Residual Microvascular Risk in Type 2 Diabetes in 2014: Is it Time for a Re-Think? A Perspective from the Residual Risk Reduction Initiative (R3i)

Abstract

Microvascular complications associated with type 2 diabetes, including diabetic retinopathy, nephropathy and neuropathy, account for much of the societal burden of diabetes. Even with effective multifactorial intervention, targeting glycemia, blood pressure and lowdensity lipoprotein cholesterol, in addition to lifestyle intervention, a high residual microvascular risk persists. The Residual Risk Reduction Initiative (R 3 i) highlights two key priorities for reducing this residual risk. First, there should be optimal management of cardiometabolic risk factors, including atherogenic dyslipidemia, elevated triglycerides and low plasma high-density lipoprotein cholesterol, to improve lipid goal attainment. Second, consistent evidence from two major trials may merit consideration of adjunctive fenofibrate therapy to slow progression of diabetic retinopathy in type 2 diabetes patients with pre-existing disease. These data provide a strong rationale for testing in a prospective study. The R 3 i strongly believes that addressing both priorities is critical to reducing the substantial residual risk of microvascular complications in type 2 diabetes.

The mixed benefit of low lipoprotein(a) in type 2 diabetes

“…As regards the increased prevalence of microangiopathy in (very) low Lp (a) patients, it is unlikely that it stemmed directly from the low level of the lipoprotein, based on the current paradigm of diabetic microvascular disease [ 21 ]. On the other hand, at least four aspects of the unfavorable cardiometabolic phenotype associated with low Lp (a) may have contributed to the genesis (or aggravation) of small vessel damage, namely ( i ) poorer glycemic control; ( ii ) higher BP; ( iii ) greater MetS score; and ( iv ) more prevalent and severe AD [ 19 , 20 , 22 – 25 ].…”