Diabetic Microvascular Complications: Can Patients At Risk Be Identified? A Review

A. Girach; D. Manner; M. Porta

Disclosures

Int J Clin Pract. 2006;60(11):1471-1483. 

In This Article

Summary and Introduction

Summary

People with diabetes have an increased risk of developing microvascular complications, diabetic retinopathy, diabetic nephropathy and diabetic neuropathy, which, if undetected or left untreated, can have a devastating impact on quality of life and place a significant burden on health care costs. In addition, diabetic microvascular complications can reduce life expectancy. The strongest risk factors are glycaemic control and diabetes duration; however, other modifiable risk factors such as hypertension, hyperlipidaemia and smoking, and unmodifiable risk factors including age at onset of diabetes and genetic factors may all play a part. Along with the presence of external risk factors, some associations have also been noted between diabetic microvascular complications themselves. There is evidence that diabetic retinopathy in association with increased blood pressure is an important risk factor for diabetic nephropathy progression. Significant correlations have also been shown between the presence of diabetic peripheral neuropathy and the presence of background or proliferative diabetic retinopathy. Clinical trials are currently in progress looking at a number of approaches to designing treatments to prevent the adverse effects of hyperglycaemia. It is essential however, that risk factors associated with the progression and development of diabetic microvascular complications are detected and treated at an early stage in order to further reduce morbidity and mortality. Considering all three complications as interrelated may well facilitate early detection of microvascular disease. Despite good long-term glycaemic and blood pressure control, diabetes remains a major cause of blindness, renal failure and amputations. As the incidence of diabetes continues to rise, the burden of diabetic microvascular complications will increase in future, hence the need for early detection. Considering the microvascular complications of diabetes as related, and enquiring proactively about complications, may well facilitate early detection of microvascular disease.

Introduction

Diabetes mellitus is a global health problem, affecting all age groups.[1] Currently, around 177 million people have diabetes worldwide; however, it has been projected that this number will increase to at least 300 million by 2025.[2] This epidemic relates in particular to type 2 diabetes, which accounts for around 90% of all diabetes cases. The increased prevalence of type 2 diabetes can be attributed to the ageing population and rising incidence of obesity in developed countries, among other factors.[3]

Prevention of complications specific to diabetes is a key issue because of the morbidity and mortality associated with the disease.[4] Clinically significant morbidity may often develop before diagnosis.[5] Between one-third and one-half of all people with diabetes have evidence of organ or tissue damage.[6,7] Although not everyone with diabetes will develop a complication, a recent epidemiological study[8] reported that two or more complications are apparent in almost one-fifth of people with diabetes.

If diabetes is undetected or not treated, or if its complications are poorly managed, it can have a devastating impact on quality of life.[1] Diabetes also places a significant burden on health care costs, with the major single item of expenditure being hospital admissions for the treatment of complications.[2]

Landmark studies, including the Diabetes Control and Complications Trial (DCCT)[9] and the United Kingdom Prospective Diabetes Study (UKPDS),[10] have shown that intensive control of blood glucose levels and tight blood pressure control reduce the risk of complications related to diabetes. In addition, early identification of risk factors can help reduce the development and progression of diabetic microvascular complications, and improve patients' quality of life.

Although it is clear that diabetes complications result from the abnormal metabolic environment engendered by chronic hyperglycaemia (specifically affected by factors such as age, age of onset and disease duration),[11] the actual development of these complications in any individual is a function of the genetic susceptibility to damage in that particular individual. One study demonstrated the familial factors influencing development of microvascular complications, suggesting a trend towards gender susceptibility.[12] Furthermore, the presence or absence of environmental factors or other conditions also affects the risk of developing complications; for example, hypertension, hyperlipidaemia, alcohol consumption, glaucoma and smoking can all influence the susceptibility of an individual to diabetes. This implies that specific gene definition may help to determine which patients require a more (or less) aggressive approach to glycaemic control and that risk of complications can be substantially reduced by attention to co-existing conditions and environmental factors.

The key to preventing complications from diabetes is to prevent the development of diabetes itself. The Diabetes Prevention Program has shown that type 2 diabetes can be prevented or delayed in a significant number of people at high risk for the disease, by means of appropriate treatment or lifestyle modification.[13] Current research is also looking at possible interventions for the prevention of type 1 diabetes.

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