151
J Gandhara Med Dent Sci
October - December 2026
SYSTEMATIC REVIEW
How to cite this article
PATTERNS OF DIABETES-RELATED COMPLICATIONS AND CLINICAL OUTCOMES IN GENERAL
MEDICINE SETTINGS: A SYSTEMATIC REVIEW WITHOUT META
-ANALYSIS
ABSTRACT
OBJECTIVES
To
systematically
synthesise
recent
observational
evidence
on
patterns
of
diabetes-related complications, clinical outcomes, glycemic-control ndings,
and
factors
associated
with
adverse
outcomes
in
general
medicine
and
related routine-care settings.
METHODOLOGY
PubMed,
Web
of
Science,
and
Scopus
were
searched
for
original
studies
published
from
2020 through
2025.
Eligible
studies
included
observational
cross-sectional,
cohort,
retrospective,
prospective,
multicenter,
hospital-
based,
and
community-based
studies
reporting
microvascular
or
macrovascular
complications,
glycemic
control,
multimorbidity,
or
related
clinical
outcomes
among
people
with
diabetes.
Review
articles,
case
reports/series,
pilot
studies,
editorials,
opinion
articles,
and
reports
with
insucient outcome data were excluded. Owing to substantial heterogeneity
in
populations,
designs,
denitions,
and
outcome
reporting,
ndings
were
synthesised
narratively
without
statistical
pooling.
Methodological
limitations
were
appraised
across
selection,
exposure/risk-factor
measurement,
outcome
assessment,
confounding,
and
data-completeness
domains.
RESULTS
Twenty studies were included after screening 613 records. The evidence base
was
predominantly
cross-sectional,
although
large
retrospective
and
prospective
cohorts
were
also
represented.
Microvascular
complications,
particularly
nephropathy/chronic
kidney
disease,
neuropathy,
and
retinopathy, were reported more consistently than macrovascular outcomes.
Studies
that
directly
assessed
both
complication
categories
generally
documented an appreciable burden of both small- and large-vessel disease.
Across
studies,
poor
glycemic
control,
longer
diabetes
duration,
hypertension,
obesity,
dyslipidemia,
older
age,
suboptimal
adherence,
and
irregular
follow-up
were
repeatedly
associated
with
greater
complication
burden.
Most
studies
were
judged
to
have
low-to-moderate
methodological
concerns,
driven
mainly
by
cross-sectional
designs,
restricted
recruitment
settings, and incomplete control of confounding.
CONCLUSION
Recent
observational
evidence
indicates
a
substantial
and
heterogeneous
burden
of
diabetes-related
complications
in
routine
clinical
settings.
The
ndings
support
integrated
surveillance
of
renal,
retinal,
neurologic,
cardiovascular,
peripheral
vascular,
and
foot
complications
alongside
sustained glycemic and cardiovascular risk-factor management. Because the
included studies
were
methodologically heterogeneous, the review
supports
clinical pattern recognition
rather than a single pooled prevalence estimate.
KEYWORDS:
Diabetes
Mellitus,
Type
2
Diabetes
Mellitus,
Diabetic
Complications, Microvascular Complications, Macrovascular Complications,
Glycemic
Control,
Hba1c,
Clinical
Outcomes,
Multimorbidity
INTRODUCTION
Diabetes
mellitus
is
a
major
chronic
non-
communicable
disease
and
a
persistent
challenge
for
general
medicine,
primary
care,
and
specialist
services.
Sustained
hyperglycemia,
together
with
coexisting cardiometabolic risk factors, contributes to
progressive
injury
involving
the
eyes,
kidneys,
peripheral
nerves,
heart,
brain,
and
peripheral
vasculature.
1,2,3
The
resulting
complications
account
for
a
substantial
share
of
diabetes-related
morbidity,
disability, healthcare use, impaired quality of life, and
Shumaila Ali Nasir
1
,Sara Malik
2
, Sadaf Fatima
3
, Anjum Raza
4
, Talat Aslam
5
, Aamena Gardazi
6
Nasir SA, Malik S, Fatima S, Raza A,
Aslam T, Gardazi A.
Patterns of
Diabetes-Related Complications and
Clinical Outcomes in General
Medicine Settings: A Systematic
Review Without Meta-Analysis. J
Gandhara Med Dent Sci. 2026;13(4):
2-6.doi:
Date Submission:
16-07-2026
Date Revised:
23-09-2026
Date Acceptance:
23-09-2026
1
Senior Registrar, Department of
Medicine, Bakhtawar Amin Trust
Teaching Hospital, Multan
3
Assistant Consultant, Department of
Internal Medicine, Mukhtar A Sheikh
Hospital, Multan
4
Senior Medical Ocer, Department
of Internal Medicine, Mukhtar A
Sheikh Hospital, Multan
5
Assistant Professor, Department of
Medicine, Bakhtawar Amin Trust
Teaching Hospital, Multan
Correspondence
2
Sara Malik, Associate Consultant,
Department of Internal Medicine,
Mukhtar A Sheikh Hospital, Multan
+92-334-9087890
sarahumair@ymail.com
:
:
http://doi.org/10.37762/jgmds.13-4.971
152
J Gandhara Med Dent Sci
October - December 2026
premature mortality.
