When does atherosclerosis begin in DM and those without DM?
-for both groups aatherosclerosis begins in childhood.
What groups of individuals always end up getting bypassed?
- Diabetics d/t multi-vessel disease
- Left main disease b/c it supplies blood to LAD and circ.
Pathophysiology of Nephropathy
- lesions occurring in a diabetic kidney
- Hammers the kidney
- Basement membrane thickens
- glomerular sclerosis (hardening allows protein/glucose to slip through more easily
- -all cause impaired blood flow, nodular lesions, and kidneys slowly die
Earliest stages of Nephropathy what do we see?
-microalbuminuria–dip stick is most sensitive, by the time you pick proteins up on this test its irreversible.
What are two specific lesions encountered in nephropathy ?
- Glomerularsclerosis (Kimmelsteil-Willson): nodular lesions in glomerular capillaries causing decreased flow and function.
- Renal Artery Stenosis: narrowing of flow to the kidneys, kidney thinks it needs to send out renin activating the Renin-angiotensin-aldosterone system leading to peripheral vasoconstriction and increased blood volume leading to 2ry HTN.
What is the key indicator of diabetic nephropathy?
-microalbuminuria
The progression of nephropathy can be slowed by?
- tight glucose control
- blood pressure control
- Protein restriction in diet
- smoking cessation
Medications for Nephropathy?
- ACEI- keep blood pressure down, protecting the kidney
- CI in those with renal artery stenosis
- every DM needs to be on an ACEI
- ARBS (Angiotensin II receptor blockers) - have antiproteinuric effect
- may consider calcium channel blocker or beta blocker but we dont use these, may mask signs of hypoglycemia, may cause sugars to increase.
When to screen for nephropathy in T1D and T2D?
- T1D we screen starting 5 years after dx
- T2D start screening at time of dx
Retinopathy
- leading cause of what?
- what is the incidence of this in T1D and T2D?
- what is one of the very first signs?
- what are the two types and what do you see on fundoscopic exam?
- leading cause of blindness
- T1D 100% incidence after 20years, T2D is 60%
- Very first signs is blurriness of vision
- Types:
- Non-proliferative: microaneurysms, hard exudates (lipids & proteins), cotton wool spots (ischemic areas)
- proliferative” neovascularization, neovascular glaucoma, retinal detachment (floaters), senile cataracts
Retinopathy:
- how often do diabetics get screened?
- Tx
- annually
- Tight glucose control, aggressive tx of HTN, statin decrease lipid deposition, laser photocoagulation, vitrectomy
Peripheral Neuropathy
- pathophysiology
- what is one of the first signs of this?
- distributional appearance of neuropathy
- signs
- what order do we lose sensation?
Patho: thickening of the walls of vessels that supply the nerve leading to ischemia, segmental demyelination leading to slower nerve conduction.
- first sign is usually loss of vibratory sensation on their toes
- glove and stocking distribution
- Signs:
- pain, numbness, hyperesthesias, paresthesias(burning, itching, tingling), sensory loss of proprioception and vibratory sense.
- Abnormal gait
- hammer toes
Order: Vibration, pain, temperature
Neuropathy:
- neuro foot exam includes?
- Tx
- which type of neuropathy is most common?
- neuro foot exam includes:
- monofilimant test
- reflexes
- vibratory sensation
- proprioception
- Tx: TCA for pain and sensory issues
- Neurontin(best and safest) & Cymbalta (SSNRI)`
-most common is somatic neuropathy
Autonomic Neuropathy:
-what are some examples?
- Tx
- CNs and limbs?
- Gastric dysmotility or Gastroparesis
- -delayed emptying
- -constipation
- -N/v
- -diarrhea
- ED
- Orthostatic Hypotension
- Cardiac rhythm disturbances
- Bladder= retention/incontinence
Tx:
- Ortho Hypotension: Fludrocortisone
- Gastraparesis: Erythromycin(causes diarrhea, given to end constipation), Imodium(to stop the diarrhea)
- ED: Viagra or Cialis
- CN: III, IV, VI, VII
- Femoral, sciatic, or peroneal neuropathy
Macrovascular
-major 3 complications
-CVD, Cerebrovascular disease, peripheral arterial disease
Atherosclerosis
- pathophysiology
- this is an _____ disease?
- what is an atheroma?
- LDL engulfed by Mfs, accumulation of foam cells, fibrofatty lesion formed in intimal lining of the large and medium sized arteries. Thickening of the lining of the vessel also occurs.
- this is an INFLAMM disease
- atheroma: fibrofatty plaque (Mf, LDL, CT)
Manifestations of Diabetes and Atherosclerosis
- narrowing of the vessel and producing ischemia, sudden vessel obstruction d/t plaque rupture leading to thrombosis and formation of emboli.
- aneurysm formation d/t weakening of the vessel wall.
- ischemia and infarction
- “Silent ischemia” diabetics have poor innervation of the hear so they dont present with classic MI sx. Angina doesnt usually occur until 70-80% blockage
Coronary Artery Disease
-preventative tx
-tx: Aspirin, statin (reduce inflamm), BS control, HTN (ACEI & ARBS), tobacco cessation, exercise, avoid carbs
BP: 120/80 optimal, 130/80 minimal goal
Preventative Tx of CVD, Peripheral, and Cerebral Disease
- Smoking cessation
- Management of Obesity
- Hyperlipidemia (LDL less than 100, HDL less than 40, Triglycerides less than 150)
- Lifestyle modifications (DIET)
- exercise
- glycemic control
What is a common sign of peripheral vascular disease?
What are the most common sites off PVD?
- intermittent claudication/ angina of the legs (intense localized pain)
- most common is femoral and popliteal
What are some common signs of PVD?
- shiney, no hair, pallor, pulseless, cold, painful/achy, cant move leg well, no O2 or blood going to the extremity
- This leg will die, requires immediate care.
Signs of Venous Occlusion signs
-hot, swollen, red, huge, tender to touch, can feel pulses, most likely die of PE.
What is ABI?
- how to calculate
- why do we do this?
- why might DM have falsely normal ABI?
- Whats a normal reading?
- Ankle Brachial Index
- Calculate: SBP Ankle/SBP ARM
- establish quality of arterial blood flow
- falsely normal b/c they are calcified, dont have any bounce.
- normal reading is anything greater than .90
can be falsely high in DM