Can the initial appearance of retinal microangiopathy at its diagnosis be attributed to diabetes?  

W.C. is a 56 year-old white male. His history was remarkable in that he had weighed 230 pounds until 2.5-3 years before, when he voluntarily went on a rigid diet and lost 50 pounds over about 1 year. He has maintained his current weight of 180-190 pounds for the last 1.5 years. Six years ago he complained of numbness in his feet and poor healing of cuts and bruises. He was seen by a physician who noted high blood glucose levels and high blood pressure. He was treated with 5 mg glipizide twice a day. He had no family history of diabetes. He denied other symptoms of diabetes.

Physical examination showed blood pressure of 156/100 mmHg, weight 200 pounds, height 5’9″ (IBW = 155-160 pounds). Fundi contained capillary aneurysms, hemorrhages, and exudates. Laboratory data showed plasma glucose 140 mg/dl, HbA1c 7.6% (normal <6.2%), serum cholesterol 172 mg/dl, and serum creatinine 0.8 mg/dl. Urinalysis was normal. A spot microalbuminuria/urine creatinine ratio indicated 10 mg/gm creatinine. (Normal, <30 mg albumin/gm creatinine.)

Questions

1. Can the initial appearance of retinal microangiopathy at its diagnosis be attributed to diabetes?

2. What is the most important risk factor that should be treated first?

3. Is treatment of glycemia adequate, or should additional hypoglycemic treatment be postulated?

4. Is management of hypertension in diabetes different from that in non-diabetic patients?