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Screening for the Microvascular Complications of Diabetes

Diabetes, a long-standing disease that may seem to be silent in the early years after diagnosis may not be really silent after all. Ten to 15 years after the diagnosis has been made (sometimes even before diagnosis), the microvascular complications arise because of poorly controlled blood sugars. In the management of diabetes, it is not only blood sugars that we are after; moreover, we are after the prevention of diabetic complications. The direct and indirect effects of high blood sugars on the blood vessels are the major source of hospitalization and even death among diabetic patients; these are called the vascular complications of diabetes.

Microvascular complications of diabetes are conditions result-ing from prolonged excess levels of glucose in the small blood vessels supplying certain body tissues. There are three primary microvascular complications related to diabetes: retinopathy (eye disease), neuropathy (nerve disease) and nephropathy (kidney disease). Let us take a look at each of them, one by one.

Retinopathy
Diabetic retinopathy is characterized by a progression of abnormalities within the eye. The small blood vessels in the retina (the light-sensitive and vision-essential region at the back of the eye) become constricted initially and eventually, become dilated to the point of bursting. New blood vessels may grow on the retina and leak blood into the eyeball. This temporarily causes dimming of vision and worse, can lead to blindness. It is the most common cause of blindness among people between 20 and 74 years old.

Good control of both blood sugar and blood pressure are the keys to preventing and treating retinopathy. People with type 1 diabetes should get screened for retinopathy within five years of diagnosis, while those diagnosed with type 2 should get a dilated eye exam right away, since the disease may have been present for some time before diagnosis. Dilated fundus examination is usually done yearly to evaluate the status of the retina, although some who have had a run of normal eye exams may be advised to have them less frequently (every two or three years). If retinopathy is detected, more frequent examinations may be necessary to monitor progression.

Other retinopathy screening procedures include: seven-field stereoscopic fundus photography (now consid
ered the gold standard) and digital retinal imaging. The treatment of choice is a laser procedure called photocoagulationin the hands of an expert ophthalmologist.

Neuropathy
Diabetic neuropathy is another microvascular complication of poorly controlled blood sugars. This includes damage to the peripheral nerves. Fifty percent of people with diabetes will develop neuropathy after approximately 25 years from diagnosis. Some of the symptoms include numbness in the fingers and toes, cramps in the arms and legs which may progress to burning pain in both upper and lower extremities. Patients may experience absence of sensation leading to loss of ability to feel hot and cold temperatures.

Nerve damage to the legs may lead to infection, ulceration and leg amputation. Because of this, diabetic patients are advised to regularly check their feet for painless puncture wounds or hidden infections. Clues that may guide patients in recognizing neuropathic pains are the location of pain (feet more than calves), the quality of the pain, and the timing of pain (present at rest, improves with walking). Neuropathy testing or testing for the integrity of the nerves is integral in every clinic visit. Sensation can be checked with either gentle pressure to the underside of the toes and the ball of the foot using either finger touch or a fine plastic strand called a monofilament. Test for vibration can be carried out using a tuning fork.

Diabetic neuropathy also includes autonomic dysfunction which causes decrease in the heart’s ability to adapt to changes in activity, “silent” heart attack described as the inability to perceive the typical chest heaviness that occurs in heart attacks among non-diabetics, erectile dysfunction, slowed digestion and bloatedness. Basic evaluation such as a 12 lead ECG at least once a year, and/or baseline stress 2D echocardiography to uncover any occult coronary artery disease can be done. Consultation with gastroenterologists may be suggested to rule out other causes of abdominal discomforts.

The best treatment for diabetic neuropathy is good sugar control. This is the best way to prevent the development and progression of neuropathy. Unfortunately, this is the only advice given to help treat the condition. There are a number of drugs that are given to try and help prevent the pain that is associated with this condition; these include pain relievers, anticonvulsants, antidepressants and even vitamin B complex. However, these should be given as prescribed by the medical specialist as these medicines have their own potential side effects.

Nephropathy
The last but definitely not the least is diabetic nephropathy. Diabetes is now one of the common causes of end stage renal disease worldwide.Patients dread the idea of hemodialysis. Hence, when the concept of diabetic kidney disease is brought up, most patients are all ears to it. But, just like diabetic neuropathy and retinopathy, this complication does not come overnight. Risk factors for its development include poor glycemic control, hypertension, smoking and a positive family history of nephropathy. Key factors for its prevention include glycemic control, blood pressure control, smoking cessation and screening for microabuminuria.

Microabuminuria is defined as urinary albumin of less than 300mg/day. This is detected in urine micral test or urine microabumin to creatinine ratio. It is a sensitive early indicator of the adverse effects of diabetes on the kidney and is a powerful predictor of subsequent course. In type 2 diabetes, annual screening for microabuminuria should start upon diagnosis. If positive, two determi-nations should be carried out in a 3-6 month interval. Positive test means detecting microabuminuria in two out of three testings.

Urine test must be carried out in the absence of infection, fever, pro-longed standing or menstruation as these can cause false positive results. When random urine test is done, positive protein indicatesproteinuria and this signifies diabetic kidney disease especially if accompanied by elevated serum creatinine. Serum creatinine is a blood test that will tell us whether the kidneys are functioning properly or not. Elevated levels indicate the inability of the kidneys to filter the body wastes. If serum creatinine is normal, it is generally requested annually but more frequently if levels are already high.

Patients with kidney disease even at the microalbuminuric stage are encouraged to have a low protein diet. Animal meat in particular is restricted and medical intervention is started. Patients may be given ACE inhibitors (angiotensin converting enzyme inhibitors) or ARBs (angiotensin receptor blockers) as these medications have been proven to decrease urinary protein excretion by the kidneys. Good blood pressure control at the level of 130/80 is desirable to halt the progression of diabetic kidney disease.

As the popular saying goes, “an ounce of prevention is better than a pound of cure”, early intervention is the key to the prevention of these microvascular complications. As diabetic patients are committed to regularly see their physicians, health care providers should also be keen at educating their diabetic patients and vigilant in screening them for the earliest signs of organ damage secondary to diabetes.

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