Microvascular Complications of Diabetes

Question 1

diabetes is the leading cause of what 3 complications?

Answer 1

blindness
dialysis
amputation

Question 2

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

Answer 2

higher HbA1c = higher risk of complications

• esp retinopathy
• parabolic curve

Question 3

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

Answer 3

higher HbA1c = higher risk

linear curve

Question 4

pathophysiology of microvascular disease?

Answer 4

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

Question 5

what are the 4 types of nephropathy?

Answer 5

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)

Question 6

risk factors for neuropathy?

Answer 6

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

Question 7

what are the symptoms of peripheral neuropathy?

Answer 7

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

Question 8

complications of peripheral neuropathy?

Answer 8

charcots foot
painless trauma
foot ulcer

Question 9

advice for foot problems?

Answer 9

advice on footwear

remove calluses etc

Question 10

pharmacological treatment for painful neuropathy?

Answer 10

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

Question 11

features of focal neuropathy?

Answer 11

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

Question 12

what is entrapment neuropathy?

Answer 12

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

Question 13

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

Answer 13

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

Question 14

what does autonomic neuropathy do?

Answer 14

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

Question 15

common GI features of autonomic neuropathy?

Answer 15

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

Question 16

how is gsatroparesis managed?

Answer 16

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

Question 17

name some promotility drugs

Answer 17

metoclopramide

domperidone

Question 18

name 2 anti-nausea medications

Answer 18

prochloperazine

ondansetron

Question 19

how can autonomic neuropathy affect sweating?

Answer 19

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

Question 20

how is anhidrosis or hyperhidrosis in diabetics managed?

Answer 20

topical glycopyrrolate, clonidine

botox

Question 21

how can autonomic neuropathy affect heart and blood vessels?

Answer 21

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

Question 22

how can autonomic neuropathy affect the eyes?

Answer 22

can make pupils less responsive to changes in light

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

Question 23

how can neuropathy be diagnosed?

Answer 23

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

Question 24

what is diabetic nephropathy and what are the characteristics?

Answer 24

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

Question 25

histology features of diabetic nephropathy?

Answer 25

microvascular changes - angiopathy of capillaries

nodular glomerulosclerosis

Question 26

what are the possible complications of diabetic nephropathy?

Answer 26

hypertension
decline in renal function
accelerated vascular disease

Question 27

main tool used for nephropathy screening?

Answer 27

urine ACR (albumin:creatinine ratio)

Question 28

SIGN guidelines for nephropathy screening?

Answer 28

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)

Question 29

features of microalbuminaemia?

Answer 29

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

Question 30

features of macroalbuminaemia?

Answer 30

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

Question 31

management of microalbuminaemia?

Answer 31

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

Question 32

what are the risk factors for progression of nephropathy?

Answer 32

hypertension
cholesterol
smoking
glycaemic control
albuminuria

Question 33

BP target for diabetics?

Answer 33

<130/80

SIGN = <130/70

Question 34

what is given for patients with microalbuminaemia or proteinuria?

Answer 34

ACE inhibitor or ARB

Question 35

what eye diseases can occur in diabetes?

Answer 35

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

Question 36

features of the back of the eye?

Answer 36

optic disc
arteries
veins
macula
fovea

Question 37

what are the stages of retinopathy?

Answer 37

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

Question 38

possible features in diabetic retinopathy?

Answer 38

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

Question 39

what is IRMA?

Answer 39

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

Question 40

how is retinal disease graded?

Answer 40

retinopathy and maculopathy are graded separately

Question 41

what are the symptoms of bleeding in the eye?

Answer 41

sudden change in vision

floaters

Question 42

how is maculopathy assessed?

Answer 42

optical coherence tomography

Question 43

how is retinopathy treated?

Answer 43

laser
vitrectomy
anti-VGEF injections

Question 44

who is screened for retinopathy and how often?

Answer 44

all low risk diabetes patients are screened annually

Question 45

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

Answer 45

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

Question 46

what medications are associated with erectile dysfunction?

Answer 46

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