Mitigating micro-and macro-vascular complications of diabetes beginning in adolescence

Figures & data

Figure 1 The Diabetes Control and Complications Trial: percent reduction of microvascular complication with intensive therapy. Patients age 13 to 39 with T1DM were divided into two cohorts, primary prevention cohort (no complications), and secondary intervention cohort (mild to moderate retinopathy, urine microalbumin <200 mg/24 h).

The patients who underwent intensive therapy with insulin showed significant reduction of microvascular complications in both cohorts.

Drawn from data of Skyler JS. Diabetic complications. The importance of glucose control. Endocrinol Metab Clin North Am. 1996;25(2):243–254.¹⁹

Figure 2 The contributions of hyperglycemia to vascular endothelial dysfunction and atherogenesis are mediated through several processes, including increased production of advanced glycation end products, activation of protein kinase C and sorbitol. These factors serve to enhance inflammatory processes including the activation of NF-κβ and the production of pro-inflammatory cytokines. In turn, these factors cause injury to the vascular endothelium. This final common mechanism promotes atherogenesis and facilitates the vascular complications of diabetes.

Abbreviations: AGEs, advanced glycation end products; DAG, diacylglycerol; PKC, protein kinase C; LDL, low-density lipoprotein; GSH, glutathione; NADPH, nicotinamide adenine dinucleotide phosphate; NF-κβ, nuclear factor-κβ.

Table 1 Screening for nephropathy in pediatric diabetes

Screening tool	24-hour urine microalbumin
	Spot urine microalbumin
	Albumin/creatinine ratio in first morning void
	Timed overnight urine collection of albumin
Screening parameters	Microalbuminuria	24-hour urine sample, spot urine, or first morning void: 30–300 mg albumin/L Timed overnight urine collection: 20–200 μg/min albumin Albumin/creatinine ratio in spot urine: 2.5–25 mg/mmol (males) 3.5–25 mg/mmol (females)
	Persistent/permanent microalbuminuria	Meets above definitions for microalbuminuria in a minimum of 2 out of 3 samples collected consecutively (preferably within a 3-to 6-month period)
	Gross proteinuria	24-hour albumin loss gt;500 mg
Age to initiate screening	Type 1 diabetes mellitus	If diabetes is diagnosed before puberty: If diabetes is diagnosed before age 4, begin screening at age 9 If diabetes is diagnosed between age 6–9, begin screening at age 11 If diabetes is diagnosed after age 10, begin screening 2 years after diagnosis If diabetes is diagnosed after puberty: Initiate screening 2 years after diagnosis
	Type 2 diabetes mellitus	Initiate screening at time of diagnosis
Frequency of screening	Screening is initially done in 6-12-month intervals With evidence of initial microalbuminuria: Repeat testing is done over the next 3–6 months to confirm or exclude persistent microalbuminuria	With evidence of intermittent microalbuminuria: Repeat testing is done every month for the next 3 months to confirm the presence of persistent microalbuminuria

Table 5 Screening for dyslipidemia in pediatric diabetes

Screening tool	Fasting lipid profile: LDL, HDL, triglycerides	Determines the body’s utilization and storage of lipids
Screening parameters	LDL cholesterol	Target: goal level < 110 mg/dL
	HDL cholesterol	Target: goal level > 35 mg/dL
	Triglycerides	Target: goal level < 150 mg/dL
	Total cholesterol	Target: goal level < 170 mg/dL
Age to initiate screening	Type 1 diabetes mellitus	If diabetes is diagnosed before puberty: with risk factors for dyslipidemia: Initiate screening in all children over 2 years of age with no risk factors for dyslipidemia: Initiate screening in all children at 12 years of age
		If diabetes is diagnosed after puberty: Initiate screening at time of diagnosis
	Type 2 diabetes mellitus	Initiate screening at time of diagnosis
Frequency of screening	If lipids are normal: screen every 2–5 years in type 1 and type 2 diabetes mellitus	If lipids are abnormal: screen annually in type 1 and type 2 diabetes mellitus

Abbreviations: HDL, high-density lipoprotein; LDL, low-density lipoprotein.

Table 2 Screening for retinopathy in pediatric diabetes

Screening tool	Visual acuity exam	Asses ability to focus and discern objects
	Dilated eye exam	Detects vascular changes in the retina
	Fundus photography and angiography	Quantifies degree of retinopathy
Screening parameters	Evidence of background nonproliferative retinopathy	Findings: Microaneurysms, dot and blot hemorrhages, hard exudates
	Evidence of preproliferative retinopathy and retinal ischemia	Findings: cotton wool spots
	Evidence of proliferative retinopathy with	Findings: neovascularization of the optic disk
Age to initiate screening	Type 1 diabetes mellitus	Starting at age 9, screen 3–5 years after diagnosis
	Type 2 diabetes mellitus	Starting at age 9, screen at time of diagnosis
Frequency of screening	Type 1 diabetes mellitus: annually	Type 2 diabetes mellitus: annually

Table 3 Screening for neuropathy in pediatric diabetes

Screening tool	Nerve conduction velocities	The gold standard: determines the adequacy of impulse the conduction of through nerves
	Semmes-Weinstein monofilament test	Detects pressure perception
	Tuning forks	Detects vibration perception
	Survey of symptoms	Review of systems to detect new symptoms such as numbness, pain, cramps, paresthesias, alteration of sensation in vibration and light touch
	Cardiovascular autonomic function testing	Detects reduced heart rate variability
Screening parameters	All modalities screen for evidence of loss of sensitivity and non-perception
Age to initiate screening	Type 1 diabetes mellitus	Starting after 5 years of disease
	Type 2 diabetes mellitus	Starting at the time of diagnosis
Frequency of screening	Type 1 diabetes mellitus: annually	Type 2 diabetes mellitus: annually

Table 4 Screening for hypertension in pediatric diabetes

Screening tool	In-office blood pressure	Static measurement of sphygmomanometer cuff pressure
	24-hour ambulatory blood pressure	Measures blood pressure at regular intervals throughout the day
Screening parameters	High-normal blood pressure	Findings: average systolic or diastolic blood pressure ≥90th but <95th percentile for age, sex, and height measured on three separate days
	Hypertension	Findings: average systolic or diastolic blood pressure ≥95th percentile for age, sex, and height measured on three separate days
Age to initiate screening	Type 1 diabetes mellitus	Starting at time of diagnosis
	Type 2 diabetes mellitus	Starting at time of diagnosis
Frequency of screening	Type 1 diabetes mellitus: every office visit	Type 2 diabetes mellitus: every office visit

SkylerJSDiabetic complications. The importance of glucose controlEndocrinol Metab Clin North Am19966252:2432548799699

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