Diabetic Microvascular Complications


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A short lecture on microvascular complications for the general physicians. Acknowledging data and pictures from other sites

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  • 50 % of all patients with type 1 DM and PDR and > 10 years duration have concomitant proteinuria
  • Measurement of the albumin-to-creatinine ratio in a random spot collection OR 2) 24-h collection with creatinine, allowing the simultaneous measurement of creatinine clearance; and OR 3) timed (e.g., 4-h or overnight) collection .
  • In the Kumamoto Study, a reduction in the conversion from micro- to macroalbuminuria was observed with intensive treatment
  • It often is considered that the clinical expression of diabetic neuropathy is the tip of the iceberg. Patients presenting with symptoms, particularly numbness and pain, represent only a small percentage of patients with neuropathy. Clinical examination may detect asymptomatic neuropathy in another 30% of patients. Further sophisticated testing, including quantitative sensory testing and electrophysiologic testing, such as nerve conduction velocity, might pick up abnormalities in another 30% to 40% of patients who cannot be detected on clinical examination, but such testing is rarely, if ever, done in clinical practice on asymptomatic patients. The clinician usually can differentiate the symptoms of neuropathy from other symptoms based on the pattern of complaints and physical findings. Occasionally, electrophysiologic testing may be required.
  • Diabetic Microvascular Complications

    1. 1. Diabetic Microvascular Complications Mathew John MD, DM, DNB Consultant Endocrinologist
    2. 2. Microvascular complication MICROVASCULAR COMPLICATIONS Retinopathy Neuropathy Nephropathy Cardiomyopathy Cheiroarhropathy Dermopathy
    3. 3. Structure of talk <ul><li>Screening </li></ul><ul><li>Diagnosis </li></ul><ul><li>Treatment </li></ul>Retinopathy Nephropathy Neuropathy
    4. 4. Therapeutic failures in diabetes <ul><li>When a patient reaches end stage renal failure </li></ul><ul><li>When a patient becomes blind or severely </li></ul><ul><li>visually impaired </li></ul><ul><li>When a patient has a leg or foot amputated </li></ul><ul><li>When a patient suffers from MI or stroke </li></ul>
    5. 5. Magnitude of the problem <ul><li>Somewhere in the world a leg is lost to diabetes every </li></ul><ul><li>thirty seconds </li></ul><ul><li>Leading cause of new onset blindness </li></ul><ul><li>10% to 20% of people with diabetes die of renal failure </li></ul><ul><li>Diabetes is the leading cause of end stage renal disease requiring dialysis </li></ul><ul><li>Every 10 seconds a person dies from diabetes-related causes </li></ul>
    6. 6. UKPDS results of Intensive therapy Risk reduction vs. conventional therapy
    7. 7. Risk factors for microvascular complications <ul><li>Degree of glycemic control </li></ul><ul><li>Duration of disease </li></ul><ul><li>Hypertension </li></ul><ul><li>Dyslipidemia </li></ul><ul><li>Smoking </li></ul>
    8. 8. Pathophysiology of complications
    9. 9. Diabetic Retinopathy
    10. 10. Retinopathy <ul><li>Sight threatening microvascular complication </li></ul><ul><li>Changes in retinal microvascular architecture </li></ul><ul><li>Leading cause of new onset blindness in the </li></ul><ul><li>developed world </li></ul><ul><li>> 90 % of vision loss resulting from proliferative retinopathy can be prevented </li></ul>
    11. 11. How common is retinopathy ? <ul><li>Type 1 diabetes : 25 % of type 1 diabetes after 5 years </li></ul><ul><li> : 60-80 % after 10-15 years </li></ul><ul><li>Type 2 diabetes : PDR present in 25 % after 15 years </li></ul>
