1. Microvascular complications Diabetes Outreach (August 2011)

2. 2 Microvascular complications Learning outcomes >understands the 3 main microvascular complications of diabetes >can state the complication screening required for microvascular disease >is aware of broad management principles.

3. 3 Microvascular disease Microvascular disease refers to the disease of the small blood vessels associated with thickening of the basement membranes. Consequences are: eye disease -retinopathy kidney disease-nephropathy nerve damage-neuropathy

4. 4 What are the risk factors? > hypertension > dyslipidemia > poor glycaemic control > age and duration of diabetes > family history > smoking.

5. 5 Prevention, Prevention, Prevention General principles: >initial screening: depends on type of diabetes and/or age of onset of diabetes >ongoing screening (cycle of care) at least annual screening (kidneys and nerves, second yearly for eyes) >early identification leads to early treatment.

6. 6 Diabetes and the eye Short term issues >high glucose causes the lens to swell and distort which can affect vision temporarily >blurry vision is common when newly diagnosed and will settle down once blood glucose levels are reduced.

7. 7 Diabetic retinopathy >occurs as a result of microvascular disease of the retina. It happens when elevated blood glucose levels damage the fine blood vessels of the retina >if retinopathy is diagnosed early (eg before vision loss) vision can be preserved >there are different levels of retinopathy depending on severity.

8. 8 BBBBB Retina Optic Nerve Iris Macula Pupil Lens Cornea The eye Bleeding blood vessels The eye Bleeding blood vessels

9. 9 Other eye problems >Cataracts: an opaque or cloudy lens can be made worse by high blood glucose. >Glaucoma: fluid in the eye builds up causing increased pressure and damage to the retina. >Infections: if glucose levels are high bacteria can grow.

10. 10 Screening and treatment for retinopathy >Review should occur at the time of diagnosis and then at least every two years and more frequently if problems exist. >Inform the person that retinopathy can occur without symptoms and so screening is essential for early identification and treatment. >If retinopathy is found laser is used to delay and prevent further vision loss.

11. 11 Diabetes and the kidney (nephropathy) Nephropathy is a microvascular (small blood vessels) complication related to high blood glucose and high blood pressure. >Glucose attaches to the small blood vessels in the nephron causing damage. >High blood pressure puts extra strain on the blood vessels.

12. 12 Screening for nephropathy >screen microalbuminuria annually by >performing an albumin/creatine ratio (mg/mmol) using early morning spot urine >if first test is positive for microalbuminuria, 2 further samples need to be taken >glomerular filtration rate (GFR) can also be used as a measure of kidney function.

13. 13 Treatment of nephropathy >maintain BP at less than 125/75 >ACE inhibitors even if BP normal >screen urine regularly for infection as this may make diabetic nephropathy worse >adequate BGL control.

14. 14 Diabetes and the nerves (neuropathy) >Peripheral neuropathy – affects the peripheral limbs of the body. >Autonomic neuropathy – affects nerves that supply the body structures that regulate BP, heart rate, bowel and bladder emptying and digestion. Neuropathy is a term used to describe nerve damage. There are two main types of neuropathy:

15. 15 Peripheral neuropathy >refers to nerve damage that affects the peripheries >nerve fibres are damaged and pain sensations can be altered >people with peripheral neuropathy are at high risk of foot problems and require intensive foot care education.

16. 16 Image from Twigg and Sorensen, Med Today, 2010,11:3 Painful neuropathy

17. 17 Peripheral neuropathy The person needs to: >have their feet checked regularly >know if they have at risk feet >have a foot protection plan appropriate to their foot risk >see a podiatrist if they have at risk feet >see their doctor at any sign of infection.

18. 18 Autonomic neuropathy >orthostatic hypotension >impaired gastric emptying (gastroparesis) >diarrhoea >erectile dysfunction >silent MI’s >hypo unawareness.

19. 19 Autonomic neuropathy may result in: >orthostatic hypotension >impaired gastric emptying >diarrhoea >delayed/incomplete bladder emptying >erectile dysfunction and retrograde ejaculation in males >reduced vaginal lubrication with arousal in women >loss of cardiac pain and ‘silent’ ischaemia or infarction >sudden, unexpected cardio-respiratory arrest especially under an anaesthetic or treatment with respiratory depressant medication >difficulty recognising hypoglycaemia.

20. 20 Treatment & management >cardiac – ECG, regular review >postural hypotension – check for this and advise to be careful when getting out of bed >gastrointestinal – dietary advice >bladder – encourage regular emptying and early treatment of infections >erectile dysfunction – counselling, medication, prostheses >hypo unawareness – adjustment of glycaemic targets, and hypo action plan that includes glucagon.

21. 21 Summary >Microvascular complications can progress without symptoms. >All people with diabetes need regular screening for microvascular complications. >Achieving glycaemic, BP and lipid targets are essential for preventing problems. >People should be encouraged and supported to stop smoking.

22. 22 References >Diabetes Outreach (2009) Diabetes Manual, Section 12, Long term complications. >Kidney Health Australia (2007) Chronic Kidney Disease (CKD) Management in General practice. Available from www.kidney.org.auwww.kidney.org.au >RACGP (2010) Diabetes Management in General Practice. Available from www.racgp.org.au/guidelines www.racgp.org.au/guidelines