Long-Term Microvascular Complications: New Ideas for Research
Despite the evidence that both type 1 and type 2 diabetes are presently treated with up-to-date therapeutic protocols, complete normalization of glycemic control for both diseases appears to be still out of reach. The gap existing between the “ideal” cure
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Long-Term Microvascular Complications: New Ideas for Research Gianpaolo Zerbini and Silvia Maestroni
Despite the evidence that both type 1 and type 2 diabetes are presently treated with up-to-date therapeutic protocols, complete normalization of glycemic control for both diseases appears to be still out of reach. The gap existing between the “ideal” cure still to come and the present pharmacological treatment of diabetes is the cause of the development of microvascular diabetic complications such as nephropathy and retinopathy.
6.1
Diabetic Retinopathy
6.1.1
Background
Addressing the topic of diabetic retinopathy (DR) and more generally of diabetes complications in a context of childhood-onset type 1 diabetes might seem unusual, but it is actually very important to have in mind the concept that the best possible prevention of diabetes complications consists in maintaining a good glycemic control since the very onset of the disease. On this regard we learned from the Diabetes Control and Complications Trial (DCCT) that tight glycemic control has a key role in preventing the onset and in slowing down the progression of diabetic complications [1]. Similarly, the EDIC study showed that early intensive glycemic control has a protective effect on the subsequent development and progression of complications, something that is maintained even after the suspension of the tight control of diabetes [2]. In line with these results, a subsequent follow-up actually demonstrated that patients formerly in the intensive control group were characterized by a lower cumulative incidence of DR, even after G. Zerbini (*) • S. Maestroni Complications of Diabetes Unit, Diabetes Research Institute, San Raffaele Scientific Institute, Milano, Italy e-mail: [email protected] © Springer International Publishing Switzerland 2017 A. Scaramuzza et al. (eds.), Research into Childhood-Onset Diabetes, DOI 10.1007/978-3-319-40242-0_6
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18 years of normal glucose control [3]. For all these reasons the sentence “Well begun is half done” is much more than just saying. As of today, DR remains a very serious problem because approximately 40 % of patients affected by type 2 diabetes and 86 % of those affected by type 1 diabetes also manifest this complication which still remains the most frequent cause of preventable blindness in working-aged adults (20–74 years) [4]. Despite the recent implementation of aggressive therapies aimed to obtain the best possible metabolic control in young type 1 diabetic patients, at least some signs of DR are already detectable 9 years after the diagnosis of diabetes in 23 % of patients, while, in the same period, the prevalence of diabetic macular edema (DME) is approximately 4.4 % [5]. DR is a microangiopathy that affects primarily the retinal arterioles, capillaries, and venules, although larger vessels may also be involved [6]. Two main phases characterize the progression of the complication: a first stage characterized by the development of progressive and diffuse retinal
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