1,4
Diabetes-related complications
are
commonly
classied
as
microvascular
and
macrovascular.
Microvascular
disease
includes
retinopathy, nephropathy, chronic kidney disease, and
peripheral neuropathy, whereas macrovascular disease
includes
coronary
artery
disease,
cerebrovascular
disease, and peripheral arterial disease.
3
Diabetic foot
disease,
infection,
impaired
wound
healing,
and
multimorbidity
add
further
complexity
and
often
reect
the
interaction
of
neuropathic,
vascular,
metabolic,
and
healthcare-related
factors.
Recent
observational studies from diverse healthcare systems
have
reported
considerable
variation
in
complication
burden.
Studies
from
Vietnam,
Ethiopia,
Italy,
and
India,
for
example,
have
documented
diering
distributions of nephropathy, neuropathy, retinopathy,
cardiovascular
disease,
peripheral
vascular
disease,
and
diabetic
foot
morbidity.
5,6,7,8
Some
complications
are
already
present
when
type
2
diabetes
is
rst
diagnosed, while others accumulate during follow-up,
underscoring the importance of early risk assessment
and
longitudinal
surveillance.
7,9
Across
the
literature,
poor
glycemic
control,
longer
disease
duration,
hypertension,
obesity,
dyslipidemia,
older
age,
treatment non-adherence, and irregular follow-up recur
as
factors
associated
with
adverse
diabetes
outcomes.
9,10
Multimorbidity
is
also
increasingly
recognised as a dening feature of diabetes care rather
than
an
exception,
with
renal,
vascular,
neurologic,
and
cardiometabolic
conditions
frequently
clustering
within
the
same
individuals.
4,11
However,
direct
comparison
across
studies
is
dicult
because
of
dierences in study design, population characteristics,
healthcare
setting,
diagnostic
criteria,
outcome
definitions, and methods of glycemic assessment. The
objective
of
this
systematic
review
was
therefore
to
synthesise
original
studies
published
from
2019
to
2025
describing
patterns
of
diabetes-related
complications
and
clinical
outcomes,
with
particular
emphasis on microvascular and macrovascular disease,
glycemic
control,
multimorbidity,
and
factors
associated with poorer outcomes in general medicine
and related routine-care settings.
METHODOLOGY
This systematic review was
designed as a qualitative
evidence synthesis
without meta-analysis because the
included
studies
diered
substantially
in
population
characteristics,
study
design,
clinical
setting,
definitions
of
complications,
and
outcome
reporting.
The
manuscript
has
been
structured
using
PRISMA
2020
reporting
principles
and
the
SWiM
reporting
guideline
for
synthesis
without
meta-analysis.
12,13
Original research studies published from 2020 through
2025
were
eligible
if
they
included
people
with
diabetes
mellitus
and
reported
one
or
more
of
the
following:
microvascular
complications,
macrovascular complications, chronic diabetes-related
complications,
glycemic-control
status,
multimorbidity,
clinical
outcomes,
or
factors
associated
with
adverse
outcomes.
Eligible
designs
included
cross-sectional,
prospective
observational,
retrospective
cohort,
prospective
cohort,
multicenter,
hospital-based,
community-based,
and
other
routine-
care
observational
studies.
Studies
were
restricted
to
English-language
full-text
reports
with
sucient
methodological
and
outcome
information
for
qualitative
synthesis.
Systematic
reviews,
meta-
analyses,
narrative
or
scoping
reviews,
case
reports,
case series, pilot studies, editorials, letters, conference
abstracts
with
insucient
data,
and
opinion
articles
were excluded. Reports were also excluded when the
study
population
was
not
clearly
dened,
relevant
diabetes-related
outcomes
were
not
reported,
data
were duplicated, or the available report did not contain
sufcient
information
for
extraction.
A
structured
literature
search
was undertaken in PubMed, Web of
Science,
and
Scopus.
The
search
covered
studies
published
from
January
2019
through
2025.
The
source review reports the use of Boolean combinations
of the following concepts:type 2 diabetes mellitus,ǁ
diabeti
complications,ǁ
microvascular
complications,ǁ
macrovascular
complications,ǁ
diabetic
nephropathy,ǁ
diabeti
neuropathy,ǁ
diabetic
retinopathy
cardiovascular
complications,ǁ
clinical
outcomes,
glycemic
control,ǁ
and
HbA1c.ǁ
The
search
identied
613
records: 241 from PubMed, 172 from Web of Science,
and
200
from
Scopus.
