputation if all else fails
35
Q

what are the types of neuropathies

A

1) peripheral neuropathy
2) peripheral neuropathy with ulceration
3) mononeuropathy
4) autonomic neuropathy

36
Q

what are symptoms of mononeuropathy

A

Usually, sudden motor loss
eg wrist drop, foot drop
Cranial nerve palsy
double vision due to 3rd (oculomotor) nerve palsy ( eye looking down and out)

37
Q

What is autonomic neuropathy

A

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

38
Q

What are the GI and cardio effects of autonomic neuropathies

A

GI tract

  • Delayed gastric emptying: nausea and vomiting (can make prandial short-acting insulin challenging)
  • Constipation / nocturnal diarrhoea

Cardiovascular

  • Postural hypotension: can be disabling - collapsing on standing.
  • Cardiac autonomic supply: sudden cardiac death
39
Q

What are treatments for macrovascular complications

A

Treatment targeted to hyperglycaemia alone has minor effect on increased risk of cardiovascular disease
Prevention of macrovascular disease requires aggressive management of multiple risk factors

40
Q

what are the modifiable and non modifiable risk factors for macrovascular disease

A 
Non-modifiable
Age
Sex
Birth weight
FH/Genes
Non-modifiable
Age
Sex
Birth weight
FH/Genes
41
Q

how can you manage cardiovascular risk in DM

A

Smoking status – support to quit
Blood pressure < 140/80 mmHg, < 130/80 mmHg if microvascular complication (NB often needs multiple agents)
Lipid profile – total chol <4, LDL <2
Weight – discuss lifestyle intervention +/- pharmacological treatments
Annual urine microalbuminuria screen – risk factor for cardiovascular disease

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Year2 Endo (13 decks)

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