micro and macrovascular complications of diabetes

Question 1

what are the 3 microvascular complications

Answer 1

retinopathy
nephropathy
neuropathy

Question 2

what are the 3 macrovasc complication

Answer 2

cerebrovascular disease
ischaemic heart disease
peripheral vascular disease - usualy affects feet

Question 3

what is the target hba1c to reduce risk of microvascular complications

Answer 3

53 mmol/mol

Question 4

what is also a major factor that increases complication risk

Answer 4

hypertension

Question 5

what are some other factors related to development of microvascular complications

Answer 5

duration of diabetes
smoking - endothelial dysfunction
genetic factors
hyperlipidaemia
hyperglycaemic memory

Question 6

what is the mechanism of damage following hyperglycaemia and hyperlipidaemia

Answer 6

1. hypoxia, increased formation of mitochondrial superoxide free radicals in endothelium = oxidative stress and generation of glycated plasma proteins to form advanced glycation end products (AGEs)
2. causes activation of inflammatory signalling cascades and pro inflammatory end products
3. damaged endothelium results in leaky capillaries and ischaemia

Question 7

what is diabetic retinopathy the main cause of

Answer 7

visual loss in people with diabetes

blindness in people of working age

Question 8

why is screening for diabtetic retinopathy required

Answer 8

early stages are asymptomatic

Question 9

how often should patients with diabetes get retinal screening

Answer 9

anually

Question 10

what is retinal screening

Answer 10

taking a picture of the back of the eye

Question 11

what is the first stage of diabetIc retinopathy

Answer 11

BACKGROUND RETINOPATHY

Question 12

what can you expect to see in background retinopathy on screening

Answer 12

hard exudates - cheese colour,lipids

dots - microaneurysms and blot haemorrhages

Question 13

what is the second stage of retinopathy

Answer 13

pre proliferative retinopathy

Question 14

what can you expect to see in pre proliferative retinopathy on screening

Answer 14

more significant haemorrhages

cotton wool spots called soft exudates - retinal ischaemia

Question 15

what is large stage of retinopathy

Answer 15

proliferative retinopathy

Question 16

what can you expect to see in proliferative retinopathy on screening

Answer 16

visible new vessels - arise due to hypoxia

on disc or elsewhere in retina

Question 17

what is the problem with the new vessels formed

Answer 17

very fragile and can be easily damaged

Question 18

what is maculopathy

Answer 18

disease of macula

Question 19

what can you expect to see in maculopathy

Answer 19

hard exudates/ oedema near macula
same as background retinopathy but near macula
can threaten vision

Question 20

what is the first line of treatment for any retinopathy

Answer 20

improve hba1c
stop smoking
lower lipids
good blood pressure control

Question 21

what is the treatment for pre proliferative or proliferative retinopathy

Answer 21

panretinal photocoagulation

Question 22

treatment for maculopathy

Answer 22

oedema - anti VEGF injections directly into eye
vegf = vascular endothelial growth factor

or use grid photocoagulation

Question 23

what is diabetic nephropathy

Answer 23

kidney disease

Question 24

why is diabetic nephropathy important

Answer 24

associated with progression to end stage renal failure requiring haemodialysis
associated with increased risk of cvd
healthcare burden

Question 25

how can we diagnose diabetic nephropathy

Answer 25

1.progressive proteinuria - urine albumin: creatinine ratio, ACR > 30mg/mmol 2. microalbuminuria >2.5 mg/mmol 3. increased bp 4. deranged renal function egfr 5. advanced - peripheral oedema nephrotic range >3000mg/24hr

Question 26

what is the mechanism of diabetic nephropathy

Answer 26

``` hyperglycaemia and hypertension causes glomerular hypertension this causes proteinuria glomerular and interstitial fibrosis glomerular filtration rate decline renal failure ```

Question 27

what are ACEinhibitors

Answer 27

antihypertensives which block ace

Question 28

what are ARBs

Answer 28

angiotensin receptor blockers are also antihypertensives which block angiotensin receptors

Question 29

effect of angiotensin 2

Answer 29

aldosterone release and vasoconstriction

Question 30

what med should you give to those with diabetic nephropathy

Answer 30

acei (- prils) or arbs ( -sartans)

Question 31

how can we manage diabetic nephropathy

Answer 31

``` aim for tighter glycaemic control acei/arbs even if normotensive but has microalbuminuria reduce bp stop smoking start sglt2 inhibitor if type 2? ```

Question 32

what is the earliest feature in diabetic nephropathy

Answer 32

microalbuminuria

Question 33

what is diabetic neuropathy

Answer 33

small vessels supplying vasa nervorum ( nerves) become blcoked

Question 34

what is neuropathy serious

Answer 34

no sensation and can lead to lower limb amputation as you dont feel injury

Question 35

what are some risk factors for neuropathy

Answer 35

``` age duration of diabetes poor glycaemia control height smoking presence of diabetic retinopathy ```

Question 36

where is neuropathy more common

Answer 36

feet - as longest nerve supply | can be painful

Question 37

what takes place during annual foot check for patients

Answer 37

look for foot deformity/ulceration assess sensation - monofilament, ankle jerks assess foot pulses - dorsalis pedis and posterior tibial

Question 38

what is the risk of reduced sensation and vascular supply to feet

Answer 38

foot ulceration | as no blood flow to tissues too

Question 39

how can we manage diabetic foot disease without ulceration

Answer 39

regular inspection of feet good footwear avoid walking barefoot podiatry/chirpody if needed

Question 40

how can we manage diabetic foot disease with ulceration

Answer 40

``` multidisciplinary diabetes foot clinic offloading revacularisation antibiotics orthotic footwear amputation if all else fails ```

Question 41

what are some neuropathies

Answer 41

mononeuropathy usually sudden motor loss e.g wrist drop, foot drop cranial nerve palsy double vision due to 3rd nerve palsy

Question 42

what is autonomic neuropathy

Answer 42

damage to sympathetic and parasympathetic nerves innervating gi tract, bladder and cv system

Question 43

what are some gi tract features we can observe in autonomic neuropathy

Answer 43

``` delayed gastric emptying nausea vomitting constipation noctural diarrhoea ```

Question 44

what are some cardiovascular features we can observe in autonomic neuropathy

Answer 44

postural hypotension cardiac autonomic supply sudden cardiac death

Question 45

what are some non modifiable risk factors for macrovascular disease

Answer 45

age sex birth weight fh/genes

Question 46

what are some modifiable risk factors for macrovascular disease

Answer 46

``` dyslipidaemia hypertension smoking diabetes mellitus central obesity ```

Question 47

how can we manage cardiovascular risk in dm

Answer 47

``` support to quit smoking lower bp lipid profile weight - lifestyle intervention annual urine microalbuminuria screen ```