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Year 2 Endo > Microvascular complications of Diabetes > Flashcards

Microvascular complications of Diabetes Flashcards

1
Q

What are the sites of microvascular complications?

A

Retinal arteries
Renal glomerular arterioles
Vasa nervosum

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2
Q

What are Vasa Nervosum

A

tiny blood vessels that supply nerve

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3
Q

What is the relationship of risk with rising HbA1c?

A

Extent of hyperglycaemia (as judged by HbA1c) is strongly associated with the risk of developing microvascular complications

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4
Q

What is the relationship at high HbA1c’s?

A

At higher HbA1c levels the line gets steeper

For a small increase in HbA1c you get a large increase in risk

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5
Q

What does the large risk increase mean for management?

A

Huge margins to gains from a small reduction in HbA1c

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6
Q

What is the relationship between hypertension and risk?

A

Clear relationship between rising systolic BP and risk of MI and microvascular complications in people with T2DM and T1DM

Therefore prevention of complications requires reduction in HbA1c and BP control

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7
Q

What other factors relate to the development of microvascular complications?

A

Severity of hyperglycaemia

Hypertension

Genetic factors – some people develop complications despite reasonable control

Hyperglycaemic memory – inadequate glucose control early on can result in higher risk of complications LATER, even if HbA1c improved

Duration? Glucose variability?

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8
Q

What is the mechanism of damage?

A

Oxidative stress
Production of advanced glycated end product which disrupts production of proteins
Local activation of pro-inflammatory cytokines

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9
Q

What are the main features of diabetic retinopathy?

A

main cause of visual loss in people with diabetes and the main cause of blindness in people of working age

early stages of retinopathy are all asymptomatic

therefore screening is needed to detect retinopathy at a stage at which it can be treated before it causes visual disturbance / loss

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10
Q

How is early detection of retinopathy achieved?

A

annual retinal screening, which involves retinal imaging: national screening programme.

People with advanced retinopathy are referred to a specialist for treatment and may be seen more frequently

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11
Q

What is the mechanism of diabetic neuropathy?

A

Hyperglycaemia leads to protein kinase C activation

Disruption of the endothelium

Retinal ischaemia (leaky vessels)

Vascular oedema

Releases factors that lead to retinal neovascularisation

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12
Q

What are the 3 stages of retinopathy?

A

Background
Pre-proliferative
Proliferative

Maculopathy, which can occur at any stage of retinopathy

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13
Q

What are the features of background retinopathy?

A 
Hard exudates (cheese colour, lipid)
Microaneurysms (“dots”)
Blot haemorrhages
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14
Q

What are the features of pre-proliferative retinopathy?

A

Cotton wool spots also called soft exudates

Represent retinal ischaemia

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15
Q

What are the features of proliferative retinopathy?

A

Visible new vessels

On disk or elsewhere in retina

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16
Q

What are the features of maculopathy?

A

Hard exudates / oedema near the macula
Same disease as background, but happens to be near macula
This can threaten direct vision

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17
Q

How do you treat background retinopathy?

A

Continued annual surveillance

Feedback to person living with diabetes

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18
Q

How do you treat pre-proliferative retinopathy?

A

If left alone will progress to new vessel growth

So, early panretinal photocoagulation

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19
Q

How do you treat proliferative retinopathy?

A

Panretinal photocoagulation

20
Q

How do you treat maculopathy?

A

Oedema: Anti-VEGF injections

Grid photocoagulation

21
Q

What causes diabetic nephropathy?

A

Hypertension
Progressively increasing proteinuria
Progressively deteriorating kidney function
Classic histological features

22
Q

How are people screened for diabetic nephropathy?

A

Actively screened for and monitored with by measurement of albumin in urine

This can be done in a spot urine sample (rather than a 24-hr collection) and expressed as a ratio to creatinine: Urine albumin creatinine ratio.

23
Q

Why is nephropathy important?

A

Associated with progression to end-stage renal failure requiring haemodialysis

Healthcare burden

Associated with increased risk of cardiovascular events

24
Q

What is the relationship between macro and micro vascular complications?

A

Microvascular complications increase risk for Macrovascular complications

25
Q

What are the histological features of diabetic nephropathy?

A

GLOMERULAR CHANGES
Mesangial expansion
Basement membrane thickening
Glomerulosclerosis

26
Q

What is the epidemiology of nephropathy?

