micro and macrovascular complications of diabetes Flashcards
what are the 3 microvascular complications
retinopathy
nephropathy
neuropathy
what are the 3 macrovasc complication
cerebrovascular disease
ischaemic heart disease
peripheral vascular disease - usualy affects feet
what is the target hba1c to reduce risk of microvascular complications
53 mmol/mol
what is also a major factor that increases complication risk
hypertension
what are some other factors related to development of microvascular complications
duration of diabetes smoking - endothelial dysfunction genetic factors hyperlipidaemia hyperglycaemic memory
what is the mechanism of damage following hyperglycaemia and hyperlipidaemia
- 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)
- causes activation of inflammatory signalling cascades and pro inflammatory end products
- damaged endothelium results in leaky capillaries and ischaemia
what is diabetic retinopathy the main cause of
visual loss in people with diabetes
blindness in people of working age
why is screening for diabtetic retinopathy required
early stages are asymptomatic
how often should patients with diabetes get retinal screening
anually
what is retinal screening
taking a picture of the back of the eye
what is the first stage of diabetIc retinopathy
BACKGROUND RETINOPATHY
what can you expect to see in background retinopathy on screening
hard exudates - cheese colour,lipids
dots - microaneurysms and blot haemorrhages
what is the second stage of retinopathy
pre proliferative retinopathy
what can you expect to see in pre proliferative retinopathy on screening
more significant haemorrhages
cotton wool spots called soft exudates - retinal ischaemia
what is large stage of retinopathy
proliferative retinopathy
what can you expect to see in proliferative retinopathy on screening
visible new vessels - arise due to hypoxia
on disc or elsewhere in retina
what is the problem with the new vessels formed
very fragile and can be easily damaged
what is maculopathy
disease of macula
what can you expect to see in maculopathy
hard exudates/ oedema near macula
same as background retinopathy but near macula
can threaten vision
what is the first line of treatment for any retinopathy
improve hba1c
stop smoking
lower lipids
good blood pressure control
what is the treatment for pre proliferative or proliferative retinopathy
panretinal photocoagulation
treatment for maculopathy
oedema - anti VEGF injections directly into eye
vegf = vascular endothelial growth factor
or use grid photocoagulation
what is diabetic nephropathy
kidney disease
why is diabetic nephropathy important
associated with progression to end stage renal failure requiring haemodialysis
associated with increased risk of cvd
healthcare burden
how can we diagnose diabetic nephropathy
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
what is the mechanism of diabetic nephropathy
hyperglycaemia and hypertension causes glomerular hypertension this causes proteinuria glomerular and interstitial fibrosis glomerular filtration rate decline renal failure
what are ACEinhibitors
antihypertensives which block ace
what are ARBs
angiotensin receptor blockers are also antihypertensives which block angiotensin receptors
effect of angiotensin 2
aldosterone release and vasoconstriction
what med should you give to those with diabetic nephropathy
acei (- prils) or arbs ( -sartans)
how can we manage diabetic nephropathy
aim for tighter glycaemic control acei/arbs even if normotensive but has microalbuminuria reduce bp stop smoking start sglt2 inhibitor if type 2?
what is the earliest feature in diabetic nephropathy
microalbuminuria
what is diabetic neuropathy
small vessels supplying vasa nervorum ( nerves) become blcoked
what is neuropathy serious
no sensation and can lead to lower limb amputation as you dont feel injury
what are some risk factors for neuropathy
age duration of diabetes poor glycaemia control height smoking presence of diabetic retinopathy
where is neuropathy more common
feet - as longest nerve supply
can be painful
what takes place during annual foot check for patients
look for foot deformity/ulceration
assess sensation - monofilament, ankle jerks
assess foot pulses - dorsalis pedis and posterior tibial
what is the risk of reduced sensation and vascular supply to feet
foot ulceration
as no blood flow to tissues too
how can we manage diabetic foot disease without ulceration
regular inspection of feet
good footwear
avoid walking barefoot
podiatry/chirpody if needed
how can we manage diabetic foot disease with ulceration
multidisciplinary diabetes foot clinic offloading revacularisation antibiotics orthotic footwear amputation if all else fails
what are some neuropathies
mononeuropathy
usually sudden motor loss e.g wrist drop, foot drop
cranial nerve palsy
double vision due to 3rd nerve palsy
what is autonomic neuropathy
damage to sympathetic and parasympathetic nerves innervating gi tract, bladder and cv system
what are some gi tract features we can observe in autonomic neuropathy
delayed gastric emptying nausea vomitting constipation noctural diarrhoea
what are some cardiovascular features we can observe in autonomic neuropathy
postural hypotension
cardiac autonomic supply
sudden cardiac death
what are some non modifiable risk factors for macrovascular disease
age
sex
birth weight
fh/genes
what are some modifiable risk factors for macrovascular disease
dyslipidaemia hypertension smoking diabetes mellitus central obesity
how can we manage cardiovascular risk in dm
support to quit smoking lower bp lipid profile weight - lifestyle intervention annual urine microalbuminuria screen
