When and how to screen Diabetic Kidney Disease (DKD) And what is the role of Urine Albumin Creatinine Ratio (UACR) All patients with type 2 diabetes must be screened for diabetic nephropathy at the time of diagnosis. Patients with type 1 diabetes should be screened five years after diagnosis and at puberty. If the initial test reveals negative result then the test has to be repeated annually for both type 1 and type 2 diabetes. Early Diabetic kidney disease expressed as Microalbuminuria (if urinary albumin excretion is 30 - 300 mg/24 h. Random urine samples should be used and the results of albumin measurement in spot collection may be expressed as urinary albumin concentration (mg/dL) or as urinary albumin to creatinine ratio (mg/g or mg/mmol). This method is often found to be the easiest to carry out in an office setting, generally provides accurate information, and is therefore preferred;

1. Diabetes Mellitus
Screening of Diabetic complications
Dr. C L Nawal
Senior Professor, Department of Medicine
SMS Medical College And Attached hospital, Jaipur

2. When and how to screen Diabetic Kidney Disease (DKD) And
what is the role of Urine Albumin Creatinine Ratio (UACR)
 All patients with type 2 diabetes must be screened for diabetic nephropathy at the time
of diagnosis.
 Patients with type 1 diabetes should be screened five years after diagnosis and at
puberty. If the initial test reveals negative result then the test has to be repeated
annually for both type 1 and type 2 diabetes.
 Early Diabetic kidney disease expressed as Microalbuminuria (if urinary albumin
excretion is 30 - 300 mg/24 h.
 Random urine samples should be used and the results of albumin measurement in spot
collection may be expressed as urinary albumin concentration (mg/dL) or as urinary
albumin to creatinine ratio (mg/g or mg/mmol).
 This method is often found to be the easiest to carry out in an office setting, generally
provides accurate information, and is therefore preferred;

3. When, how to screen Diabetic retinopathy (DR) and how frequently we should
screen Diabetic retinopathy.
 Prevalence of Diabetic Retinopathy (DR) approximately 18% in urban areas and 10%
in rural areas.
 Screening of DR Recommended at the time of diagnosis in Type 2 Diabetes mellitus
and within 5 years of diagnosis of Type 1 diabetes and has to be repeated annually for
both type 1 and type 2 diabetes.
 Patients visiting ophthalmologists for cataract surgery or any other surgical procedures
should have at least one RBS test done. If the RBS is ≥200 mg/dl or Hba1c is > 6.5%,
a dilated fundus examination and status of DR should be recorded before surgery
 All people with type 1 diabetes and 60% of patients with type 2 diabetes are found to
have some form of retinopathy by the first decade of incidence of diabetes mellitus.
 Retinal screening can be done with any or all of the following methods:
 Indirect ophthalmoscopy
 Slit lamp 78D/90 D evaluation
 Retinal imaging (Fundus photography)
 Stereoscopic colour film fundus photography
 Fluorescein angiography
 The gold standard for grading the severity of Diabetic Retinopathy is stereoscopic
fundus photography through dilated pupils, using seven standard fields, and grading
guidelines for these photographs established by the Early Treatment Diabetic
Retinopathy Study (ETDRS) group

4. What is Diabetes neuropathy Usual subtype and symptoms.
 Diabetic neuropathy (DN) is a highly prevalent complication of type 1 or type 2
diabetes.
 Neuropathic complications of diabetes are so distressing with considerable
morbidities such as non-healing ulcer, diabetic foot, and gangrene.
 Peripheral neuropathy is characterised by : Numbness, "Pins and needles“, Burning
feet, Feeling of walking on cotton, Heaviness in feet, A sensation like the crawling of
insects, Sharp pain etc.
1. Cardiac autonomic neuropathy
 The patient has palpitations and/or giddiness, especially on getting up from the bed
or chair, or while urinating. This may lead to falls and injury. Clinical examination
reveals resting tachycardia and a decline in blood pressure on standing.
2. Gastrointestinal autonomic neuropathy
 This may take one of the several forms, namely gastroparesis, constipation, or
diarrhoea. Gastroparesis causes upper abdominal discomfort, postprandial abdominal
fullness, nausea, and loss of appetite. Diabetic diarrhoea causes considerable distress
and typically occurs at night.
3. Genitourinary neuropathy
 Neuropathy contributes significantly to erectile dysfunction in men. It can also affect
the urinary bladder and causes cystopathy in both men and women.

