Longterm complications of Diabetes Year 4 Paediatrics Notes

Longterm complications of Diabetes Year 4 · Paediatrics Collection: 4TH YEAR ALL NOTES / PAEDS / PAEDS 4.3 / Munge / ENDOCRINOLOGY -- Slide 1 Long-Term Complications: Relation to Glycemic Control Complications of DM include microvascular complications, such as retinopathy and nephropathy; macrovascular complications, including coronary artery disease, cerebrovascular disease, and peripheral vascular disease; peripheral and autonomic neuropathies; and diabetic osteopathy manifesting as increased risk for osteoporosis and fracture. Slide 2 Diabetic Retinopathy The risk of diabetic retinopathy after 15 yr duration of diabetes is 98% for individuals with T1DM and 78% for those with T2DM. Rates for diabetic retinopathy range from close to 15% to up to 30%.\nLens opacities (caused by glycation of tissue proteins and activation of the polyol pathway) are present in at least 5% of those younger than age 19 yr.\nMetabolic control has an impact on the development of this complication, as prevalence rates are substantially higher with increased duration of diabetes, and higher HbA1c, blood pressure, and cholesterol.\nIndependent of duration, the prevalence of diabetic retinopathy is higher in T1DM.\nHowever, genetic factors also have a role, because only 50% of patients develop proliferative retinopathy. Slide 3 The earliest clinically apparent manifestations of diabetic retinopathy are classified as nonproliferative or background diabetic retinopathy—microaneurysms, dot and blot hemorrhages, hard and soft exudates, venous dilation and beading, and intraretinal microvascular abnormalities. These changes do not impair vision. The more severe form is proliferative diabetic retinopathy, which manifests by neovascularization, fibrous proliferation, and preretinal and vitreous hemorrhages.\nProliferative retinopathy, if not treated, is relentlessly progressive and impairs vision, leading to blindness. The mainstay of treatment is panretinal laser photocoagulation. In advanced diabetic eye disease—manifested by severe vitreous hemorrhage or fibrosis, often with retinal detachment—vitrectomy is an important therapeutic modality.\nEventually, the eye disease becomes quiescent, a stage termed involutional retinopathy. A separate subtype of retinopathy is diabetic maculopathy, which is manifested by severe macular edema impairing central vision. Focal laser photocoagulation may be effective in treating diabetic maculopathy. Slide 4 Guidelines suggest that diabetic patients have an initial dilated and comprehensive examination by an ophthalmologist shortly after the diagnosis of diabetes is made in patients with T2DM, and within 3-5 yr after the onset of T1DM (but not before age 10 yr).\nAny patients with visual symptoms or abnormalities should be referred for ophthalmologic evaluation.\nSubsequent evaluations for both T1DM and T2DM patients should be repeated every 1-2 yr as recommended by an eye-care professional experienced in the diagnosis and management of diabetic retinopathy Slide 5 Diabetic Nephropathy Most ESRD from diabetic nephropathy is preventable.\nDiabetic nephropathy affects 20–30% of patients with T1DM and 15–20% of T2DM patients 20 yr after onset.\nThe mean 5 yr life expectancy for patients with diabetes-related ESRD is less than 20%.\nThe increased mortality risk in long-term T1DM may be due to nephropathy, which may account for approximately 50% of deaths.\nThe risk of nephropathy increases with duration of diabetes (up until 25-30 yr duration, after which this complication rarely begins), degree of metabolic control, and genetic predisposition to essential hypertension.\nOnly 30–40% of patients affected by T1DM eventually experience ESRD. The glycation of tissue proteins results in glomerular basement membrane thickening. Slide 6 The course of diabetic nephropathy is slow.\nAn increased urinary albumin excretion rate of 30-300 mg/24 hr (20-200 μg/min) —microalbuminuria —can be detected and constitutes an early stage of nephropathy from intermittent to persistent (incipient), which is commonly associated with glomerular hyperfiltration and blood pressure elevation.\nAs nephropathy evolves to early overt stage with proteinuria (albumin excretion rate 300 mg/24 hr, or 200 μg/min), it is accompanied by hypertension. Advanced-stage nephropathy is defined by a progressive decline in renal function (declining glomerular filtration rate and elevation of serum blood urea and creatinine), progressive proteinuria, and hypertension.\nProgression to ESRD is recognized by the appearance of uremia, the nephritic syndrome, and the need for renal replacement (transplantation or dialysis). Slide 7 Screening for diabetic nephropathy is a routine aspect of diabetes care.\nThe American Diabetes Association recommends yearly screening for individuals with T2DM and yearly screening for those with T1DM after 5 yr duration of disease with a random spot urine sample for albumin to creatinine ratio.\nAbnormal results should be confirm