Pediatric complications beyond glycemic control

Abstract

Clinically overt microvascular and macrovascular complications related to type 1 diabetes (T1D) are uncommon during childhood and adolescence. However, functional and structural abnormalities begin early in life and remain subclinical for many years. Therefore, the cornerstone of pediatric diabetes care is the early identification and management of modifiable risk factors (RFs), including hyperglycemia, dyslipidemia, obesity, smoking, and hypertension.

Long-term exposure to hyperglycemia, traditionally assessed by glycated hemoglobin (HbA1c), has long been recognized as the major risk factor for diabetes-related complications. More recently, evidence from large international cohorts, such as the SWEET registry, together with cross-sectional studies using continuous glucose monitoring (CGM), haves demonstrated that several CGM-derived metrics—including increased glycemic variability, hypoglycemia, and reduced time in range (TIR)—are independently associated with a higher prevalence of cardiovascular risk factors (CVRFs), such as dyslipidemia, overweight, and elevated blood pressure. These findings indicate that these variables represent additional determinants of cardiovascular risk beyond glycemic control alone.

Office blood pressure measurements are frequently insufficient to detect hypertension, as they may fail to identify nocturnal hypertension or abnormalities in the circadian blood pressure profile. Traditionally, international consensus guidelines have recommended ambulatory blood pressure monitoring (ABPM) primarily to confirm the diagnosis of hypertension. However, accumulating evidence over recent years suggests a broader role for ABPM as a tool for the early stratification of cardiovascular risk. Several studies, including some involving individuals with normal office blood pressure, have shown that isolated nocturnal hypertension and a non-dipping blood pressure pattern (defined as the absence of the normal >10% decline in blood pressure during sleep) precede the development of albuminuria and diabetic retinopathy. Loss of the normal nocturnal blood pressure decline may reflect early autonomic dysfunction and increased arterial stiffness. Furthermore, a systematic review demonstrated that even small differences in ABPM-derived blood pressure parameters among individuals with T1D are associated with a lower incidence and slower progression of diabetic nephropathy and retinopathy.

Despite the remarkable advances achieved in the treatment of T1D, cardiovascular disease remains the leading cause of mortality in this population. Consequently, contemporary pediatric T1D management should extend beyond glycemic control alone and incorporate the systematic identification and early treatment of modifiable cardiovascular risk factors.