Microvascular Complications

Question 1

What are the major macrovascular complications of diabetes?

Answer 1

Coronary heart disease and stroke

Question 2

What are the major microvascular complications of diabetes?

Answer 2

Neuropathy, nephropathy, retinopathy

Question 3

The main mortality in diabetes is due to what?

Answer 3

Increased CV risk

Question 4

What are the end stages of each of the main microvascular complications of diabetes?

Answer 4

Blindness, dialysis, amputation

Question 5

The pathophysiology of microvascular complications begins as a result of what?

Answer 5

Hyperglycaemia and hyperlipidaemia

Question 6

As a result of hyperglycaemia and hypertriglyceridaemia, there is hypoxia, oxidative stress, inflammation and mitochondrial dysfunction of where in the body?

Answer 6

The vessels

Question 7

What causes damage to the nerves?

Answer 7

Reduced blood flow

Question 8

How does microvascular disease tend to present?

Answer 8

Often asymptomatic and so can be quite severe on presentation

Question 9

What are some risk factors for neuropathy?

Answer 9

Increased length of diabetes, poor control, high cholesterol/lipids, smoking and alcohol, inherited traits, mechanical injury

Question 10

Patients with which type of diabetes are at increased risk of neuropathy?

Answer 10

Type 1

Question 11

What is meant by inherited traits being a risk factor for neuropathy?

Answer 11

Certain families with diabetes may be susceptible to a particular microvascular complication

Question 12

Peripheral neuropathy usually affects which nervous system? What can happen if it gets very severe?

Answer 12

Predominantly sensory, though in very severe cases the motor aspect can also be involved

Question 13

What are some symptoms of peripheral neuropathy?

Answer 13

Numbness, tingling/burning, sharp pains/cramps, loss of balance and coordination

Question 14

What complications can peripheral neuropathy lead to?

Answer 14

Painless trauma, foot ulcers and Charcot foot

Question 15

What is usually the cause of foot ulcers in peripheral neuropathy?

Answer 15

Ill-fitting shoes or something in the shoe which cannot be felt

Question 16

Do diabetic foot ulcers heal well? Why/why not?

Answer 16

They do not heal well because of the vascular compromise. There will be delayed healing which can result in chronic ulcers.

Question 17

Why does Charcot foot occur?

Answer 17

As a result of loss of proprioception

Question 18

What happens in Charcot foot?

Answer 18

There are multiple traumas which the patient is unaware of which damages the deep structures of the foot and leads to increased bone resorption (osteoclastic activity)

Question 19

If peripheral neuropathy is painful, what analgesics can be used?

Answer 19

Atypicals such as amitriptyline or gabapentin

Question 20

If atypical analgesics are not recommended for a patient with localised pain from diabetic neuropathy, what can be used?

Answer 20

Capsaicin cream

Question 21

What is the onset of focal neuropathy?

Answer 21

Sudden onset

Question 22

What nerves does focal neuropathy affect?

Answer 22

Specific nerves, most often in the head, torso or leg

Question 23

If nerves of the eye are involved in focal neuropathy, what can this lead to?

Answer 23

Inability to focus eyes, diplopia, aching behind eyes

Question 24

Within which group of neuropathies is entrapment neuropathy included?

Answer 24

Focal neuropathy

Question 25

What is entrapment neuropathy?

Answer 25

Weakness in one nerve or a group of nerves which cause muscle weakness or pain e.g. Carpal tunnel

Question 26

What does proximal neuropathy include?

Answer 26

Lumbosacral plexus neuropathy, femoral neuropathy, diabetic amyotrophy (wasting)

Question 27

How does proximal neuropathy often present?

Answer 27

Pain in the thighs, hips, buttocks or legs, usually on one side of the body

Question 28

Who is proximal neuropathy most common in?

Answer 28

Elderly patients with T2DM and marked weight loss

Question 29

The nerves involved in autonomic neuropathy control what?

Answer 29

Regulation of the heartbeat and BP, as well as control of lots of internal organs

Question 30

How can autonomic neuropathy often be picked up?

Answer 30

Tachycardia

Question 31

How can autonomic neuropathy present in terms of the GI system?

Answer 31

Gastric slowing/frequency, constipation/diarrhoea

Question 32

How can gastroparesis as a result of autonomic neuropathy present?

Answer 32

Persistent nausea and vomiting, bloating and loss of appetitie

Question 33

If a patient has hypoglycaemia around 30 mins after eating, what can this suggest?

Answer 33

Gastroparesis (slow stomach emptying)

Question 34

What are some treatment options for gastroparesis?

