madman
Super Moderator
Diabetes-Related Microvascular Complications – A Practical Approach (2022)
Basem M. Mishriky, MD, Doyle M. Cummings, Pharm, FCP, FCCP, James R. Powell, MD
DIABETIC SYMMETRIC POLYNEUROPATHY
What is Diabetic Symmetric Polyneuropathy?
Diabetic neuropathy is classified into diffuse neuropathy, mononeuropathy, and radiculopathy/polyradiculopathy.1 Diabetic symmetric polyneuropathy (DSPN) is the most common form of diffuse neuropathy, which is the most common form of diabetic neuropathy.1 DSPN affects 50% of individuals with type 2 diabetes (T2DM) after 10 years of disease duration and at least 20% of individuals with type 1 diabetes (T1DM) after 20 years of diagnosis.1 DSPN can be referred to as distal symmetric polyneuropathy or even, although less accurate, as diabetic neuropathy.2
The American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation define distal symmetric polyneuropathy (including DSPN) as polyneuropathy that must begin in the feet and include symptoms and signs that are the same on both sides of the body.3,4 The symptoms may be primarily sensory, primarily motor, or combined. The signs may include pain, impairment to touch, impairment to proprioception, weakness, and atrophy of muscles, depressed/absent ankle reflexes, or autonomic system.3,4 Signs are better predictors of polyneuropathy compared with symptoms and multiple concurrent abnormalities provide greater sensitivity in predicting polyneuropathy.
In the position statement by the American Diabetes Association (ADA), DSPN is defined as the presence of symptoms or signs of peripheral nerve dysfunctions after excluding other causes.1
*Can Patients without Numbness, Tingling, or Pain in the Feet have Diabetic Symmetric Polyneuropathy, and Why is this Important?
*How do Individuals with Diabetic Symmetric Polyneuropathy Present?
-Small-fiber involvement
-Large-fiber involvement
*Is Ongoing Foot Pain and Numbness in Individuals with Diabetes Always Diabetic Symmetric Polyneuropathy?
*What are the Criteria for Requesting a Nerve Conduction Study (Possible Reasons for Specialist Referral)?
*What are the Minimum Criteria Required to Diagnose Diabetic Symmetric Polyneuropathy?
*When Should the Health Care Providers Screen for Diabetic Symmetric Polyneuropathy?
*How Should the Health Care Providers Screen for Diabetic Symmetric Polyneuropathy?
-History
-Examination
*A Monofilament Test is Insensate to 5.07 but Intact to 6.65. Tuning Fork Vibrations Sense was Lost after Five Seconds. The Ankle Reflex and Pinprick Sensation were Intact Bilaterally. What is the Significance of that Foot Examination?
*What Measures can Health Care Providers do to Prevent Diabetic Symmetric Polyneuropathy and Ulcerations?
-Foot care education
-Proper footwear
-Glycemic control
*Management of Symptomatic Diabetic Symmetric Polyneuropathy
DIABETIC KIDNEY DISEASE
What is Diabetic Kidney Disease?
The ADA defined diabetic kidney disease (DKD) as chronic kidney disease (CKD) attributed to diabetes, and CKD as the persistent presence of elevated urinary albumin excretion low estimated glomerular filtration rate (GFR), or other manifestations of kidney damage.17
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines defined CKD as abnormalities of the kidney structure or function present for ≥ 3 months.18 In 2007, the KDIGO guidelines recommended using the term “DKD” instead of “diabetic nephropathy” as there is no consensus definition of diabetic nephropathy.19 In 2020, the KDIGO guidelines used the term “Diabetes and CKD” over “DKD” although DKD was still considered appropriate, to ensure that other causes of CKD are considered and to avoid the assumption that all cases of CKD are caused by traditional diabetes pathophysiology.18
*How Common is Diabetic Kidney Disease?
*When should Health Care Providers Initiate Screening for Diabetic Kidney Disease? How Often Should the Screening be Done?
*How Should the Health Care Providers Interpret the Urine Albumin-to-creatinine Ratio?
*What is the Likelihood of Diabetic Kidney Disease in Individuals with Moderate/Severe Albuminuria?
*When to Refer to Nephrology?
*How Should the Health Care Providers Monitor Glycemic Control in Individuals with Diabetic Kidney Disease?
-What Measures can Reduce the Risk of Developing Diabetic Kidney Disease?
