Vascular complications of DM

Question 1

what are the microvascular complications of diabetes mellitus?

Answer 1

retinopathy
nephropathy
neuropathy

Question 2

what are the macrovascular complications of diabetes mellitus?

Answer 2

cerebrovascular disease
ischaemic heart disease
peripheral vascular disease

Question 3

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

Answer 3

53mmol/mol (<7%)

Question 4

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

Answer 4

duration of diabetes
smoking
genetic factors
hyperlipidaemia
hyperglycaemic memory
hypertension

Question 5

how do we aim to detect retinopathy?

Answer 5

theough screening as early stages are asymptomatic

Question 6

describe the appearance of a normal retina

Answer 6

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

Question 7

describe background retinopathy?

Answer 7

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

Question 8

describe pre proliferative retinopathy

Answer 8

more extensive haemorrhage
soft exudates (cotton wool spots)

Question 9

describe proliferative retinopathy

Answer 9

new vessels visible

Question 10

describe maculopathy retinopathy

Answer 10

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

Question 11

how do you treat background retinopathy?

Answer 11

you can’t.
annual surveillance
lifestyle changes

Question 12

how do you treat pre proliferative retinopathy

Answer 12

early panretinal photocoagulation

Question 13

how do you treat proliferative retinopathy?

Answer 13

panretinal photocoagulation

Question 14

how do you treat diabetic maculopathy?

Answer 14

grid photocoagulation

anti-VEGF injections directly into eye

Question 15

what are the risks of panretinal photocoagulation?

Answer 15

loss of some peripheral vision

Question 16

how do you diagnose diabetic nephropathy?

Answer 16

urinalysis (microalbuminuria >25.mg/mmol proteinuria (ACR>30mg/mmol), nephrotic range (>3000mg/24hr))
increased blood pressure
eGFR (deranged)

Question 17

what is the mechanism of diabetic nephropathy?

Answer 17

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

Question 18

what is the renin-angiotensin system?

Answer 18

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

Question 19

what is given to prevent further decline of nephropathy?

Answer 19

ACE inhibitors (ACEi) or angiotensin-2 receptor blockers (ARB)

Question 20

when are nephropathy treatments prescribed?

Answer 20

even when normotensive with microalbuminuria or proteinuria

Question 21

how is nephropathy managed?

Answer 21

smoking cessation
tighter glycaemic control
reduce blood pressure via ACEi or A2RB
start SGLT-2 inhibitor if T2DM

Question 22

when does diabetic neuropathy occur?

Answer 22

when vasa nervorum get blocked (blood vessels supplying nerves)

Question 23

what are the risk factors of diabetic neuropathy?

Answer 23

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

Question 24

where is most common for diabetic neuropathy to show?

Answer 24

glove&stocking distribution

longest nerves supply feet

Question 25

what is included in annual foot checks?

Answer 25

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

Question 26

when is the risk of ulceration highest?

Answer 26

patients with reduced foot sensation | poor vascular supply to feet

Question 27

what is the management of peripheral neuropathy with ulceration?

Answer 27

``` multidisciplinary diabetes foot clinic offloading revascularisation if concomitant PVD antibiotics if infected orthotic footwear amputation ```

Question 28

presentation of mononeuropathy

Answer 28

usually sudden motor loss (foot drop, wrist drop) | cranial nerve palsy - double vision due to 3rd nerve palsy

Question 29

what is autonomic neuropathy?

Answer 29

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

Question 30

what are the GI effects of autonomic neuropathy?

Answer 30

delayed gastric emptying (makes post prandial insulin hard) | constipation/nocturnal diarrhoea

Question 31

how is the CV system affected by autonomic neuropathy?

Answer 31

``` postural hypertension (collapsing on standing) cardiac autonomic supply causing sudden cardiac death ```

Question 32

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

Answer 32

age sex birth weight FH/genetics

Question 33

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

Answer 33

dyslipidaemia hypertension smoking central obesity

Question 34

how is CV risk in DM managed?

Answer 34

``` support smoking cessation blood pressure control lipid profiles weight interventions annual microalbuminuria screens ```