Top Banner
Diabetic Diabetic Microvascular Microvascular Complications Complications Mathew John MD, DM, DNB Consultant Endocrinologist
56

Diabetic Microvascular Complications

Nov 12, 2014

Download

Documents

drmathewjohn

A short lecture on microvascular complications for the general physicians. Acknowledging data and pictures from other sites
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: Diabetic  Microvascular  Complications

Diabetic Diabetic Microvascular Microvascular ComplicationsComplications

Mathew John MD, DM, DNB

Consultant Endocrinologist

Page 2: Diabetic  Microvascular  Complications

Microvascular complication

MICROVASCULAR COMPLICATIONS

Retinopathy

Neuropathy

NephropathyCardiomyopathy

Cheiroarhropathy

Dermopathy

Page 3: Diabetic  Microvascular  Complications

Structure of talk

• Screening • Diagnosis • Treatment

Retinopathy Nephropathy

Neuropathy

Page 4: Diabetic  Microvascular  Complications

Therapeutic failures in diabetes

• When a patient reaches end stage renal failure

• When a patient becomes blind or severely visually impaired

• When a patient has a leg or foot amputated

• When a patient suffers from MI or stroke

Page 5: Diabetic  Microvascular  Complications

Magnitude of the problem

• Somewhere in the world a leg is lost to diabetes every thirty seconds

• Leading cause of new onset blindness

• 10% to 20% of people with diabetes die of renal failure

• Diabetes is the leading cause of end stage renal disease requiring dialysis

• Every 10 seconds a person dies from diabetes-related causes

Page 6: Diabetic  Microvascular  Complications

UKPDS results of Intensive therapy

Risk reduction vs. conventional therapy

Page 7: Diabetic  Microvascular  Complications

Risk factors for microvascular complications

• Degree of glycemic control• Duration of disease • Hypertension • Dyslipidemia • Smoking

Page 8: Diabetic  Microvascular  Complications

Pathophysiology of complications

Page 9: Diabetic  Microvascular  Complications

Diabetic Retinopathy

Page 10: Diabetic  Microvascular  Complications

Retinopathy

• Sight threatening microvascular complication

• Changes in retinal microvascular architecture

• Leading cause of new onset blindness in the developed world

• > 90 % of vision loss resulting from proliferative retinopathy can be prevented

Page 11: Diabetic  Microvascular  Complications

How common is retinopathy ?

• Type 1 diabetes : 25 % of type 1 diabetes after 5 years

: 60-80 % after 10-15 years

• Type 2 diabetes : PDR present in 25 % after 15 years

Page 12: Diabetic  Microvascular  Complications

International Clinical Diabetic Retinopathy (DR) Disease Severity Scale

• No apparent DR

• Mild nonproliferative DR

• Moderate nonproliferative DR

• Severe nonproliferative DR

• Proliferative DR

Page 13: Diabetic  Microvascular  Complications

Mild non proliferative retinopathy

Flame shaped hemorrhages

MicroaneursmsDot & Blot hemorrhages

Page 14: Diabetic  Microvascular  Complications

Severe non proliferative retinopathy

Page 15: Diabetic  Microvascular  Complications

Proliferative retinopathy

Page 16: Diabetic  Microvascular  Complications

Clinically Significant Macular edema

www.retinalphysician.com/archive%5C2009%5CJan

Page 17: Diabetic  Microvascular  Complications

Vitreous hemorrhage

Page 18: Diabetic  Microvascular  Complications

Symptoms of diabetic retinopathy

NO SYMPTOMS

Even stages up to proliferative retinopathy can be asymptomatic

Visual loss : Macular edema Vitreous hemorrhage Retinal detachment

Page 19: Diabetic  Microvascular  Complications

Screening & Diagnosis

• Dilated fundus evaluation : annually / 6 monthly • Ophthalmologist

Only 50 % of the eyes are correctly classified as to the presence of retinopathy through undilated eye examinations

Appropriate eye evaluation

Pupillary dilatationSlit lamp biomicroscopyIndirect ophthalmoscopy for retinal periphery Gonioscopy Flourescein Angiogram

Page 20: Diabetic  Microvascular  Complications

Prognosis

• High risk PDR : 28 % risk of severe vision loss within 2 years

• Untreated CSME is associated with a 25 % moderate visual loss after 3 years

PDR : Proliferative diabetic retinopathy CSME : Clinically significant Macular edema ETDRS study, 1991

Page 21: Diabetic  Microvascular  Complications

Effective LASER treatment

HIGH RISK PDR

• This risk is reduced to < 4 % by panretinal photocoagulation

• Reduced need for pars plana vitrectomy(PPV) by 50 %

CLINICALLY SIGNIFICANT MACULAR EDEMA

Loss of vision in CSME reduced by 50 % after focal laser photocoagulation

Page 22: Diabetic  Microvascular  Complications

Metabolic management

• Glycemic control • Intensive BP control : 34 % improvement in

retinopathy outcomes after intensive BP control

• Lipid management • Anemia correction

Page 23: Diabetic  Microvascular  Complications

Diabetic Nephropathy

Page 24: Diabetic  Microvascular  Complications

Nephropathy

• Leading cause of chronic renal failure in the developed world 

• It is also one of the most significant long-term complications in terms of morbidity and mortality for individual patients with diabetes.  