Study
selection
proceeded
sequentially.
Titles
and
abstracts
were
screened
to
remove
clearly
irrelevant
records,
after
which
potentially
eligible
reports
underwent
full-text
assessment
against
the
prespecied
inclusion
and
exclusion criteria. Of 613 records identied, 103 were
removed before screening, 410 were excluded during
title/abstract
screening,
8
reports
could
not
be
retrieved,
and
72
full-text
reports
were
excluded,
leaving 20 studies for qualitative synthesis (Figure 1).
A structured extraction form was used to record author
and year, country or region, study design, sample size,
diabetes
population,
clinical
setting,
study
focus,
reported
microvascular
and
macrovascular
complications,
dominant
complication
patterns,
glycemic-control
ndings,
clinical
outcomes,
and
factors associated with poorer outcomes. The principal
outcomes of interest were nephropathy/chronic kidney
disease,
neuropathy,
retinopathy,
albuminuria,
cardiovascular
disease,
coronary
artery
disease,
stroke/cerebrovascular
disease,
peripheral
vascular
or
Patterns of Diabetes-Related Complications and Clinical Outcomes
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J Gandhara Med Dent Sci
October - December 2026
arterial disease, diabetic foot complications, glycemic-
control status, multimorbidity, healthcare burden, and
clinically
relevant
associated
factors.
The
source
review
used
a
qualitative
domain-based
appraisal
informed
by
Joanna
Briggs
Institute
(JBI)
and
NewcastleOttawa
Scale
concepts.
14,15
The
recorded
domains
were
participant
selection,
measurement
of
exposures or risk factors, outcome assessment, control
of confounding, and completeness of data. Each study
was
categorised
as
having
low,
moderate,
or
low-to-
moderate
overall
concern
based
on
the
pattern
of
domain-level
judgments.
Because
the
source
extraction
did
not
preserve
design-specific
item-by-
item JBI or NOS scoring, these ratings are presented
as
an
author-dened
qualitative
appraisal
rather
than
as validated JBI/NOS summary scores. Meta-analysis
was
not
undertaken
because
outcome
denitions,
study
designs,
populations,
clinical
settings,
and
reporting
metrics
were
too
heterogeneous
for
defensible
statistical
pooling.
Studies
were
therefore
grouped
and
compared
descriptively
by
design
and
setting,
complication
pattern,
glycemic-control
findings,
associated
factors,
and
reported
clinical
outcomes. Particular emphasis was placed on recurrent
patterns
across
independent
settings
rather
than
on
deriving a single pooled prevalence estimate.
Figure
1:
PRISMA-Style
Flow
Diagram
of
Study
Identification
and Selection.
RESULTS
Twenty
original
studies
published
between
2020
and
2025
were
included.
The
studies
represented
Asia,
Africa, the Middle East, Europe, North America, and
South
America and included outpatient, primary-care,
hospital,
referral-centre,
community,
multicenter,
integrated-health-system,
and
electronic-medical-
record
settings.
Cross-sectional
and
other
observational
designs
predominated,
although
the
evidence
base
also
included
long-term
retrospective
and
prospective
cohorts.
Sample
sizes
ranged
from
140
participants
in
smaller
hospital-based
studies
to
496,408
patients
in
a
large
electronic-medical-record
network
analysis.
Table
1
summarises
the
included
studies.