5. How can we mitigate the risk Atherosclerotic cardiovascular
disease (ASCVD) in Diabetes patients And role of Statins
 Cardiovascular disease is the leading cause of death in people with diabetes.
 Insulin resistance and hyperglycaemia cause oxidative stress, which leads to endothelial
dysfunction by decreasing nitric oxide availability at vascular endothelium.
 Increased proinflammatory cytokines also promote atherogenesis.
 Increased levels of free fatty acids in diabetes contribute to plaque formation in vessels.
 Early intensive glycaemic control has a legacy effect and results in cardiovascular benefit
(about 15% reduction the risk of myocardial infarction) over time as seen in the 10 year
follow up.
 All people with diabetes should be evaluated for coronary risk factors like hypertension,
dyslipidaemia, smoking, family history, and obesity.
 Presence of microalbuminuria significantly increases the risk of Coronary artery disease.
 In addition, risk factors like high sensitivity C reactive protein (hsCRP), apolipoprotein B
to apolipoprotein A ratio, lipoprotein (a) and homocysteine may help in assessing cardiac
risk.

6. How can we mitigate the risk Atherosclerotic cardiovascular
disease (ASCVD) in Diabetes patients And role of Statins
 Statins improve plasma cholesterol levels by regulating the number of LDL
receptors on the membrane surface of liver cells and the expression of genes
related to HDL metabolism.
 Statins can repair endothelial function by inhibiting mononuclear and macrophage
adhesion to Endothelial cells and improving the bioavailability of Nitrous oxide.
 Statins inhibit inflammation by inhibiting the production of pro-inflammatory
factors, Reactive Oxygen Species and CRP.
 Statins limit plaque progression by inhibiting inflammation, promoting
macrophage phenotypic transformation, and fibrous cap thickening.

7. Role of Ankle-Brachial Index (ABI) in screening of Atherosclerotic
cardiovascular disease (ASCVD)
 Ankle-Brachial Index (ABI) is a non-invasive test can be done by ascertaining the
blood pressure of both arms and both legs.
 The ABI is the ratio of the systolic blood pressure at the ankle (measuring the
pressure just proximal to the dorsalis pedis or posterior tibial artery) and compared
to the systolic blood pressure at the brachial artery (standard arm assessment) in
both arms and legs.
 A value less than 0.9 is indicative of peripheral artery disease (PAD).
 For asymptomatic persons, an ABI <0.9 is considered to indicate increased risk of
CVD events (as a risk enhancing factor in the ACC/AHA 2018 guideline), thereby
warranting initiation or intensification of risk factor management.
 It has been studied as a marker of ASCVD risk and atherosclerosis in the peripheral
arteries.

8. Role of Ankle-Brachial Index (ABI) in screening of ASCVD
 It has been recommended in the 2018 AHA/ACC Guideline on Management of
Blood Cholesterol for additional risk assessment in patients with borderline or
intermediate risk.
 The US Preventive Services Task Force (USPSTF) found adequate evidence
that adding the ABI, hs-CRP, and Coronary artery calcium (CAC) score to
existing CVD risk assessment models may improve calibration, discrimination,
and reclassification.
 It remains most often used in clinical practice as a predictor of obstructive
Peripheral Artery Disease (PAD) in patients with possible claudication and may
thus be most useful in older persons with multiple risk factors who have a
greater likelihood of PAD.