• Diabetes is responsible for 30-40% of all end-stage renal disease (ESRD)

• Microalbuminuria is a cardiovascular risk factor

Page 25: Diabetic  Microvascular  Complications

Signs & Symptoms

• None • None • None • New onset hypertension/ resistant

hypertension • Edema• Reducing insulin requirements

As diabetic nephropathy is asymptomatic, we need to screen for nephropathy in all our patients with diabetes mellitus

Page 26: Diabetic  Microvascular  Complications

Laboratory investigations

• Urine microalbumin • Serum creatinine • Serum potassium • Urine routine

Page 27: Diabetic  Microvascular  Complications

Urine microalbumin Measurement of the albumin-to-creatinine ratio

in a random spot collection

Preferable : early morning urine

Short-term hyperglycemia, exercise, urinary tract infections, marked hypertension, heart failure, and acute febrile illness can cause transient elevations in urinary albumin excretion

Repeat urine sample to confirm microalbuminuria

Page 28: Diabetic  Microvascular  Complications

Progression of nephropathy

Normal Microalbuminuria 2% per annum

Clinical Nephropathy> 300 mg/gm

2% per annum

< 30 mg/gm 30-300 mg/gm

Page 29: Diabetic  Microvascular  Complications

If microalbumin is positive

• Do urine routine

• Urine microalbumin > 300 mg/gm : do 24 hour urine protein• Creatinine, serum potassium

• Consider ultrasound abdomen

Page 30: Diabetic  Microvascular  Complications

Treatment

• Intensive glycemic control 25% risk reduction (P = .0099) in microvascular end points in UKPDS

trial 33 % in RR reduction after microalbuminuria or clinical grade

nephropathy after 12 years

• Hypertension control Risk reduction in diabetic nephropathy progression with the use

of antihypertensive therapy : 29 % in UKPDS study

Page 31: Diabetic  Microvascular  Complications

Treatment

• Blockage of renin-angiotensin-aldosterone( RAAS) ACE inhibitor •Ramipril : 2.5 to 10 mg/day•Perindopril : 4-8 mg/day •Enalapril : 2.5 –20mg/day•Lisinopril : 2.5-20 mg/day

Agents that block the RAAS provide additional benefit on reduction of microalbumin independent of blood pressure reduction

Page 32: Diabetic  Microvascular  Complications

Prevention of nephropathy progression

• Dietary protein restriction • Blood pressure : < 130/80 mm Hg

< 120/75 mm Hg if proteinuria or renal insufficiency is present

• Blood sugars HbA1c < 7 %

• ACE inhibitor/ Angiotensin receptor blocker

• Statins for CV risk

Page 33: Diabetic  Microvascular  Complications

Diabetic Neuropathy

Page 34: Diabetic  Microvascular  Complications

WHO definition

A disease characterized by decline and damage of nerve function leading loss of sensation, ulceration and subsequent amputation.

Page 35: Diabetic  Microvascular  Complications

Why is neuropathy important ?

• Neuropathy increases risk of amputation 1.7 fold

• Neuropathy + deformity: increases risk of amputation 12 fold

• Neuropathy + deformity + previous ulceration: increases risk by 36 fold

• Autonomic neuropathy: 25-50 % , 5 –10 year mortality

Page 36: Diabetic  Microvascular  Complications

Classification

• Symmetric polyneuropathy• Polyradiculopathy• Mononeuropathy• Autonomic neuropathy

Page 37: Diabetic  Microvascular  Complications

Symmetric polyneuropathy

• Most common form of diabetic neuropathy

• Affects distal lower extremities and hands (“stocking-glove” sensory loss)

• Symptoms/Signs– Pain– Paresthesia/dysesthesia– Loss of vibratory sensation

Page 38: Diabetic  Microvascular  Complications

Symmetric neuropathy

Small fiber neuropathy • Involves A delta and C

fibres• Painful paraesthesias

that are burning, stabbing, crushing, aching, or cramp like, with increased severity at night