A

Type 1 DM : 20-40% after 30-40 years

Type 2 DM : Probably equivalent – BUT
Age at development of disease
Ethnic differences
Age at presentation

27
Q

How do you diagnose nephropathy?

A

Progressive proteinuria (urine ACR - Albumin:Creatinine ratio)

Increased blood pressure

Deranged renal function (eGFR)

Advanced: peripheral oedema

28
Q

What are the ranges for microalbuminuria?

A

> 2.5 mg/mmol (men)

>3.5 mg/mmol (women)

29
Q

What is the mechanism of nephropathy?

A

Diabetes associated with hypertension

High BP at glomerular level

Destruction of glomeruli

Interstitial fibrosis

Decreased GFR

30
Q

What are the strategies for intervention for nephropathy?

A

Decreasing HbA1c reduces risk of microvascular complications

Manage blood pressure

Inhibit the renal-angiotensin-aldosterone system

SGLT-2 inhibition

31
Q

Why does a blockade of RAS work?

A

Mediation of glomerular hyperfiltration

Increased tubular uptake of proteins

Induction of pro fibrotic cytokines

Stimulation of glomerular and tubular growth

Generation of ROS & NF-kB

Stimulates fibroblast proliferation

Up regulation of adhesion molecules on endothelial cells

Up regulation of lipoprotein receptors

32
Q

Summarise nephropathy treatment?

A
  1. Aim for tighter glycaemic control
  2. Reduce BP as much as tolertated
  3. Usually through ACEi or A2RB
  4. Stop smoking
  5. Start an SGLT-2 inhibitor if T2DM?
33
Q

What are the main features of diabetic neuropathy?

A

Diabetes is the most common cause of neuropathy and therefore lower limb amputation

Small vessels supplying nerves are called vasa nervorum

Neuropathy results when these get blocked

34
Q

What are the different types of diabetic neuropathy?

A 
Peripheral polyneuropathy
Mononeuropathy
Mononeuritis multiplex
Radiculopathy
Autonomic neuropathy
Diabetic amyotrophy
35
Q

Why are people with diabetes at risk of foot issues?

A

Longest nerves supply feet
Loss of sensation
More common in tall people
Danger is that patients will not sense an injury to the foot (eg. Stepping on a nail)

All people with diabetes: annual foot check with GP

36
Q

What are the clinical features of peripheral neuropathy?

A

Loss of sensation (10g monofilament)

Loss of vibration sense

Loss of temperature sensation

Loss of proporioception

Loss of ankle jerks

Classic ‘glove and stocking’ distribution

Danger is no sense an injury to the foot (eg. Stepping on a nail)

37
Q

How do you manage peripheral neuropathy?

A
  1. Regular inspection of feet by affected individual
  2. Good footwear
  3. Avoid barefoot walking
    Podiatry and chiropody if needed
38
Q

How do you manage peripheral neuropathy with ulceration?

A 
Multidisciplinary diabetes foot clinic
Offload pressure 
Revascularisation if concomitant Peripheral Vascular Disease
Antibiotics if infected
Orthotic footwear
Amputation if all else fails
39
Q

What is mononeuropathy?

A

Usually sudden motor loss
wrist drop, foot drop
Cranial nerve palsy:
double vision due to 3rd nerve palsy

40
Q

What is mononeuritis multiplex?

A

A random combination of peripheral nerve lesions

41
Q

What is radiculopathy?

A

Pain over spinal nerves, usually affecting a dermatome on the abdomen or chest wall

42
Q

What is autonomic neuropathy?

A

Loss of sympathetic and parasympathetic nerves to GI tract, bladder, cardiovascular system

43
Q

What is autonomic neuropathy?

A

Loss of sympathetic and parasympathetic nerves to GI tract, bladder, cardiovascular system

44
Q

What are the GI symptoms of autonomic neuropathy?

A

Difficulty swallowing
Delayed gastric emptying: nausea and vomiting
Constipation / nocturnal diarrhoea
Bladder dysfunction

45
Q

What are the Cardiovascular symptoms of autonomic neuropathy?

A

Postural hypotension: can be disabling: collapsing on standing.
Cardiac autonomic supply: case reports of sudden cardiac death

Year 2 Endo (15 decks)

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