    12. 12. International Clinical Diabetic Retinopathy (DR) Disease Severity Scale <ul><li>No apparent DR </li></ul><ul><li>Mild nonproliferative DR </li></ul><ul><li>Moderate nonproliferative DR </li></ul><ul><li>Severe nonproliferative DR </li></ul><ul><li>Proliferative DR </li></ul>
    13. 13. Mild non proliferative retinopathy Flame shaped hemorrhages Microaneursms Dot & Blot hemorrhages
    14. 14. Severe non proliferative retinopathy
    15. 15. Proliferative retinopathy
    16. 16. Clinically Significant Macular edema www.retinalphysician.com/archive%5C2009%5CJan
    17. 17. Vitreous hemorrhage
    18. 18. Symptoms of diabetic retinopathy <ul><li>NO SYMPTOMS </li></ul><ul><li>Even stages up to proliferative retinopathy can be asymptomatic </li></ul><ul><li>Visual loss : Macular edema </li></ul><ul><li>Vitreous hemorrhage </li></ul><ul><li>Retinal detachment </li></ul>
    19. 19. Screening & Diagnosis <ul><li>Dilated fundus evaluation : annually / 6 monthly </li></ul><ul><li>Ophthalmologist </li></ul>Only 50 % of the eyes are correctly classified as to the presence of retinopathy through undilated eye examinations Appropriate eye evaluation Pupillary dilatation Slit lamp biomicroscopy Indirect ophthalmoscopy for retinal periphery Gonioscopy Flourescein Angiogram
    20. 20. Prognosis <ul><li>High risk PDR : 28 % risk of severe vision loss within 2 years </li></ul><ul><li>Untreated CSME is associated with a 25 % moderate visual loss after 3 years </li></ul>PDR : Proliferative diabetic retinopathy CSME : Clinically significant Macular edema ETDRS study, 1991
    21. 21. Effective LASER treatment <ul><li>HIGH RISK PDR </li></ul><ul><li>This risk is reduced to < 4 % by </li></ul><ul><li>panretinal photocoagulation </li></ul><ul><li>Reduced need for pars plana </li></ul><ul><li>vitrectomy(PPV) by 50 % </li></ul><ul><li>CLINICALLY SIGNIFICANT MACULAR EDEMA </li></ul><ul><li>Loss of vision in CSME reduced by 50 % </li></ul><ul><li>after focal laser photocoagulation </li></ul>
    22. 22. Metabolic management <ul><li>Glycemic control </li></ul><ul><li>Intensive BP control : 34 % improvement in retinopathy outcomes after intensive BP control </li></ul><ul><li>Lipid management </li></ul><ul><li>Anemia correction </li></ul>
    23. 23. Diabetic Nephropathy
    24. 24. Nephropathy <ul><li>Leading cause of chronic renal failure in the developed world   </li></ul><ul><li>It is also one of the most significant long-term complications in terms of morbidity and mortality for individual patients with diabetes.   </li></ul><ul><li>Diabetes is responsible for 30-40% of all end-stage renal disease (ESRD) </li></ul><ul><li>Microalbuminuria is a cardiovascular risk factor </li></ul>
    25. 25. Signs & Symptoms <ul><li>None </li></ul><ul><li>None </li></ul><ul><li>None </li></ul><ul><li>New onset hypertension/ resistant hypertension </li></ul><ul><li>Edema </li></ul><ul><li>Reducing insulin requirements </li></ul>As diabetic nephropathy is asymptomatic, we need to screen for nephropathy in all our patients with diabetes mellitus
    26. 26. Laboratory investigations <ul><li>Urine microalbumin </li></ul><ul><li>Serum creatinine </li></ul><ul><li>Serum potassium </li></ul><ul><li>Urine routine </li></ul>
    27. 27. Urine microalbumin <ul><li>Measurement of the albumin-to-creatinine ratio in a </li></ul><ul><li>random spot collection </li></ul><ul><li>Preferable : early morning urine </li></ul><ul><li>Short-term hyperglycemia, exercise, urinary tract infections, marked hypertension, heart failure, and acute febrile illness can cause transient elevations in urinary albumin excretion </li></ul>Repeat urine sample to confirm microalbuminuria
    28. 28. Progression of nephropathy Normal Microalbuminuria 2% per annum Clinical Nephropathy > 300 mg/gm 2% per annum < 30 mg/gm 30-300 mg/gm
