Complications

Microvascular Vs Macrovascular

Optimization of glycemic control in diabetes mellitus is associated with a reduced risk of microvascular complications mainly. (benefit on preventing macrovascular complications is not very well established yet; ?long-term benefit)

Diabetic nephropathy

affects 30-40% of type 1 and 20-30% of type 2 diabetics

Hyperproliferation, proteinuria, and ESRD

Pathology:

Most common = diffuse glomerulsclerosis >> widening of glomerular basement membrane and mesangial thickening.

Nodular glomerulsclerosis can occur and results in hyalinization of afferent glomerular arterioles (Kimmelstiel-Wilson syndrome)

Mx

strict sugar control

N.B. The strongest predictors of progressive DKD are the presence of poor glycemic control, hypertension, and glomerular hyperfiltration. Importantly, as DKD progresses, the requirements for insulin to maintain glycemic control diminish as renal metabolism andexcretion of insulin concomitantly and progressively decreases.

ACE-inhibitors

dialysis or renal transplant

Screen for proteinuria annually by ordering a urine microalbumin (Overt >300mg/day; microalbuminuria is >30mg/day)

• *Diabetes is the most common cause of ESRD in the U.S.

Clinical remission of renal disease has taken place when proteinuria declines to <1 g/24-h, and regression is defined by a declinein proteinuria to <0.3 g/24-h.

Diabetic retinopathy

• Screen at the time of Dx and then annually