• Loss or pain & temperature sensation

• Preserved reflexes

Large fiber neuropathy• Large fiber sensory nerves

• Electric tingling or a snug bandlike sensation around ankles and feet

• Prominent ataxia

• Absent ankle jerk reflexes, prominent proprioceptive sensory impairment

• Gait instability with eyes closed

Page 39: Diabetic  Microvascular  Complications

Signs of sensory neuropathy

• Dystrophic nails• Callus • Dry skin/ cracked skin ( autonomic

neuropathy)• Charcot’s feet

Page 40: Diabetic  Microvascular  Complications

Signs of motor neuropathy

• Muscle wasting • Muscle weakness

Claw toe

                                                                                    

              

Page 41: Diabetic  Microvascular  Complications

Diagnosis

• Clinical signs• Sensation: Vibration with tuning fork (128 Hz) Proprioception Touch/ pressure • Deep tendon reflexes : Ankle jerk Knee jerk

Page 42: Diabetic  Microvascular  Complications

Simple tools

Monofilament: 5.07 Semmes-Weinstein (10-g) nylon filament test (10-g monofilament test)

Page 43: Diabetic  Microvascular  Complications

Biothesiometer

• Basically an electronic tuning fork• To detect the vibration perception threshold

Picture courtesy: http://www.diabetes.usyd.edu.au/foot/Fexam1.html

>25 volts: suggestive of neuropathy

Page 44: Diabetic  Microvascular  Complications

Road to ulcer

Bunions Clawed toes Abnormal toe nails

Page 45: Diabetic  Microvascular  Complications

Fissure Story –Origin: Dysautonomia Autonomic neuropathy

Dry Feet

Fissuring

Infection

Abscess

Ulcer

Page 46: Diabetic  Microvascular  Complications

The Callus Story- Origin: Motor Motor Neuropathy

Deformity

Abnormal pressures

Callus

Callus haematoma

Abscess

Ulcer

Page 47: Diabetic  Microvascular  Complications

The Extent of Diabetic Neuropathy

Page 48: Diabetic  Microvascular  Complications

Carpal Tunnel Syndrome

• Most common entrapment neuropathy in type 2 DM

• Tingling, numbness, parasthesias• Women > men • Surgical release by severing the carpal ligament

Page 49: Diabetic  Microvascular  Complications

Diabetic Amyotrophy

• Acute or subacute pain, weakness, and atrophy of the pelvic girdle and thigh musculature.

• Weak hip flexion• Absent knee jerk • Initially unilateral• Weight loss

Page 50: Diabetic  Microvascular  Complications

Cranial Nerve Palsy

• 3 rd nerve palsy is the common

• Diplopia, eye pain, ptosis

• Usually pupillary sparing

• Spontaneous recovery present

Page 51: Diabetic  Microvascular  Complications

Treatment

• Foot care education • Foot care education • Foot care education

Effective patient education can reduce the incidence of foot ulceration and amputation by over 50 %

Boulton AJM. Lowering the risk of neuropathy, foot ulcers and amputationsDiabetic Medicine Volume 15 Issue S4, Pages S57 - S59

Page 52: Diabetic  Microvascular  Complications

Basic foot care education

Washing and inspecting feet on a daily basis Selecting and using appropriate and properly

fitted footwear Using slippers indoors (i.e., no bare feet). Providing proper nail and callus care (e.g., no

bathroom surgery) Avoiding extreme temperatures Avoiding soaking feet for > 10 min Promptly reporting problems, such as infections,

ulcers, and cuts that do not heal.

Page 53: Diabetic  Microvascular  Complications

Drugs for symptomatic relief

• Tricyclic antidepressants: amytryptline, imipramine

• Selective serotonin uptake inhibitors: Paroxetine, Escitalopram, Duloxetine

• Anticonvulsants : Carbamazepine, Gabapentin, Pregabalin

• Analgesics : Tramadol

Page 54: Diabetic  Microvascular  Complications

Autonomic Neuropathy

• Cardiovascular • Gastrointestinal• Genitourinary • Erectile dysfunction

Page 55: Diabetic  Microvascular  Complications

Key messages

• Diabetic microvascular complications are preventable

• SCREEN 1. Microalbumin to detect nephropathy 2. Neurological exam for neuropathy 3. Retina evaluation for retinopathy • TREAT 1. ACEI/ ARB for nephropathy 2. Foot care education for neuropathy 3. Good metabolic control for all

microvascular complications

Page 56: Diabetic  Microvascular  Complications

Thank you

• Nishanth S, Endocrinologist • Aniyan Poulose, Registrar • Pradeep R, Podiatrist • Vani KB, Diabetes Educator

The Endocrinology & Diabetes PracticeTrivandrum www.endocrinologydiabetes.com