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J Gandhara Med Dent Sci
October - December 2026
Table 1: Characteristics of Included Studies
Author &
Year
Country
/Region
Study Design
Sample
Size
Diabetes
Type/Population
Study Setting
Main Focus
Nguyen et
al., 2020 (5)
Vietnam
Observational, non-
interventional cross-
sectional study
1,631
Type 2 diabetes
mellitus
Hospital outpatient
diabetes care
Diabetes
management, glycemic
control, and complications
Sheleme et
al., 2020 (6)
Ethiopia
Prospective
observational study
400
Diabetes mellitus
patients
Mettu Karl Referral
Hospital ambulatory
clinic
Prevalence, pattern, and predictors of
chronic diabetic complications
Bonora et al.,
2020 (7)
Italy
Observational study
160
Newly diagnosed
type 2 diabetes
Verona Diabetes
Clinic
Chronic complications at diagnosis
and related clinical features
Venguidesva
rane et al.,
2020 (8)
India
Hospital-based cross-
sectional study
390
Type 2 diabetes
mellitus
Rural health and
training centre
Microvascular and macrovascular
complications and related factors
An et al.,
2021 (11)
United
States
Retrospective cohort
study
135,199
Newly diagnosed
type 2 diabetes
Integrated
healthcare system
Fifteen-year prevalence and incidence
of microvascular and macrovascular
complications
Seid et al.,
2021(16)
Ethiopia
Cross-sectional study
200
Type 2 diabetes
mellitus
Dessie town
hospitals
Microvascular complications and
predictors among T2DM patients
Hafidh et al.,
2022(17)
Middle
East and
Africa
Baseline cross-
sectional analysis of a
prospective
observational cohort
3,525
Type 2 diabetes
starting second-
line therapy
Multicountry
DISCOVER study
Vascular complications and associated
risk factors
Alnaim et
al., 2023 (18)
Saudi
Arabia
Retrospective cross-
sectional study
935
Type 2 diabetes
mellitus
Diabetes clinics,
National Guard
hospitals
Prevalence of microvascular
complications
Ewid et al.,
2023 (19)
Saudi
Arabia
Cross-sectional
descriptive study
200
Type 2 diabetes
mellitus
Al-Qassim region
Glycemic control and diabetic
complications
Dweib et al.,
2023 (20)
Palestine
Cross-sectional study
882
Adults with
diabetes mellitus
Primary healthcare
centres, West Bank
Diabetes-related microvascular
complications in primary care
Russo
et al.,
2023 (21)
Argentin
a
Observational cross-
sectional study
150,725
afliates
; 12,832
with
diabetes
Adults with
diabetes
Outpatient/private
health system
Diabetes prevalence, epidemiology,
comorbidities, and vascular
complications
Zhang et al.,
2023 (22)
China
Network-based
observational study
using electronic
medical records
496,408
People with type 2
diabetes
Electronic medical
records from 35
hospitals in
Shanghai
Multimorbidity patterns in T2DM
Shillah et al.,
2024 (23)
Tanzania
Cross-sectional
analytical hospital-
based study
140
Type 2 diabetes
mellitus
Singida and
Dodoma regional
referral hospitals
Predictors of microvascular
complications
Merid et al.,
2024 (24)
Ethiopia
Institution-based
cross-sectional study
378
Type 2 diabetes
mellitus
Southern Ethiopia
Microvascular complications and
associated factors
Negussie et
al., 2024 (25)
Ethiopia
Institution-based
cross-sectional study
381
Adult type 2
diabetes patients
Adama, central
Ethiopia
Microvascular complications among
adults with T2DM
Solela et al.,
2024 (26)
Ethiopia
Retrospective study
140
Type 2 diabetes
mellitus
Teaching hospital,
Addis Ababa
Patterns and determinants of vascular
complications
El Aameri et
al., 2024 (27)
Morocco
Cross-sectional study
300
Type 2 diabetes
mellitus
Clinical/biological
assessment setting
Chronic diabetic complications and
associated factors
Alrubaiee,
2025(28)
Yemen
Cross-sectional study
222
Follow-up diabetic
patients
National Diabetic
Referral Centre,
Sana’a
Chronic diabetic complications and
risk factors
Sreedevi et
al., 2025 (29)
India
Observational study
300
Type 2 diabetes
mellitus
Clinical/community
diabetic population
Prevalence and determinants of
neuropathy, retinopathy, and
peripheral arterial disease
De Zoysa et
al., 2025 (30)
Sri
Lanka
Multicenter hospital-
based cross-sectional
study
2,013
Type 2 diabetes
mellitus
Seven tertiary care
hospitals
Glycemic control and
demographic/behavioral factors linked
to clinical outcomes
Patterns of Diabetes-Related Complications and Clinical Outcomes
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J Gandhara Med Dent Sci
October - December 2026
Across
the
included
evidence,
microvascular
complications
were
reported
more
consistently
than
macrovascular outcomes. Nephropathy/chronic kidney
disease,
neuropathy,
and
retinopathy
were
the
most
recurrent
microvascular
conditions,
while
cardiovascular
disease,
cerebrovascular
disease,
peripheral
vascular/arterial
disease,
and
diabetic
foot
complications represented the main macrovascular or
mixed
clinical
outcomes.
Importantly
more
frequently
reportedǁ
does
not
necessarily
indicate
a
higher
pooled
prevalence
because
not
all
studies
assessed
both
complication
categories
using
comparable
methods.
Where
both
categories
were
directly
evaluated,
an
appreciable
burden
of
microvascular and macrovascular disease was evident.
Venguidesvarane
et
al.
reported
microvascular
complications
in
52.1%
and
macrovascular
complications in 29.7% of a
rural Indian sample.
8
In
the DISCOVER Middle East and Africa cohort, crude
prevalence
was
17.7%
for
microvascular
and
10.7%
for macrovascular complications among 3,525 patients
initiating
second-line
therapy.