    29. 29. If microalbumin is positive <ul><li>Do urine routine </li></ul><ul><li>Urine microalbumin > 300 mg/gm : </li></ul><ul><li>do 24 hour urine protein </li></ul><ul><li>Creatinine, serum potassium </li></ul><ul><li>Consider ultrasound abdomen </li></ul>
    30. 30. Treatment <ul><li>Intensive glycemic control </li></ul><ul><li>25% risk reduction ( P = .0099) in microvascular end points in UKPDS trial </li></ul><ul><li>33 % in RR reduction after microalbuminuria or clinical grade nephropathy after 12 years </li></ul><ul><li>Hypertension control </li></ul><ul><li>Risk reduction in diabetic nephropathy progression with the use of antihypertensive therapy : 29 % in UKPDS study </li></ul>
    31. 31. Treatment <ul><li>Blockage of renin-angiotensin-aldosterone( RAAS) </li></ul><ul><li>ACE inhibitor </li></ul><ul><li>Ramipril : 2.5 to 10 mg/day </li></ul><ul><li>Perindopril : 4-8 mg/day </li></ul><ul><li>Enalapril : 2.5 –20mg/day </li></ul><ul><li>Lisinopril : 2.5-20 mg/day </li></ul>Agents that block the RAAS provide additional benefit on reduction of microalbumin independent of blood pressure reduction
    32. 32. Prevention of nephropathy progression <ul><li>Dietary protein restriction </li></ul><ul><li>Blood pressure : < 130/80 mm Hg </li></ul><ul><li> < 120/75 mm Hg if proteinuria or renal insufficiency is present </li></ul><ul><li>Blood sugars HbA1c < 7 % </li></ul><ul><li>ACE inhibitor/ Angiotensin receptor blocker </li></ul><ul><li>Statins for CV risk </li></ul>
    33. 33. Diabetic Neuropathy
    34. 34. WHO definition <ul><li>A disease characterized by decline and damage of nerve function leading loss of sensation, ulceration and subsequent amputation. </li></ul>
    35. 35. Why is neuropathy important ? <ul><li>Neuropathy increases risk of amputation 1.7 fold </li></ul><ul><li>Neuropathy + deformity: increases risk of amputation 12 fold </li></ul><ul><li>Neuropathy + deformity + previous ulceration: increases risk by 36 fold </li></ul><ul><li>Autonomic neuropathy: 25-50 % , 5 –10 year mortality </li></ul>
    36. 36. Classification <ul><li>Symmetric polyneuropathy </li></ul><ul><li>Polyradiculopathy </li></ul><ul><li>Mononeuropathy </li></ul><ul><li>Autonomic neuropathy </li></ul>
    37. 37. Symmetric polyneuropathy <ul><li>Most common form of diabetic neuropathy </li></ul><ul><li>Affects distal lower extremities and hands (“stocking-glove” sensory loss) </li></ul><ul><li>Symptoms/Signs </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Paresthesia/dysesthesia </li></ul></ul><ul><ul><li>Loss of vibratory sensation </li></ul></ul>
    38. 38. Symmetric neuropathy <ul><li>Small fiber neuropathy </li></ul><ul><li>Involves A delta and C fibres </li></ul><ul><li>Painful paraesthesias that are burning, stabbing, crushing, aching, or cramp like, with increased severity at night </li></ul><ul><li>Loss or pain & temperature sensation </li></ul><ul><li>Preserved reflexes </li></ul><ul><li>Large fiber neuropathy </li></ul><ul><li>Large fiber sensory nerves </li></ul><ul><li>Electric tingling or a snug bandlike sensation around ankles and feet </li></ul><ul><li>Prominent ataxia </li></ul><ul><li>Absent ankle jerk reflexes, prominent proprioceptive sensory impairment </li></ul><ul><li>Gait instability with eyes </li></ul><ul><li>closed </li></ul>
    39. 39. Signs of sensory neuropathy <ul><li>Dystrophic nails </li></ul><ul><li>Callus </li></ul><ul><li>Dry skin/ cracked skin ( autonomic neuropathy) </li></ul><ul><li>Charcot’s feet </li></ul>
    40. 40. Signs of motor neuropathy <ul><li>Muscle wasting </li></ul><ul><li>Muscle weakness </li></ul>Claw toe                                                                                                    
    41. 41. Diagnosis <ul><li>Clinical signs </li></ul><ul><li>Sensation: Vibration with tuning fork (128 Hz) </li></ul><ul><li>Proprioception </li></ul><ul><li>Touch/ pressure </li></ul><ul><li>Deep tendon reflexes : Ankle jerk </li></ul><ul><li>Knee jerk </li></ul>
