Microvascular Complications of Diabetes: What's Relevant for Practice?

Kim Anne Pickett, MS, FNP-BC

Disclosures

Journal for Nurse Practitioners. 2016;12(10):683-689. 

In This Article

Abstract and Introduction

Abstract

Microvascular complications of diabetes include eye disease, kidney disease, and peripheral and/or autonomic neuropathy. This study illustrates the importance of early screening and detection of microvascular complications, while also focusing on treatment guidelines and indications for specialist referral.

Introduction

Diabetes mellitus (DM) is a chronic disease that is classified, based on etiology, into 4 main groups: type 1 (T1DM); type 2 (T2DM); gestational; and "other."[1] As a brief review, T1DM, most commonly an autoimmune process, is due to pancreatic islet β-cell destruction, resulting in absolute or near-total insulin deficiency.[1,2] The worldwide incidence of T1DM varies; the highest incidence is in Scandinavia and northern Europe (approximately 20–40 cases per 100,000 per year among youths ≤ 14 years old), and the lowest incidence in China and parts of South America (< 1 case per 100,000 people a year).[1] In the United States, approximately 1.25 million adults and children, or approximately 5% of all patients with diabetes, are estimated to have T1DM.[3,4] T2DM, representing approximately 80%-90% of patients with diabetes, involves mechanisms of insulin resistance, impaired insulin secretion, and increased production of glucose, resulting in a relative insulin deficiency.[1] Gestational diabetes results from glucose intolerance which develops during pregnancy; it occurs in approximately 7% of all pregnancies in the US.[2] Other types of diabetes result from monogenic disorders, genetic syndromes, certain medications or infections, or are due to pancreatic disease.[1]

Diabetes continues to be a costly disease that greatly impacts overall morbidity and mortality. The Centers for Disease Control and Prevention (CDC) estimates that there are currently > 29 million Americans living with DM,[3] with 1.4 million new cases diagnosed in the US annually.[4] The economic consequence of diabetes in the US is alarming, with an estimated total cost reaching $245 billion in 2012.[4]

For years, nurse practitioners (NPs) have been well versed in the prevention, recognition, and treatment of vascular and nonvascular complications of DM. Complications may not be apparent until several years of prolonged hyperglycemia;[2] therefore, NPs remain in an excellent position to not only continue to educate patients about the importance of early detection and prevention of complications, but to actively participate in facilitating optimal disease management while reducing the medical and financial system burden.

As a review, microvascular complications of diabetes, which affect small blood vessels, are known to lead to diabetic eye disease, kidney disease, and neuropathy; optimal management is proven to reduce complications in hallmark studies. The Diabetes Control and Complications Trial, a longitudinal study of 1,441 patients with T1DM over 10 years (1983–1993), demonstrated a significant risk reduction of microvascular complications for patients treated intensively for diabetes versus a control group, which received non-intense glycemic control. Retinopathy was reduced by 76%, diabetic kidney disease was reduced by 50%, and neuropathy was reduced by 60% among patients in the intervention group.[5] In the United Kingdom Prospective Diabetes Study, which studied benefits of glycemic control in patients with T2DM, a 1% reduction in hemoglobin A1c was associated with a 37% reduction in microvascular complications.[6] Although an increased incidence of hypoglycemia with adverse effects was noted in both trials, this should not deter health care providers from aiming to achieve target hemoglobin A1c levels. Attaining optimal glycemic control (while avoiding episodes of severe or prolonged hypoglycemia), along with recognizing and screening patients for complications related to diabetes, remains essential. This article highlights common microvascular complications of diabetes, with a primary focus on implications for T1DM and T2DM. Current standards for early detection, screening, and treatment are discussed with the aim to continue having NPs offer high-quality, evidence-based, cost-effective care to their patients. For a summary of recommendations, please refer to Table 1.

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