-Nutrition
-Lipid management
-Blood pressure
-Glycemic control
-Smoking
*A 55-year-old Individual with T2DM Treated with Metformin. His Last Creatinine was 1.7 mg/dL, GFR 51 mL/min/1.73 m2 , and UACR 389 mg/g. Should Metformin be Discontinued?
*How can Health Care Providers Delay Progression of Diabetic Kidney Disease? Renin–angiotensin system blockade
-Renin–angiotensin system blockade
-Sodium-glucose co-transporter-2 inhibitors
*What Anti-diabetic Medications Should be Added if Glycemic Control is not Achieved by Metformin and Sodium-glucose Co-transporter-2 Inhibitors?
*Novel Therapy in Diabetic Kidney Disease
DIABETIC RETINOPATHY
What is Diabetic Retinopathy?
The most common diabetes-related eye disease is diabetic retinopathy (DR). DR is characterized by a gradually progressive alteration in the retinal microvasculature resulting in areas of retinal nonperfusion with a resultant increase in vascular endothelial growth factor-A (VEGF). Elevated levels of VEGF can result in abnormal development of new blood vessels (neovascularization). Those new vessels can be friable and bleed into the vitreous cavity, causing vitreous hemorrhage. Vision-threatening DR develops in about 10% of people with diabetes and remains the leading cause of new cases of legal blindness.26
*When Should Screening Begin and How Frequently Should Testing be Done?
*Are Pregnant Women Screened Similarly?
*How Should the Health Care Providers Classify Diabetic Retinopathy?
*What is the Role of the Health Care Providers in Preventing/Treating Diabetic Retinopathy?
-Ensure regular eye examination
-Hyperglycemia
-Lipid control
-Lifestyle modifications
*What are the Treatment Options for Diabetic Retinopathy?
SUMMARY
In summary, microvascular complications including DSPN, DKD, and DR are common in patients with long-standing type 1 diabetes and new or existing type 2 diabetes and require active screening. Complications can be prevented or delayed by careful attention to risk factors, careful education and monitoring by the patient, and prompt evaluation and treatment by consultants when indicated. This evaluation, monitoring, prevention, and treatment can help improve patients’ quality of life and can be associated with reductions or delays in treatments such as dialysis with reduced cost.
Basem M. Mishriky, MD, Doyle M. Cummings, Pharm, FCP, FCCP, James R. Powell, MD
DIABETIC SYMMETRIC POLYNEUROPATHY
What is Diabetic Symmetric Polyneuropathy?
Diabetic neuropathy is classified into diffuse neuropathy, mononeuropathy, and radiculopathy/polyradiculopathy.1 Diabetic symmetric polyneuropathy (DSPN) is the most common form of diffuse neuropathy, which is the most common form of diabetic neuropathy.1 DSPN affects 50% of individuals with type 2 diabetes (T2DM) after 10 years of disease duration and at least 20% of individuals with type 1 diabetes (T1DM) after 20 years of diagnosis.1 DSPN can be referred to as distal symmetric polyneuropathy or even, although less accurate, as diabetic neuropathy.2
The American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation define distal symmetric polyneuropathy (including DSPN) as polyneuropathy that must begin in the feet and include symptoms and signs that are the same on both sides of the body.3,4 The symptoms may be primarily sensory, primarily motor, or combined. The signs may include pain, impairment to touch, impairment to proprioception, weakness, and atrophy of muscles, depressed/absent ankle reflexes, or autonomic system.3,4 Signs are better predictors of polyneuropathy compared with symptoms and multiple concurrent abnormalities provide greater sensitivity in predicting polyneuropathy.
In the position statement by the American Diabetes Association (ADA), DSPN is defined as the presence of symptoms or signs of peripheral nerve dysfunctions after excluding other causes.1
*Can Patients without Numbness, Tingling, or Pain in the Feet have Diabetic Symmetric Polyneuropathy, and Why is this Important?
*How do Individuals with Diabetic Symmetric Polyneuropathy Present?
-Small-fiber involvement
-Large-fiber involvement
*Is Ongoing Foot Pain and Numbness in Individuals with Diabetes Always Diabetic Symmetric Polyneuropathy?
*What are the Criteria for Requesting a Nerve Conduction Study (Possible Reasons for Specialist Referral)?
*What are the Minimum Criteria Required to Diagnose Diabetic Symmetric Polyneuropathy?
