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BRS Year 2 > Vascular complications of DM > Flashcards

Vascular complications of DM Flashcards

1
Q

what are the microvascular complications of diabetes mellitus?

A

retinopathy
nephropathy
neuropathy

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2
Q

what are the macrovascular complications of diabetes mellitus?

A

cerebrovascular disease
ischaemic heart disease
peripheral vascular disease

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3
Q

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

A

53mmol/mol (<7%)

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4
Q

what are the other risk factors (besides HbA1c) for complications of diabetes?

A 
duration of diabetes
smoking- endothelial dysfunction
genetic factors
hyperlipidaemia
hyperglycaemic memory- inadequate glucose control early on can lead to higher risk of complications later even with improved HbA1c
hypertension
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5
Q

how do we aim to detect retinopathy?

A

through screening as early stages are asymptomatic

we want it to be early when it can be treated before visual disturbances/loss

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6
Q

describe the appearance of a normal retina

A

optic disk: bright spot visible
thin veins semi visible
macula: dense/pink spot visible

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7
Q

describe background retinopathy?

A

hard exudates (white cheesy spots)
microaneuyrsms (dots)
blot haemorrhages
enhanced blood vessels

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8
Q

describe pre proliferative retinopathy

A

more extensive haemorrhage
soft exudates (cotton wool spots)
represents retinal ischaemia

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9
Q

describe proliferative retinopathy

A

new vessels visible

on disk or elsewhere in retina

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10
Q

describe maculopathy retinopathy

A

hard exudates/oedema near macula
(same as background just near macula)
can threaten vision

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11
Q

how do you treat background retinopathy?

A

you can’t.
annual surveillance
lifestyle changes

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12
Q

how do you treat pre proliferative retinopathy

A

early panretinal photocoagulation

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13
Q

how do you treat proliferative retinopathy?

A

panretinal photocoagulation

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14
Q

how do you treat diabetic maculopathy?

A

grid photocoagulation

anti-VEGF injections directly into eye

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15
Q

what are the risks of panretinal photocoagulation?

A

loss of some peripheral vision

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16
Q

how do you diagnose diabetic nephropathy?

A 
Progressive proteinuria (urine albumin:creatinine ratio):
- Microalbuminuria: >2.5mg/mmol
- Proteinuria = ACR >30mg/mmol
- Nephrotic range >3000mg/24hr
Increased BP
Deranged
 eGFR
Advanced: peripheral oedema
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17
Q

what is the mechanism of diabetic nephropathy?

A

hypertension & hyperglycaemia lead to glomerular hypertension
this leads to proteinuria, glomerular &interstitial fibrosis
glomerular filtration rate decline
renal failure

18
Q

what is the renin-angiotensin system?

A

angiotensinogen in liver, kidney produces renin which converts this to angiotensin I
angiotensin converting enzyme converts this to angiotensin II which causes vasoconstriction and release of aldosterone from the zona glomerulosa of the adrenal cortex

19
Q

what is given to prevent further decline of nephropathy?

A

Block RAS with ACE inhibitors (ACEi) or angiotensin-2 receptor blockers (ARB)- no evidence that both at the same time is beneficial (Can lead to hyperkalemia)

20
Q

when are nephropathy treatments prescribed?

A

even when normotensive with microalbuminuria or proteinuria

21
Q

how is nephropathy managed?

A 
smoking cessation
tighter glycaemic control 
reduce blood pressure via ACEi or A2RB
aim for BP <130/80mmhg
start SGLT-2 inhibitor if T2DM
22
Q

when does diabetic neuropathy occur?

A

Small blood vessels supplying nerves are called vasa nervorum
Diabetic neuropathy occurs when vasa nervorum get blocked (blood vessels supplying nerves)

23
Q

what are the risk factors of diabetic neuropathy?

A 
age
duration of diabetes
poor glycaemic control
height
smoking
prescence of diabetic retinopathy
24
Q

where is most common for diabetic neuropathy to show?

What is an associated danger?

A

glove & stocking distribution
longest nerves supply feet- so most common in feet
danger is that patients will not sense injury foot

25
Q

what is included in annual foot checks?

A 
inspection for foot deformity, ulceration
assess sensation (monofilament, ankle jerks)
assess foot pulses (dorsalis pedis, posterior tibial)
26
Q

when is the risk of ulceration highest?

A

patients with reduced foot sensation (peripheral neuropathy)

poor vascular supply to feet (peripheral vascular disease)

27
Q

what is the management of peripheral neuropathy with ulceration?

A 
multidisciplinary diabetes foot clinic
offloading
revascularisation if concomitant PVD
antibiotics if infected
orthotic footwear
amputation
28
Q

presentation of mononeuropathy

A

usually sudden motor loss (foot drop, wrist drop)

cranial nerve palsy - double vision due to 3rd nerve palsy

29
Q

what is autonomic neuropathy?

A

damage to sympathetic & parasympathetic nerves innervating GI tract, bladder, CV system

30
Q

what are the GI effects of autonomic neuropathy?

A

delayed gastric emptying (makes post prandial insulin hard)

constipation/nocturnal diarrhoea

31
Q

how is the CV system affected by autonomic neuropathy?

A 
postural hypertension (collapsing on standing)
cardiac autonomic supply causing sudden cardiac death
32
Q

what are the non-modifiable risk factors for macrovascular complications of DM?

A

age
sex
birth weight
FH/genetics

33
Q

what are the modifiable risk factors for macrovascular complications of DM?

A

dyslipidaemia
hypertension
smoking
central obesity

34
Q

how is CV risk in DM managed?

A 
support smoking cessation
blood pressure control
lipid profiles
weight interventions 
annual microalbuminuria screens
35
Q

What is the mechanism of damage leading to microvascular complications?

A

Increased formation of mitochondrial superoxide free radicals in endothelium
Generation of glycated plasma proteins to form advanced glycation end products (AGEs)
Activation of inflammatory pathways (pro-inflammatory cytokines)
Damaged endothelium results in:
- leaky capillaries
- ischaemia

36
Q

What are 3 things hyperglycemia and hyperlipidemia can lead to in the mechanism of damage?

A

Oxidative stress
AGE-RAGE
Hypoxia

37
Q

How is diabetic retinopathy screened for in the uk?

A

Annual screening for all patients with diabetes

38
Q

Why is diabetic nephropathy important?

A

Associated with progression to end-stage renal failure requiring haemodialysis
Healthcare burden
Associated with increased risk of CV events

39
Q

what is the management of peripheral neuropathy no ulceration?

A

Regular inspection of feet by affected individual
Good footwear
Avoid barefoot walking
Podiatry and chiropody if needed

40
Q

Whos most at risk of cardiovascular mortality?

A

Males with T1DM

Females with T1DM

BRS Year 2 (110 decks)

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