Answer 34

Improved glycemic control, small and frequent meals, promotability drugs, pain relief

Question 35

Autonomic neuropathy can involve the nerves which control sweating. What can this lead to?

Answer 35

Profuse sweating at night or while eating

Question 36

How can excessive sweating as a result of diabetic neuropathy be treated?

Answer 36

Glycopyrolate

Question 37

What effect can autonomic neuropathy have on the eyes? When can this cause problems?

Answer 37

Less responsive to changes in light. Can cause problems when a light is turned on in a dark room or when driving at night

Question 38

What investigation can determine the type and extent of nerve damage and how well muscles respond to nerve stimuli?

Answer 38

Nerve conduction studies or electromyography

Question 39

What investigation can be used to asses whether the bladder and urinary tract are working properly in terms of neuropathy?

Answer 39

Ultrasound

Question 40

What tests can be done for gastroparesis?

Answer 40

Gastric emptying studies

Question 41

How often should diabetic patients be screened for neuropathy?

Answer 41

Yearly

Question 42

What should be done when assessing a diabetic patient for neuropathy?

Answer 42

Assess feet and circulation to assess the risk of ulceration

Question 43

Describe diabetic nephropathy?

Answer 43

Progressive kidney disease caused by damage to the capillaries in the glomeruli

Question 44

What characterises diabetic nephropathy?

Answer 44

Nephrotic syndrome and scarring of the glomeruli

Question 45

In diabetic nephropathy there can be classic nodules which are seen in no other condition. What are these known as?

Answer 45

Kimmelstein-Wilson nodules

Question 46

Why is screening necessary for nephropathy?

Answer 46

It does not present with symptoms until it is well established

Question 47

What are some consequences of diabetic nephropathy?

Answer 47

Hypertension, decline in renal función, accelerated vascular disease

Question 48

What is used to screen for nephropathy?

Answer 48

Urinary albumin to creatinine ratio

Question 49

When should screening for diabetic nephropathy occur?

Answer 49

At the time of diagnosis and annually from age 12 onwards

Question 50

If microalbuminuria occurs in diabetes, what should you do?

Answer 50

Check if there is any other cause for renal disease and also check for retinopathy and hypertension

Question 51

What can slow the progression of nephropathy?

Answer 51

Improved glycemic control

Question 52

What are some risk factors for the progression of nephropathy?

Answer 52

Hypertension, high cholesterol, smoking, poor glycemic control, microalbuminuria

Question 53

What is the drug of choice to control hypertension in diabetes?

Answer 53

ACE inhibitor (ARB if intolerant)

Question 54

Where should blood pressure be maintained in all patients with diabetes?

Answer 54

< 130/80

Question 55

Any patient with microalbuminuria or proteinuria should be started on what therapy?

Answer 55

ACE inhibitor/ARB

Question 56

What is the target HbA1c for good control?

Answer 56

53mmol/mol

Question 57

What may need to happen to the dose of insulin if a patient has renal impairment?

Answer 57

Decreased (since it will be excreted slower by the kidneys)

Question 58

What are some eye pathologies which can occur in diabetes?

Answer 58

Diabetic retinopathy, cataracts, glaucoma

Question 59

Acute hyperglycaemia can have what effect on the eyes?

Answer 59

Reversible blurring of vision

Question 60

Dot/blot/flame on fundoscopy refers to what?

Answer 60

Haemorrhage

Question 61

Cotton wool spots on fundoscopy refer to what?

Answer 61

Ischaemic areas

Question 62

Hard exudates on funduscopy refer to what?

Answer 62

Lipid breakdown products

Question 63

What may be seen in mild, non proliferative retinopathy?

Answer 63

Haemorrhages and microaneurysms

Question 64

What may be seen in moderate, non proliferative retinopathy?

Answer 64

Microaneurysms, hard exudates, haemorrhages

Question 65

What may be seen in severe, non proliferative retinopathy?

Answer 65

Microvascular abnormalities, venous bleeding, haemorrhages

Question 66

What will be seen in proliferative retinopathy?

Answer 66

New vessel formation

Question 67

In terms of the eyes, what conditions are screened for annually?

Answer 67

Retinopathy and maculopathy

Question 68

What are some complications of bleeding in the eye?

Answer 68

Sudden changes in vision, floaters, secondary glaucoma, retinal detachment

Question 69

How can retinopathy be treated?

Answer 69

Lasers or surgery (vitrectomy)

Question 70

How common in erectile dysfunction in diabetics?

Answer 70

50% of men

Question 71

What are some medications which can cause erectile dysfunction?

Answer 71

Anti-hypertensives, beta blockers, CNS drugs