13
In
the
US
retrospective
cohort,
chronic
kidney
disease
was
the
most prevalent complication at diagnosis (12.3%), and
complication
burden
within
primary
or
referral
care.
Dweib
et
al.
reported
at
least
one
microvascular
complication in 34.4% of 882 participants in the West
Bank,
while
studies
from
Tanzania,
Ethiopia,
Morocco,
and
Yemen
documented
varying
but
clinically
meaningful
prevalences
of
retinopathy,
neuropathy,
nephropathy,
and
chronic
complications.
16,19,20,21,22,23,24
Table
2
summarises
study-level complication patterns.
up.
11
Several
studies
also
demonstrated
substantial
new complications accumulated over long-term follow-
Table 2: Patterns of Diabetes-Related Complications Reported In Included Studies
Author &
Year
Microvascular
Complications Reported
Macrovascular / Other
Complications Reported
Most Common / Main
Reported Pattern
Key Finding
Nguyen et
al., 2020 (5)
Retinopathy,
nephropathy, neuropathy
Cardiovascular and other
diabetes-related
complications
Mixed diabetic
complications
The study described glycemic control
and diabetes-related complications
among Vietnamese patients with type 2
diabetes.
Sheleme et
al., 2020 (6)
Retinopathy, neuropathy,
nephropathy
Cardiovascular disease and
diabetic foot-related
complications
Chronic diabetic
complications
Nearly two-fths of patients had
chronic complications, with poor
glycemic control and hypertension
contributing to higher risk.
Bonora et
al., 2020 (7)
Neuropathy, retinopathy,
albuminuria, chronic
kidney disease
Cardiovascular disease
Complications already
present at diagnosis
Chronic complications were observed
even among newly diagnosed type 2
diabetes patients, showing the need for
early screening.
Venguidesv
arane et al.,
2020 (8)
Neuropathy, nephropathy,
retinopathy
Coronary artery disease
and peripheral vascular
disease
Microvascular
complications were
more frequent
Microvascular complications were
reported in 52.1%, while macrovascular
complications were found in 29.7% of
patients.
An et al.,
2021 (11)
Chronic kidney disease,
retinopathy, neuropathy
Cardiovascular disease,
cerebrovascular disease,
peripheral vascular disease
Chronic kidney disease
was prominent
At diagnosis, chronic kidney disease
was the most prevalent complication
(12.3%); incident complications
accumulated during follow-up.
Seid et al.,
2021(16)
Retinopathy, neuropathy,
nephropathy
Not the main focus
Microvascular
complications
The study focused on microvascular
complications and showed that these
complications remained common
among type 2 diabetes patients.
Hafidh et al.,
2022(17)
Neuropathy, nephropathy,
retinopathy
Cardiovascular disease,
stroke, peripheral arterial
disease
Microvascular
complications more
prevalent than
macrovascular
complications
In the DISCOVER Middle East/Africa
cohort, crude prevalence was 17.7% for
microvascular and 10.7% for
macrovascular complications.
Alnaim et
al., 2023
(18)
Nephropathy,
retinopathy, neuropathy
Not the main focus
Nephropathy was the
leading complication
Nephropathy was the most commonly
reported microvascular
complication,
followed by retinopathy and
neuropathy.
Ewid et al.,
2023 (19)
Diabetes
-
related
microvascular
complications
Diabetes
-
related
macrovascular
complications
Complications
linked
with poor glycemic
control
Suboptimal glycemic control was an
important clinical issue and was
associated with diabetes-related
complications.
Continue...
Patterns of Diabetes-Related Complications and Clinical Outcomes
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J Gandhara Med Dent Sci
October - December 2026
Dweib et
al., 2023
(20)
Retinopathy, neuropathy,
nephropathy
Not the main focus
At least one
microvascular
complication
At least one microvascular
complication was reported in 34.4% of
participants; retinopathy was the most
frequent individual complication.
Russo et al.,
2023 (21)
Microvascular
complications
Vascular and
cardiometabolic
complications
Vascular complications
with comorbid burden
The study described diabetes
prevalence, comorbidities, and vascular
complications in a large outpatient
population.
Zhang et
al., 2023
(22)
Diabetic kidney disease,
retinopathy, neuropathy
within multimorbidity
patterns
Cardiovascular and
metabolic comorbidities
Multimorbidity
clustering
Large-scale electronic medical records
showed multimorbidity clustering
among people with type 2 diabetes.
Shillah et
al., 2024
(23)
Retinopathy, neuropathy,
nephropathy
Not the main focus
Retinopathy was the
most frequent
microvascular
complication
Microvascular complications were
present in 57.6% of patients, with
retinopathy being the most common
reported complication.
