Microvascular Complications of Diabetes Flashcards by Joanne McEwan

diabetes is the leading cause of what 3 complications?

blindness
dialysis
amputation

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how does HbA1c correlate to risk of microvascular complications in type 1?

higher HbA1c = higher risk of complications

esp retinopathy
parabolic curve

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how does HbA1c correlate to risk of microvascular disease in type 2?

higher HbA1c = higher risk

linear curve

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pathophysiology of microvascular disease?

hyperglycaemia and hyperlipidaemia cause
- AGE RAGE
- hypoxia
- oxidative stress
- inflammation
-mitochondrial dysfunction
via reduced blood flow which leads to nerve damage
causes retinopathy, nephropathy and neuropathy

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what are the 4 types of nephropathy?

peripheral - pain/loss of feeling in hands and feet
autonomic = changes in bowel, bladder, sexual response, sweating, HR, BP
proximal = pain in thighs, hips or buttocks leading to leg weakness
focal neuropathy = sudden weakness in one nerve or a group of nerves causing muscle weakness or pain (carpal tunnel, ulnar mono neuropathy, foor drop, bells palsy, cranial nerve palsy)

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risk factors for neuropathy?

length of diabetes
poor glycaemic control
type 1 (more than 2)
high cholesterol/lipids
smoking
lcohol
genetics
mechanical injury

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what are the symptoms of peripheral neuropathy?

numbness/insensitivity
tingling/burning
sharp pain or cramps
sensitivity to touch
loss of balance and coordination

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complications of peripheral neuropathy?

charcots foot
painless trauma
foot ulcer

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advice for foot problems?

advice on footwear

remove calluses etc

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pharmacological treatment for painful neuropathy?

amitriptyline, duloxetine, gabapentin or pregabalin
- combinations not recommended
topical capsaicin cream can be used if localized and patient wants to avoid medication

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features of focal neuropathy?

sudden and affects specific nerves - usually head, torso or leg
- cant focus eye
double vision
aching behind eye
- bells palsy
-pain in thigh/chest/lower back/pelvis
pain on outside of foot

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what is entrapment neuropathy?

weakness in one nerve or a group of nerves causing muscle weakness or pain (e.g carpal tunnel)

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what are the 3 types of proximal neuropathy and how do they present?

lumbosacral plexus neuropathy
femoral neuropathy
diabetic amytrophy
starts with pain in thighs, hips, buttocks or legs often on one side
associated with proximal muscle weakness and weight loss

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what does autonomic neuropathy do?

affects nerves regulating heart rate and BP as well as control of internal organs - gastric motility, resp function, urination, sexual, vision etc

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common GI features of autonomic neuropathy?

gastric slowing/frequency
constipation/diarrhoea (can have both)
gastroparesis - can make blood glucose levels fluctuate widely
oesophagus nerve damage making swallowing difficult

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how is gsatroparesis managed?

improved glycaemic control
small, frequent meals with low fat and low fibre
promotility drugs
anti-nausea drugs
pain control
botulinum toxin
gastric pacemaker

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name some promotility drugs

metoclopramide

domperidone

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name 2 anti-nausea medications

prochloperazine

ondansetron

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how can autonomic neuropathy affect sweating?

can affect nerves which control sweating preventing them from working properly
can cause gustatory sweating as body cant control temp as it should

how is anhidrosis or hyperhidrosis in diabetics managed?

topical glycopyrrolate, clonidine

botox

how can autonomic neuropathy affect heart and blood vessels?

cardio nerve damage interferes with ability to adjust blood pressure and HR
can cause postural hypotension
HR can stay high instead of rising and falling in response to normal body functions and exercise

how can autonomic neuropathy affect the eyes?

can make pupils less responsive to changes in light

may be unable to see well when light turned on or in the dark

how can neuropathy be diagnosed?

nerve conduction studies/electromyography
HR variability
US
gastric emptying studies
foot screening

what is diabetic nephropathy and what are the characteristics?

AKA - nodular glomerulosclerosis, Kimmelsteil-wilson syndrome
progressive kidney disease caused by damage to the capillaries in the kidneys glomeruli
characterised by nephrotic syndrome and diffuse scarring of the glomeruli

histology features of diabetic nephropathy?

microvascular changes - angiopathy of capillaries | nodular glomerulosclerosis

what are the possible complications of diabetic nephropathy?

hypertension decline in renal function accelerated vascular disease

main tool used for nephropathy screening?

urine ACR (albumin:creatinine ratio)

SIGN guidelines for nephropathy screening?

screen all patients over 12 at diagnosis and annually may use RANDOM rather than 1st pass urine as initial check dipstick at point of care confirm abnormal result with EMU also do Us&Es (eGFR)

features of microalbuminaemia?

``` urine ACR male = 2.5-25 female = 3.5-35 24 hr urine albumin = 30-300 urine PCR male = 4-40 female = 6-60 24 hr urine protein = 50-500 ```

features of macroalbuminaemia?

``` urine ACR male = >25 female = >35 24hr urine albumin = >300 urine PCR male = >40 female = >60 24hr urine protein = >500 ```

management of microalbuminaemia?

screen for CVD, retinopathy, PVD, other causes of renal disease monitor lipids, serum creatinine tighten glycaemic control and discourage smoking

what are the risk factors for progression of nephropathy?

``` hypertension cholesterol smoking glycaemic control albuminuria ```

BP target for diabetics?

<130/80 | SIGN = <130/70

what is given for patients with microalbuminaemia or proteinuria?

ACE inhibitor or ARB

what eye diseases can occur in diabetes?

``` diabetic retinopathy cataract glaucoma acute hyperglycaemia - reversible visual blurring retinal detachment ```

features of the back of the eye?

``` optic disc arteries veins macula fovea ```

what are the stages of retinopathy?

mild non-proliferative moderate non-proliferative severe non-proliferative proliferative

possible features in diabetic retinopathy?

haemorrhages - dots/blots/flames cotton wool spots - ischaemic areas hard exudates - lipid breakdown products IRMA - intra retinal microvascular abnormalities

what is IRMA?

abnormalities of blood vessels/precursor to neovascularisation but blood vessels are patent (not leaking)

how is retinal disease graded?

retinopathy and maculopathy are graded separately

what are the symptoms of bleeding in the eye?

sudden change in vision | floaters

how is maculopathy assessed?

optical coherence tomography

how is retinopathy treated?

laser vitrectomy anti-VGEF injections

who is screened for retinopathy and how often?

all low risk diabetes patients are screened annually

what causes erectile dysfunction in diabetes and how common is it?

vascular and neuropathy occurs in 50% of men (55% over 60)

what medications are associated with erectile dysfunction?

``` antihypertensives (mostly thiazides and beta blockers) CNS drugs (antidepressants, tricyclics, SSRIs, tranquilizers, sedatives, analgesics) ```