Micro/macrovascular

Question 1

examples of microvascular complications?

Answer 1

neuropathy, retinopathy, nephropathy

Question 2

examples of macrovascular complications?

Answer 2

cerebrovascular disease, ischaemic heart disease, peripheral vascular disease

Question 3

what is one factor strongly associated with developing microvascular complications?

Answer 3

HbA1c levels

Question 4

What should patients aim for

Answer 4

target 53 mmol/L

Question 5

main other factor that increases risk?

Answer 5

Hypertension
Smoking
Duration of diabetes
Genetic factors
Hyperlipidaemia
Hyperglyaemic memory

Question 6

Hyperglycemic memory

Answer 6

inadequate glucose control early on can cause complications later even if HbA1c is brought under control

Question 7

How does hyperglycemias cause vascular complications

Answer 7

increased formation of mitochondrial free radicals in endothelium

formation of advanced glycation end products (AGE)

hypoxia

Leads to inflammatory signaling

Question 8

What does inflammatory signalling result in

Answer 8

inflammation → endothelium damage → leaky capillaries, ischaemia

Question 9

What does diabetic retinopathy result in

Answer 9

Vision loss

Question 10

Why is screening so important

Answer 10

Early stages are asymptomatic

Question 11

what does background retinopathy look like?

Answer 11

hard exudates, blot haemorrhages, dots → microaneurysms

Question 12

What is the next stage of background retinopathy

Answer 12

Pre proliferation retinopathy

Question 13

Pre proliferative

Answer 13

cotton wool spots → soft exudates, represent retinal ischaemia

haemorrhages

Question 14

Next stage of pre proliferative

Answer 14

Proliferative retinopathy

Question 15

Proliferative retinopathy

Answer 15

visible new vessels on optic disc or elsewhere

Question 16

what is maculopathy?

Answer 16

hard exudates/oedema near macula
can threaten vision

Question 17

Clinical relevance of maculopathy

Answer 17

Same disease as background but can threaten vision

Question 18

what is the treatment approach for each stage?

Answer 18

background → annual screening

pre-proliferative → early panretinal photocoagulation

proliferative → panretinal photocoagulation

macular → anti-VEGF injections, grid photocoagulation

Question 19

clinical relevance of diabetic nephropathy?

Answer 19

associated with progression to end stage renal failure, increased cardiovascular event risk

Question 20

• how is surveillance for nephropathy done?

Answer 20

urine sample looking for albumin:creatinine ratio

Question 21

Benchmark for microalbuminurea

Answer 21

3+ mmol/L

Question 22

Benchmark for proteinuria

Answer 22

30+ mmol/L

Question 23

Nephrotic range

Answer 23

3000mg/24hr

Question 24

considerations for UACR test?

Answer 24

false positives common eg fever/infection → positive albumin needs to be repeated to confirm microalbuminuria

Question 25

What is the mechanism behind diabetic nephropathy

Answer 25

hyperglycaemia + hypertension = glomerular hypertension

leads to proteinuria, glomerular fibrosis, filtration rate decline, renal failure

Question 26

treatment options for diabetic nephropathy?

Answer 26

ACE inhibitor ,angiotensin 2 receptor blocker
Give one of the two to all diabetes patients with microalbumin/proteinuria even if normotensive

Question 27

Clinical relevance of microalbuminuria

Answer 27

risk factor for cardiovascular disease

Question 28

how is diabetic nephropathy managed?

Answer 28

aim for good glycaemic control, manage bp, ACEi/ARB if normotensive + microalbuminuria, stop smoking, SGLT-2 possible for type II DM

Question 29

What is diabetic neuropathy

Answer 29

Blockage of small vessels supplying nerves (small vessels are called vasa nervorum)

Question 30

Risk factors for diabetic neuropathy

Answer 30

age, duration of DM, HbA1c, height as longer nerves in taller ppl, smoking, presence of retinopathy

Question 31

Where are complications most common present and what’s the clinical release

Answer 31

Feet (longest nerves supplying)
Painful, patients might not sense injury to affected area

Question 32

Risks associated with disease development

Answer 32

Reduced sensation in feet and poor vascular supply to feet causes higher risk of foot ulceration

Question 33

How do you screen for complications

Answer 33

Annual foot checks
Check for foot deformity,ulceration,sensation,pulses
if all fails then foot amputation

Question 34

Other neuropathies

Answer 34

Mononeuropathy
Autonomic neuropathy

Question 35

What does mononeuropathy involve

Answer 35

Sudden motor loss usually eg foot drop,wrist drop
Cranial nerve palsy also possible eg 3rd causes double vision and improper eye movement

Question 36

What does autonomic neuropathy involve

Answer 36

Damage to parasympathetic and sympathetic nerves innervating GI,cardiovascular,bladder etc

Question 37

GI tract manifestations

Answer 37

Delayed gastric emptying causes nausea,vomiting which makes short acting insulin challenging,constipation,nocturnal diarrhoea

Question 38

Cardiovascular manifestations

Answer 38

postural hypotension (possibly disabling)

cardiac autonomic supply compromised → sudden cardiac death

form of autonomic neuropathy

Question 39

how does treatment of hyperglycaemia alone affect macrovascular disease?

Answer 39

minor effect, multiple risk factors need to be monitored

Question 40

Examples of CVD non modifiable risk factors

Answer 40

Age
Sex
Birth weight
FH
Genes

Question 41

Examples of modifiable risk factors

Answer 41

Dylipidaemia
Hypertensive
Smoking
DM
Central obesity

Question 42

What should be screened for annually

Answer 42

Microalbuminuria

Question 43

What lipid profile is ideal

Answer 43

Total cholesterol less than 4,LDL less than 2

Question 44

Ideal bp if microvascular complication present

Answer 44

130/80