Merid et al.,
2024 (24)
Neuropathy, nephropathy,
retinopathy
Not the main focus
Neuropathy was the
leading complication
Microvascular complications were
found in 26.5% of patients; neuropathy
was most common, followed by
nephropathy and retinopathy.
Negussie et
al., 2024
(25)
Neuropathy, retinopathy,
nephropathy
Not the main focus
Microvascular
complications
More than one-fth of adults with type
2 diabetes had microvascular
complications, mainly related to poor
glycemic control and hypertension.
Solela et
al., 2024
(26)
Neuropathy, nephropathy,
retinopathy
Coronary artery disease
and other vascular
complications
Both microvascular and
macrovascular
complications
Overall vascular complications were
reported in 39%; microvascular
complications were 23.5% and
macrovascular complications were 21%.
El Aameri
et al., 2024
(27)
Retinopathy,
nephropathy, neuropathy
Cardiovascular disease
Combined chronic
complications
The study assessed chronic
complications among Moroccan type 2
diabetes patients and emphasised both
microvascular and cardiovascular
involvement.
Alrubaiee,
2025(28)
Nephropathy,
retinopathy, neuropathy
Diabetic foot and other
chronic complications
High overall
complication burden
Chronic diabetic complications were
reported in 62.6% of patients; non-
adherence, obesity, uncontrolled
hypertension, and irregular follow-up
were major risk factors.
Sreedevi et
al., 2025
(29)
Peripheral neuropathy,
diabetic retinopathy
Peripheral arterial disease
Peripheral neuropathy
and peripheral arterial
disease were common
Peripheral neuropathy, diabetic
retinopathy, and peripheral arterial
disease were common, showing a
combined microvascular and peripheral
vascular burden.
De Zoysa et
al., 2025
(30)
Complications considered
in relation to glycemic
control
Clinical outcomes related
to diabetes control
Glycemic control-
related outcome pattern
The study highlighted behavioural and
demographic factors associated with
optimal glycemic control among type 2
diabetes patients.
Poor
glycemic
control
was
the
most
consistent
modifiable factor associated with complication burden.
Across studies, higher or uncontrolled HbA1c, longer
diabetes duration, hypertension, obesity, dyslipidemia,
older
age,
suboptimal
treatment
adherence,
and
irregular
clinical
follow-up
recurred
as
factors
associated
with
adverse
outcomes.
Because
most
included studies were cross-sectional, these factors are
described primarily as associations rather than causal
predictors.
The
outcome
spectrum
extended
beyond
the
presence
of
individual
complications.
Studies
described long-term incident vascular disease, renal
impairment,
multimorbidity,
diabetic
foot
morbidity,
and
poorer
overall
clinical
stability
among
patients
with uncontrolled or inadequately monitored diabetes.
Large electronic-health-record data also demonstrated
complex clustering of cardiometabolic, vascular, renal,
and other chronic conditions among people with type
2
diabetes.
18
Table
3
summarises
the
main
clinical
outcomes and associated factors.
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157
J Gandhara Med Dent Sci
October - December 2026
Table 3:
Clinical Outcomes and Factors Associated with Adverse Outcomes
Author &
Year
Main Clinical Outcomes
Reported
Glycemic Control /
HbA1c-Related Findings
Factors associated with
adverse outcomes
Overall Interpretation
Nguyen et al.,
2020 (5)
Diabetes control status,
treatment pattern, and presence
of complications
Poor glycemic control was
common among patients
with type 2 diabetes
Longer diabetes duration,
suboptimal treatment
adherence, and inadequate
metabolic control
Uncontrolled diabetes was
associated with a greater
burden of diabetes-related
complications.
Sheleme et al.,
2020 (6)
Chronic diabetic complications
and related morbidity
Poor glycemic control
increased the likelihood of
chronic complications
Hypertension, long disease
duration, poor glycemic
control, and irregular
follow-up
Patients with uncontrolled
diabetes and coexisting
hypertension were more
likely to develop chronic
complications.
Bonora et al.,
2020 (7)
Chronic complications at the
time of diabetes diagnosis
Newly diagnosed patients
already showed metabolic
and clinical risk burden
Older age, obesity,
hypertension,
dyslipidemia, and
metabolic abnormalities
Complications may begin
before formal diagnosis,
supporting early screening
and risk assessment.
Venguidesvara
ne et al., 2020
(8)
Microvascular and
macrovascular complications
Poor glycemic control was
linked with higher
complication frequency
Increasing age, longer
diabetes duration,
hypertension, and poor
glucose control
Both microvascular and
macrovascular complications
were clinically important in
rural type 2 diabetes patients.