    42. 42. Simple tools <ul><li>Monofilament: 5.07 Semmes-Weinstein (10-g) nylon filament test (10-g monofilament test) </li></ul>
    43. 43. Biothesiometer <ul><li>Basically an electronic tuning fork </li></ul><ul><li>To detect the vibration perception threshold </li></ul>Picture courtesy: http://www.diabetes.usyd.edu.au/foot/Fexam1.html >25 volts: suggestive of neuropathy
    44. 44. Road to ulcer Bunions Clawed toes Abnormal toe nails
    45. 45. Fissure Story –Origin: Dysautonomia <ul><li>Autonomic neuropathy </li></ul><ul><li>Dry Feet </li></ul><ul><li>Fissuring </li></ul><ul><li>Infection </li></ul><ul><li>Abscess </li></ul><ul><li>Ulcer </li></ul>
    46. 46. The Callus Story- Origin: Motor <ul><li>Motor Neuropathy </li></ul><ul><li>Deformity </li></ul><ul><li>Abnormal pressures </li></ul><ul><li>Callus </li></ul><ul><li>Callus haematoma </li></ul><ul><li>Abscess </li></ul><ul><li>Ulcer </li></ul>
    47. 47. The Extent of Diabetic Neuropathy
    48. 48. Carpal Tunnel Syndrome <ul><li>Most common entrapment neuropathy in type 2 DM </li></ul><ul><li>Tingling, numbness, parasthesias </li></ul><ul><li>Women > men </li></ul><ul><li>Surgical release by severing the </li></ul><ul><li>carpal ligament </li></ul>
    49. 49. Diabetic Amyotrophy <ul><li>Acute or subacute pain, weakness, and atrophy of the pelvic girdle and thigh musculature. </li></ul><ul><li>Weak hip flexion </li></ul><ul><li>Absent knee jerk </li></ul><ul><li>Initially unilateral </li></ul><ul><li>Weight loss </li></ul>
    50. 50. Cranial Nerve Palsy <ul><li>3 rd nerve palsy is the common </li></ul><ul><li>Diplopia, eye pain, ptosis </li></ul><ul><li>Usually pupillary sparing </li></ul><ul><li>Spontaneous recovery present </li></ul>
    51. 51. Treatment <ul><li>Foot care education </li></ul><ul><li>Foot care education </li></ul><ul><li>Foot care education </li></ul>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 amputations Diabetic Medicine Volume 15 Issue S4, Pages S57 - S59
    52. 52. Basic foot care education <ul><li>Washing and inspecting feet on a daily basis </li></ul><ul><li>Selecting and using appropriate and properly fitted footwear </li></ul><ul><li>Using slippers indoors (i.e., no bare feet). </li></ul><ul><li>Providing proper nail and callus care (e.g., no bathroom surgery) </li></ul><ul><li>Avoiding extreme temperatures </li></ul><ul><li>Avoiding soaking feet for > 10 min </li></ul><ul><li>Promptly reporting problems, such as infections, ulcers, and cuts that do not heal. </li></ul>
    53. 53. Drugs for symptomatic relief <ul><li>Tricyclic antidepressants: amytryptline, imipramine </li></ul><ul><li>Selective serotonin uptake inhibitors: Paroxetine, Escitalopram, Duloxetine </li></ul><ul><li>Anticonvulsants : Carbamazepine, Gabapentin, Pregabalin </li></ul><ul><li>Analgesics : Tramadol </li></ul>
    54. 54. Autonomic Neuropathy <ul><li>Cardiovascular </li></ul><ul><li>Gastrointestinal </li></ul><ul><li>Genitourinary </li></ul><ul><li>Erectile dysfunction </li></ul>
    55. 55. Key messages <ul><li>Diabetic microvascular complications are preventable </li></ul><ul><li>SCREEN 1. Microalbumin to detect nephropathy </li></ul><ul><li>2. Neurological exam for neuropathy </li></ul><ul><li>3. Retina evaluation for retinopathy </li></ul><ul><li>TREAT 1. ACEI/ ARB for nephropathy </li></ul><ul><li>2. Foot care education for neuropathy </li></ul><ul><li>3. Good metabolic control for all microvascular complications </li></ul>
    56. 56. Thank you <ul><li>Nishanth S, Endocrinologist </li></ul><ul><li>Aniyan Poulose, Registrar </li></ul><ul><li>Pradeep R, Podiatrist </li></ul><ul><li>Vani KB, Diabetes Educator </li></ul>The Endocrinology & Diabetes Practice Trivandrum www.endocrinologydiabetes.com