MICROVASCULAR AND MACROVASCULAR COMPLICATIONS OF DIABETES MELLITUS Flashcards by Eric Lee

List the microvascular complications of DM

Retinopathy
Nephropathy
Neuropathy

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List the macrovascular complications of DM

Cerebrovascular disease
Ischaemic heart disease
Peripheral vascular disease

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

< 53 mmol/mol (<7%)

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What are the factors which can increase the risk of microvascular complications in DM?

Hyperglycaemia
Hypertension (rising systolic BP)
Duration of DM
Smoking (endothelial dysfunction)
Genetic factors
Hyperlipidaemia (+ high cholesterol)
Hyperglycaemic memory (poor glucose control early on even if improved)

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How do we try and prevent diabetic retinopathy in the UK?

Annual retinal screening in the UK for all diabetes patients since early stages of retinopathy are asymptomatic

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What is the macula?

Center of the retina which is responsible for the central vision, most of colour vision and high resolution.

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Name the stages of retinopathy

Background retinopathy
Pre-proliferative retinopathy
Proliferative retinopathy

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What can be seen in background retinopathy?

Hard exudates (lipids leaked out) giving cheese colour
Microaneurysms (dots)
Blot haemorrhages

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What can be seen in pre-proliferative retinopathy?

Cotton wool spots (soft exudates)
Haemorrhage
Retinal ischaemia

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What can be seen in proliferative retinopathy and why?

Visible new blood vessels grown due to hypoxia in order to try and prevent ischaemia.
But they are very weak and liable to haemorrage

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What can be seen in maculopathy?

Hard exudates/oedema near macula
(same as background retinopathy but near macula)
Can threaten vision

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How can you treat retinopathy and maculopathy?

Improve HbA1c
Stop smoking
Lower lipids
Control BP (<130/80 mmHg)

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What should the specific treatment for a patient with background retinopathy be?

Continued annual surveillance

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What should the specific treatment for a patient with pre-proliferative retinopathy be?

Early panretinal photocoagulation as if left alone will progress to proliferative retinopathy

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What should the specific treatment for a patient with proliferative retinopathy be?

Panretinal photocoagulation

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What should the specific treatment for a patient with diabetic maculopathy be?

If oedema:
- Anti-VEGF injections into eye which inhibits
inflammation cascade

Grid photocoagulation

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What is photocoagulation and when is it done?

Burn through retina preventing new blood vessels from forming and causing existing one to shrink and scar up decreasing the risk of haemorrhage

The patient will lose some peripheral vision

Pre-proliferative and proliferative retinopathy - panretinal photocoagulation

Maculopathy - grid photocoagulation

Why does diabetic nephropathy need to be taken seriously?

Associated with progression to end-stage renal failure requiring haemodialysis

Associated with increased risk of cardiovascular events

Healthcare burden

What is the diagnosis of diabetic nephropathy?

Increased BP
Progressive proteinuria (urine albumin:creatinine > 30mg/mmol)
Microalbuminuria > 2.5 mg/mmol

End stage diabetic kidney disease:

Deranged renal function (eGFR)
Peripheral oedema

Describe the mechanism of diabetic nephropathy

Hyperglycaemia and hypertension leading to glomerular hypertension causing proteinuria, glomerular and interstitial fibrosis and thus glomerular filtration rate decline.

Resulting in renal failure

What are some antihypertensives to help prevent diabetic nephropathy?

ACE inhibitors

Angiotensin receptor blockers (ARBs)

What is the suffix for ACE inhibitors and ARBs?

ACEi = "-pril"
ARB = "-sartan"

Who should be prescribed ACEi/ARBs?

All diabetic patients who have microalbuminuria/proteinuria even if normotensive

What is microalbuminuria a risk factor for?

Cardiovascular disease

What is the management for diabetic nephropathy?

``` Tighter glycaemic control ACEi/ARB if patient has microalbuminuria Reduce BP < 130/80 mmHg Stop smoking If T2DM start SGLT-2 inhibitor ```

What is the name of the small vessels which supply nerves?

Vasa nervorum

What is neuropathy in DM a result of?

Vasa nervorum getting blocked

What are the risk factors for neuropathy in DM?

``` Age Duration of diabetes Poor glycaemic control Height (longer nerves in lower limbs of tall people) Smoking Diabetic retinopathy ```

Where is diabetic neuropathy most commonly found?

Feet since it is supplied by the longest nerves

What is the common distribution of neuropathy in the body?

Glove and stocking

What is examined in an annual foot check for a diabetic patient?

``` Look for foot deformity, ulceration Assess sensation (using monofilament, ankle jerks) Assess foot pulses ```

What are the risk factors for foot ulceration in patients?

``` Peripheral neuropathy (reduced sensation) Peripheral vascular disease preventing blood supply to heal ulcer ```

What is the management of diabetic patients with only peripheral neuropathy?

Regular inspection of feet Good footwear Avoid barefoot walking

What is the management of diabetic patients with peripheral neuropathy with ulceration?

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

What are some neuropathies which don't affect the feet?

Mononeuropathy | Autonomic neuropathy

What does mononeuropathy present as?

Sudden motor loss e.g. wrist/foot drop | Cranial nerve palsy e.g 3rd nerve palsy (double vision)

What does autonomic neuropathy present as?

Damage to SNS and PNS innervating Gi tract, bladder, cardiovascular system GI: - Delayed gastric emptying (nausea and vomiting) - Constipation/ nocturnal diarrhoea Cardiovascular: - Postural hypotension - Sudden cardiac death

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

Age Sex Birth weight Genes

What are the modifiable risk factors for macrovascular disease of DM?

``` Dyslipidaemia Hypertension Smoking Diabetes mellitus Central obesity ```

How should prevention of macrovascular disease in DM be carried out?

Aggressive management of multiple risk factors

List the factors which should be changed to manage cardiovascular risk in diabetes mellitus

- Smoking cessation - Blood pressure < 140/80 mmHg, <130/80 mmHg is microvascular complication - Lipid profile (total chol < 4, LDL < 2) - Weight - Annual urine microalbuminuria screen as it is risk factor for cardiovascular disease