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Markers of microvascular complications in insulin dependent diabetes
  1. C J Schultz,
  2. R Amin,
  3. D B Dunger
  1. Department of Paediatrics, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK
  1. Correspondence to:
    Prof. D B Dunger, Department of Paediatrics, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK;
    david.dunger{at}paediatrics.ox.ac.uk

https://doi.org/10.1136/adc.87.1.10

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    Annual screening for early markers of microvascular disease during puberty should be encouraged

    Screening for early markers of microvascular disease is now generally recommended from around the age of 10 years in children with type 1 diabetes mellitus (TIDM). Annual assessment should include direct fundal examination or fundus photography, monitoring of arterial blood pressure (BP), and measurement of urinary albumin excretion. The basis of all screening programmes is that those most at risk can be correctly identified and that there should be appropriate and effective interventions. The value of retinal screening is beyond doubt as the detection of early preproliferative or proliferative retinopathy may lead to successful intervention with laser therapy, but such events are rare before the age of 18 years. The evidence supporting screening for other markers of microvascular disease, such as microalbuminuria (MA) and hypertension is more contentious and this is the subject of the current review. Symptomatic autonomic or sensory nephropathy is relatively rare in children and adolescents and this will not be discussed further.

    WHEN TO SCREEN

    The decision to introduce screening at age 10 years reflects the influence of puberty on the risk for microvascular disease. Several cross sectional studies and at least two large longitudinal studies (the Berlin Retinopathy Study and the Oxford Regional Prospective Study (ORPS)) have shown that microvascular complications are rare before puberty.1,2 Puberty confers a three- to fourfold increase in risk of MA after adjusting for other major risk factors such as diabetes duration, HbA1c, and gender.1,3 Prepubertal duration of diabetes may contribute to the risk of MA, but this only becomes evident after the onset of puberty.1 Contrary to historical belief, MA is not rare4 and may progress5 within the first five years after the diagnosis of TIDM in pubertal subjects.4,5 Puberty …

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