Microvascular and Macrovascular Complications of Diabetes: Editor's Note: This Article Is The 6th in A
Microvascular and Macrovascular Complications of Diabetes: Editor's Note: This Article Is The 6th in A
Editor’s note: This article is the 6th in a Microvascular Complications of retinopathy. In animal models, sugar
12-part series reviewing the fundamentals Diabetes alcohol accumulation has been linked
Diabetic retinopathy is generally Microalbuminuria is defined as albumin treated to the lowest safe glucose level
classified as either background or prolif- excretion of 30–299 mg/24 hours. With- that can be obtained to prevent or control
erative. It is important to have a general out intervention, diabetic patients with diabetic nephropathy.9,11,12 Treatment
understanding of the features of each to microalbuminuria typically progress to with angiotensin-converting enzyme
interpret eye examination reports and proteinuria and overt diabetic nephropa- (ACE) inhibitors has not been shown to
advise patients of disease progression thy. This progression occurs in both type prevent the development of microalbu-
and prognosis. 1 and type 2 diabetes. minuria in patients with type 1 diabetes
Background retinopathy includes As many as 7% of patients with type but has been shown to decrease the risk
such features as small hemorrhages in 2 diabetes may already have microalbu- of developing nephropathy and cardio-
the middle layers of the retina. They minuria at the time they are diagnosed vascular events in patients with type 2
clinically appear as “dots” and therefore with diabetes.9 In the European Diabetes diabetes.9,13
in creatinine and must be monitored for peripheral sensation are > 87% sensitive with increased risk of silent myocardial
hyperkalemia. Considerable increase in in detecting the presence of neuropathy. ischemia and mortality.18
creatinine after initiation of these agents Patients also typically experience loss There is no specific treatment of
should prompt an evaluation for renal of ankle reflex.16 Patients who have lost diabetic neuropathy, although many
artery stenosis.9,14 10-g monofilament sensation are at drugs are available to treat its symptoms.
considerably elevated risk for developing The primary goal of therapy is to control
Diabetic neuropathy foot ulceration.17 symptoms and prevent worsening of
Diabetic neuropathy is recognized by the Pure sensory neuropathy is relatively neuropathy through improved glycemic
American Diabetes Association (ADA) rare and associated with periods of poor control. Some studies have suggested
as “the presence of symptoms and/or glycemic control or considerable fluctua- that control of hyperglycemia and
signs of peripheral nerve dysfunction in tion in diabetes control. It is character- avoidance of glycemic excursions may
people with diabetes after the exclusion improve symptoms of peripheral neurop-
ized by isolated sensory findings without
of other causes.”15 As with other micro- athy. Amitriptyline, imiprimine, parox-
the formation of a lipid-rich atheroscle- in this setting of multiple risk factors, There has not been a large, long-
rotic lesion with a fibrous cap. Rupture type 2 diabetes acts as an independent term, controlled study showing
of this lesion leads to acute vascular risk factor for the development of isch- decreases in macrovascular disease
infarction.19 emic disease, stroke, and death.27 Among event rates from improved glycemic
In addition to atheroma formation, people with type 2 diabetes, women control in type 2 diabetes. Modifica-
there is strong evidence of increased may be at higher risk for coronary heart tion of other elements of the metabolic
platelet adhesion and hypercoagulability disease than men. The presence of syndrome, however, has been shown to
in type 2 diabetes. Impaired nitric oxide microvascular disease is also a predictor very significantly decrease the risk of
generation and increased free radical of coronary heart events.28 cardiovascular events in numerous stud-
formation in platelets, as well as altered Diabetes is also a strong independent ies. Blood pressure lowering in patients
calcium regulation, may promote platelet predictor of risk of stroke and cerebro- with type 2 diabetes has been associated
aggregation. Elevated levels of plas- vascular disease, as in coronary artery with decreased cardiovascular events and
minogen activator inhibitor type 1 may disease.29 Patients with type 2 diabetes mortality. The UKPDS was among the
High-Density Lipoprotein Cholesterol of painful peripheral neuropathy may monitored closely for possible adverse
Intervention Trial.20,26,35–39 be effective in improving quality of life reactions of therapy.15
in patients but do not appear to alter the Aspirin therapy (75–162 mg/day)
Practice Recommendations natural course of the disease. For this is indicated in secondary prevention
Patients with type 1 diabetes of > 5 reason, patients and physicians should of CVD and should be used in patients
years’ duration should have annual continue to strive for the best possible with diabetes who are > 40 years of
screening for microalbuminuria, and glycemic control. age and in those who are 30–40 years
all patients with type 2 diabetes should In light of the above strong evidence of age if other risk factors are present.
undergo such screening at the time of linking diabetes and CVD and to control Patients < 21 years of age should not
diagnosis and yearly thereafter. All and prevent the microvascular complica- receive aspirin therapy because of the
patients with diabetes should have serum tions of diabetes, the ADA has issued risk of Reye’s syndrome. Patients who
creatinine measurement performed cannot tolerate aspirin therapy because
practice recommendations regarding the
annually. Patients with microalbuminuria of allergy or adverse reaction may be
9
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