An et al., 2021
(11)
Long
-
term incidence of
microvascular and
macrovascular complications
Baseline and follow-up
metabolic control
inuenced complication
development
Older age, baseline
comorbidities, renal
impairment, and duration
of diabetes
New complications continued
to develop over time,
showing the need for long-
term surveillance.
Seid et al.,
2021(16)
Microvascular complications
among type 2 diabetes patients
Poor glucose control
contributed to
microvascular disease
Longer duration of
diabetes, hypertension,
and uncontrolled blood
glucose
Microvascular outcomes were
associated with chronic
exposure to poor metabolic
control.
Continue...
Hafidh et al.,
2022(17)
Vascular complications in
patients receiving second-line
therapy
Uncontrolled diabetes
remained an important
background factor
Older age, longer diabetes
duration, hypertension,
dyslipidemia, and obesity
Patients requiring treatment
intensication had a
meaningful
vascular
complication burden.
Alnaim et al.,
2023 (18)
Nephropathy, retinopathy,
neuropathy, and other
microvascular outcomes
Glycemic control was
relevant to microvascular
complication occurrence
Longer diabetes duration,
elevated HbA1c,
hypertension, and age
Microvascular complications
were common, particularly
among patients with poor
long-term
diabetes control.
Ewid et al.,
2023 (19)
Diabetes complications and
metabolic control status
Poor HbA1c control was
frequently observed
Poor adherence,
inadequate glycemic
control, obesity, and
comorbid disease
Complication risk was greater
when diabetes remained
uncontrolled or poorly
monitored.
Dweib et al.,
2023 (20)
Microvascular complications in
primary healthcare patients
Glycemic status inuenced
the occurrence of
microvascular outcomes
Older age, longer disease
duration, hypertension,
and poor diabetes control
Primary care diabetic patients
showed substantial
microvascular morbidity,
requiring routine screening.
Russo et al.,
2023 (21)
Vascular complications and
comorbid conditions
Diabetes control was
evaluated with
clinical and
epidemiological factors
Older age, cardiovascular
risk factors, hypertension,
and associated
comorbidities
Diabetes was associated with
a high cardiometabolic and
vascular disease burden.
Zhang et al.,
2023 (22)
Multimorbidity patterns among
people with type 2 diabetes
Glycemic control
contributed to disease
clustering but was not the
only factor
Age, obesity,
hypertension,
dyslipidemia, and multiple
chronic conditions
Type 2 diabetes frequently
occurred with multimorbidity,
increasing the complexity of
clinical management.
Shillah et al.,
2024 (23)
Microvascular complications in
hospital-based patients
Poor glycemic control was
linked to microvascular
complications
Older age, long duration of
diabetes, hypertension,
and poor glucose control
Retinopathy and other
microvascular outcomes were
important indicators of
disease progression.
Merid et al.,
2024 (24)
Neuropathy, nephropathy, and
retinopathy
Inadequate glycemic
control increased
microvascular risk
Long diabetes duration,
hypertension, poor
glycemic control, and
treatment-related factors
Microvascular disease
remained a major outcome
among type 2 diabetes
patients in Southern Ethiopia.
Negussie et
al., 2024 (25)
Microvascular complications
among adults with type 2
diabetes
Poor glucose control was
associated with higher
complication risk
Hypertension,
uncontrolled diabetes,
older age, and longer
disease duration
The study emphasised the
importance of early
identication of high-risk
patients.
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Solela et al.,
2024 (26)
Overall vascular complications,
including microvascular and
macrovascular
disease
Glycemic status
contributed to vascular
risk
.
Age, hypertension,
diabetes duration, lipid
abnormality, and poor
glycemic control
Both small-vessel and large-
vessel complications
contributed to the overall
outcome burden.
El Aameri et
al., 2024 (27)
Chronic complications and
associated clinical factors
Poor control was related to
chronic complication
development
Longer diabetes duration,
hypertension, obesity, and
poor metabolic control
Chronic complications were
common and reected
delayed control of modiable
risk factors.
Alrubaiee,
2025(28)
Chronic complications, diabetic
foot, and follow-up-related
outcomes
Uncontrolled diabetes
increased chronic
complication risk
Non-adherence, obesity,
uncontrolled hypertension,
irregular follow-up, and
poor glucose control
Complications were frequent
among patients with poor
adherence and inadequate
disease monitoring.
Sreedevi et al.,
2025 (29)
Neuropathy, retinopathy, and
peripheral arterial disease
Glycemic control was
relevant to complication
development
Age, diabetes duration,
hypertension, poor
glycemic control, and
vascular risk factors
The study showed combined
microvascular and peripheral
vascular disease burden
among type 2 diabetes
patients.
