Endo - Chonic Complications Of Diabetes

Front 1

What are the main acute complications of diabetes?
- which has the highest risk of mortality?

Back 1

1. hyperglycemia
2. DKA - diabetic ketoacidosis
3. Hyperosmolarity (HIGH MORTALITY)

Front 2

What are the 2 categories of chronic complications of diabetes?
- % diabetics affected?

Back 2

Microvascular - 80% diabetics; 50% type II diabetics at time of dx!!!!
- retinopathy
- nephropathy
- neuropathy (foot problems)
- erectile dysfunction

Macrovascular- CAD and stroke
- 2-6-fold increased risk in diabetics (compared to non-diabetics)

Front 3

Diabetes is the #1 cause of...???
(3 things)

Back 3

- end-stage renal failure
- blindness in working-aged adults
- non-traumatic leg amputations

Front 4

What are the biochemical consequences of hyperglycemia?

Back 4

- tissue damage - via AGEs
- glucose activates cellular kinases (protein kinase C)
- increased sorbitol in nervous tissue --> swelling --> dysfunction
- increased basement membrane thickness in kidney
- increased oxidative stress

Front 5

AGEs
- what are?
- how formed?
- what do they do?

Back 5

= Advanced Glycosylation End-Products (AGEs)

- Formed from the addition of Glu to the NH2 groups on proteins (reversible) --> modified via highly reactive carbonyl derivatives (irreversible)

**cause tissue damage - responsible for many of the cellular complications of diabetes due to hyperglycemia

Front 6

HbA1c
- what is?
- how formed?

Back 6

= good marker for blood Glucose
- Formed from addition of Glu to NH2 terminus of Beta-chain of HbA (in RBCs)

Front 7

What is role of GROWTH FACTORS in chronic diabetes?

Back 7

TGF-beta
- induced by hyperglycemia
- associated with renal hypertrophy and nephropathy

VEGF (vascular endothelial growth factor)
- induced by hypoxia in retina due to microvascular damage from hyperglycemia
- causes neovascularization - proliferation of abnormally frail blood vessels; causes hemorrhage and scarring

Front 8

What was the DCCT?
What was the UKPDS?
... results?

Back 8

DCCT - clinical trial on Type I DM
UKPDS - clinical trial on Type II DM

... showed that TIGHT CONTROL over glucose levels led to LESS COMPLICATIONS

Front 9

What is the main limitation to achieving tight patient control over diabetes?

Back 9

HYPOGLYCEMIA --> unpleasant sx!!!
- and can be life-threatening
... patients want to avoid this, so don't take their meds

Front 10

What are the stages of Diabetic Retinopathy?

Back 10

1. Non-proliferative/Background Retinopathy
- dots (microaneurysms)
- blots (small intraretinal hemorrhages)
- cotton wool spots (retinal ischemia)
- hard exudates (lipids form circles around leaking blood vessels)
- Intraretinal Microvascular Abnormalities (IRMA)
- maculopathy - exudates around macula (more common in type II DM)


2. Proliferative Retinopathy
- new vessel formation due to VEGF secreted in response to retinal ischemia --> fragile - tendency to hemorrhage --> can lead to retinal detachment, permanent blindness

Front 11

Other than retinopathy, what eye problems are associated with chronic diabetes?

Back 11

- increased rate of age-related cataracts and type I specific cataracts
- refractory defects due to altered osmotic pressure within lens
- glaucoma rates increased!
- infections

Front 12

What are important management recommendations for diabetics at risk of eye problems?

Back 12

- tight control!!
- laser surgery to decrease O2 and thus decrease VEGF
- periodic ophthalmologist exams

Front 13

Diabetic Neurophathy
- percent diabetic patients affected?
- types?

Back 13

- affects 20-50% patients with TYPE II DM

Acute Reversible
- Hyperglycemic Neuropathy

Persistent, Peripheral Polyneuropathy
- dysesthesia (numbness)
- paresthesia (pins and needles - painful)

Pressure Palsies
- carpel tunnel - median nerve
- ulnar nerve compression at elbow

Mononeuropathy
- diabetic amyotrophy (femoral n - wasting of muscle tissue)
- III, VI nerves
- truncal nerves

Autonomic Neuropathy
- GI tract - diarrhea, gastric dilatation
- CV - postural hypotension, abdnormal cardiac refexes, edema
- Bladder Neck Dysfunction
- Erectile Dysfunction
- Eyes - abnormal pupillary reflex

Front 14

Diabetic Nephropathy
- type I v type II?
- stages?
- assessment?
- meds?

Back 14

- Risk in Type I > Type II bc II has later onset
... BUT more Type II on dialysis bc such a high prevalence

Stages:
- hyperfiltration and renal hypertrophy - expansion of tubular tissue
- microalbuminuria
- glomerulosclerosis (accelerated by HTN)
- late stage: kidneys fibrotic and atrophied

Assessment:
- monitor microalbumin in urine (creatinine ratio is sensitive marker!!!) - normal is < 30
- later signs: creatinine, BUN, clearance

GIVE ACE INHIBITORS!!

Front 15

What is microalbuminuria a marker of?

Back 15

= independent risk factor for CV disease!!!

Front 16

What are the main causes of Diabetic Foot Ulcers?

Back 16

- Neuropathy
--- peripheral
--- motor - characteristic posture of raised arch and clawed toes- puts pressure (calluses) on metatarsal hads and heels - hemorrhage and necrosis within callus --> ulcer
--- autonomic (reduced sweating --> dry, cracked skin --> infection entry); charcot arthropathy

- Peripheral vascular disease
--- reduced blood supply to feet - low O2 and nutrition

- Infections

Front 17

What is recommended foot care for diabetics?

Back 17

- daily self-exam
- exam by physicians - MONOFILAMENT ESTHESIOMETER
- properly fitted shoes

Front 18

Macrovascular Complications
- men v. women?
- mortality rate?
- risk factors?

Back 18

Men: 2-4-fold increased risk of MI and stroke
Women: (postmenopausal): 10-fold increased risk

***>80% diabetics die from CV disease

Risk factors leading to accelerated atherosclerosis:
- hyperglycemia
- traditional risks - HTN, dyslipidemia, obesity, renal dysfunction