Clinical Gems

David Levy, MD, FRCP      Pre-proliferative retinopathy An important diagnosis, as there is a very high risk of progression to proliferative retinopathy and significant visual loss. Pre-proliferative changes are characterized by the following. Multiple (> 5) cotton-wool spots. Multiple large blot hemorrhages. Venous abnormalities: irregularities, beading, looping or reduplication. Intraretinal microvascular abnormalities: …

David Levy, MD, FRCP      Non-proliferative diabetic retinopathy Background retinopathy Microaneurysms Small, red, intraretinal lesions usually found at the posterior pole of the eye, around the disc and macula. They occur in areas of capillary non-perfusion and show leakage of fluorescein. It is worthwhile estimating the number of microaneurysms as it has …

David Levy, MD, FRCP      Introduction Diabetic retinopathy is the most common clinically significant microvascular complication of diabetes, but cataract is the most common ocular complication, with a prevalence of about 60% in those aged 30–54, five times more frequent than in those without diabetes. Diabetes is also associated with raised intraocular …

David Levy, MD, FRCP Renal replacement therapy The decision to start dialysis is often difficult. The clinical decision is based on many factors, including the presence of uremic symptoms and weight loss, and biochemical measurements including serum creatinine (e.g. serum creatinine 700–800 μmol/L(small mu), eGFR < 12–14 mL/min, falling albumin, hyperkalemia). …

David Levy, MD, FRCP Other management problems in diabetic nephropathy Glycemic control Once nephropathy is established, good control of blood pressure and lipids is probably more important than glycemic control. Observational studies abound and show that, for example, patients with advanced renal failure entering renal replacement programmes survive longer with a …

David Levy, MD, FRCP Management of diabetic nephropathy Investigations Mid-stream urine if leucocytes on routine urinalysis. Renal tract ultrasound scan: a. Normal renal length is about 11 cm, correlating weakly with height and BMI; it is about 10 cm in South Asian and oriental subjects. Kidneys are large in the poorly …

David Levy, MD, FRCP Quantification of Urinary Albumin Excretion The following methods are in current use: Spot early-morning urine specimen expressed as ACR (mg/mmol or mg/g): albumin excretion corrected for urine output; 24-hour urinary albumin excretion (mg per 24 hours); Timed (usually overnight) AER (µg/min); Urinary albumin concentration uncorrected for creatinine …

David Levy, MD, FRCP Overview of Diabetic Kidney Disease End-stage renal disease (ESRD) is a common and terrible outcome of diabetes. However, recent data in both type 1 and type 2 diabetes are encouraging. In type 1 diabetes, where not long ago diabetic nephropathy was almost inevitable after 20–30 years, fewer …

David Levy, MD, FRCP Diabetic foot infections (see also Chapter 10) Multidisciplinary teamwork with specialist podiatrists is crucial. Patients in primary care must be referred for specialist wound débridement and dressing, which are as important as antibiotic treatment. Worsening clinical features of infection are associated with increasing rates of hospitalization and …

David Levy, MD, FRCP Urinary tract infections (British National Formulary, section 5.1.13) Type 1 patients in the long-term EDIC study were no more likely to have cystitis than non-diabetic women. Poor glycemic control and vascular complications were not associated with increased risk of cystitis and pyelonephritis, but cystitis was strongly associated …