*When Should the Health Care Providers Screen for Diabetic Symmetric Polyneuropathy?
*How Should the Health Care Providers Screen for Diabetic Symmetric Polyneuropathy?
-History
-Examination
*A Monofilament Test is Insensate to 5.07 but Intact to 6.65. Tuning Fork Vibrations Sense was Lost after Five Seconds. The Ankle Reflex and Pinprick Sensation were Intact Bilaterally. What is the Significance of that Foot Examination?
*What Measures can Health Care Providers do to Prevent Diabetic Symmetric Polyneuropathy and Ulcerations?
-Foot care education
-Proper footwear
-Glycemic control
*Management of Symptomatic Diabetic Symmetric Polyneuropathy
DIABETIC KIDNEY DISEASE
What is Diabetic Kidney Disease?
The ADA defined diabetic kidney disease (DKD) as chronic kidney disease (CKD) attributed to diabetes, and CKD as the persistent presence of elevated urinary albumin excretion low estimated glomerular filtration rate (GFR), or other manifestations of kidney damage.17
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines defined CKD as abnormalities of the kidney structure or function present for ≥ 3 months.18 In 2007, the KDIGO guidelines recommended using the term “DKD” instead of “diabetic nephropathy” as there is no consensus definition of diabetic nephropathy.19 In 2020, the KDIGO guidelines used the term “Diabetes and CKD” over “DKD” although DKD was still considered appropriate, to ensure that other causes of CKD are considered and to avoid the assumption that all cases of CKD are caused by traditional diabetes pathophysiology.18
*How Common is Diabetic Kidney Disease?
*When should Health Care Providers Initiate Screening for Diabetic Kidney Disease? How Often Should the Screening be Done?
*How Should the Health Care Providers Interpret the Urine Albumin-to-creatinine Ratio?
*What is the Likelihood of Diabetic Kidney Disease in Individuals with Moderate/Severe Albuminuria?
*When to Refer to Nephrology?
*How Should the Health Care Providers Monitor Glycemic Control in Individuals with Diabetic Kidney Disease?
-What Measures can Reduce the Risk of Developing Diabetic Kidney Disease?
-Nutrition
-Lipid management
-Blood pressure
-Glycemic control
-Smoking
*A 55-year-old Individual with T2DM Treated with Metformin. His Last Creatinine was 1.7 mg/dL, GFR 51 mL/min/1.73 m2 , and UACR 389 mg/g. Should Metformin be Discontinued?
*How can Health Care Providers Delay Progression of Diabetic Kidney Disease? Renin–angiotensin system blockade
-Renin–angiotensin system blockade
-Sodium-glucose co-transporter-2 inhibitors
*What Anti-diabetic Medications Should be Added if Glycemic Control is not Achieved by Metformin and Sodium-glucose Co-transporter-2 Inhibitors?
*Novel Therapy in Diabetic Kidney Disease
DIABETIC RETINOPATHY
What is Diabetic Retinopathy?
The most common diabetes-related eye disease is diabetic retinopathy (DR). DR is characterized by a gradually progressive alteration in the retinal microvasculature resulting in areas of retinal nonperfusion with a resultant increase in vascular endothelial growth factor-A (VEGF). Elevated levels of VEGF can result in abnormal development of new blood vessels (neovascularization). Those new vessels can be friable and bleed into the vitreous cavity, causing vitreous hemorrhage. Vision-threatening DR develops in about 10% of people with diabetes and remains the leading cause of new cases of legal blindness.26
*When Should Screening Begin and How Frequently Should Testing be Done?
*Are Pregnant Women Screened Similarly?
*How Should the Health Care Providers Classify Diabetic Retinopathy?
*What is the Role of the Health Care Providers in Preventing/Treating Diabetic Retinopathy?
-Ensure regular eye examination
-Hyperglycemia
-Lipid control
-Lifestyle modifications
*What are the Treatment Options for Diabetic Retinopathy?
SUMMARY
In summary, microvascular complications including DSPN, DKD, and DR are common in patients with long-standing type 1 diabetes and new or existing type 2 diabetes and require active screening. Complications can be prevented or delayed by careful attention to risk factors, careful education and monitoring by the patient, and prompt evaluation and treatment by consultants when indicated. This evaluation, monitoring, prevention, and treatment can help improve patients’ quality of life and can be associated with reductions or delays in treatments such as dialysis with reduced cost.