De Zoysa et
al., 2025 (30)
Optimal glycemic control and
related clinical outcomes
Optimal glycemic control
was associated with
behavioural and
demographic factors
Lifestyle behaviour,
demographic prole,
treatment adherence, and
clinical monitoring
Better glycemic control was
linked with modiable
behavioural and healthcare-
related factors.
Most
included
studies
were
categorised
as
having
low,
low-to-moderate,
or
moderate
methodological.
Common strengths included clearly described clinical
populations,
direct
clinical
or record-based
outcome
ascertainment, and, in several studies, large samples
or
multicenter
recruitment.
Recurrent
limitations
included
cross-sectional
design,
single-centre
or
referral-centre
sampling,
limited
temporal
information, incomplete adjustment for confounding,
and
inconsistent
reporting
of
glycemic-control
or
complication-screening methods.
Table 4
Domain
Based Methodological Appraisal of Included Studies
:
-
Author &
Year
Selection
Bias
Measurement of
Exposure / Risk
Factors
Outcome
Assessment
Control of
Confounding
Completeness
of Data
Overall
Risk of
Bias
Main Reason for Judgment
Nguyen et
al., 2020 (5)
Low
Low
Low
Moderate
Low
Low to
Moderate
Large sample and clear clinical
assessment, but observational
design limited causal
interpretation.
Sheleme et
al., 2020 (6)
Moderate
Low
Low
Moderate
Moderate
Moderate
Prospective design was useful,
but some confounding factors
may not have been fully
controlled.
Bonora et
al., 2020 (7)
Low
Low
Low
Low
Low
Low
Newly diagnosed diabetic
patients were systematically
assessed with good reporting
of clinical features.
Venguidesv
arane et al.,
2020 (8)
Moderate
Low
Low
Moderate
Low
Moderate
Hospital/rural health-centre
recruitment may limit
generalizability, although
complication assessment was
clearly reported.
An et al.,
2021 (11)
Low
Low
Low
Low
Low
Low
Large retrospective cohort
with long follow-up and clear
reporting of microvascular and
macrovascular outcomes.
Seid et al.,
2021(16)
Moderate
Low
Low
Moderate
Moderate
Moderate
Cross-sectional design
restricted temporality, and
residual confounding remained
possible.
Hafidh et
al., 2022(17)
Low
Low
Low
Low
Low
Low
Multicountry prospective
cohort design strengthened
external validity and
complication reporting.
Continue...
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October - December 2026
Alnaim et
al., 2023
(18)
Moderate
Low
Low
Moderate
Low
Moderate
Retrospective cross-sectional
design was appropriate for
prevalence estimation but
limited causal inference.
Ewid et al.,
2023 (19)
Moderate
Moderate
Low
Moderate
Moderate
Moderate
Descriptive design and modest
sample size increased the
possibility of selection and
confounding bias.
Dweib et al.,
2023 (20)
Moderate
Low
Low
Moderate
Low
Moderate
Primary-care-based design
improved relevance, but cross-
sectional data limited
interpretation of predictors.
Russo et al.,
2023 (21)
Low
Low
Low
Moderate
Low
Low to
Moderate
Very large population
improved precision, but
observational design and
database-based assessment
may have introduced residual
confounding.
Zhang
et al.,
2023 (22)
Low
Low
Low
Moderate
Low
Low to
Moderate
Network-based analysis
provided broad multimorbidity
information, but clinical detail
for individual complications
may have varied.
Shillah et
al., 2024
(23)
Moderate
Low
Low
Moderate
Low
Moderate
Hospital-based cross-sectional
design may have
overrepresented patients with
more advanced disease.
Merid et al.,
2024 (24)
Moderate
Low
Low
Moderate
Low
Moderate
Institution-based design and
cross-sectional analysis limited
generalizability and temporal
conclusions.
Negussie et
al., 2024
(25)
Moderate
Low
Low
Moderate
Low
Moderate
Adequate complication
assessment was reported, but
selection from a limited
geographic area may reduce
external validity.
Solela et al.,
2024 (26)
Moderate
Moderate
Low
Moderate
Moderate
Moderate
Retrospective records may
have incomplete information
on exposures, follow-up, and
confounders.
El Aameri et
al., 2024
(27)
Moderate
Low
Low
Moderate
Low
Moderate
Cross-sectional design was
suitable for estimating chronic
complications but could not
establish direction of
association.
Alrubaiee,
2025(28)
Moderate
Low
Low
Moderate
Low
Moderate
Referral-center sampling may
have included patients with
more severe disease, aecting
representativeness.
Sreedevi et
al., 2025
(29)
Moderate
Low
Low
Moderate
Low
Moderate
Community screening
improved detection, but
observational design limited
causal interpretation of
determinants.
De Zoysa et
al., 2025
(30)
Low
Low
Low
Moderate
Low
Low to
Moderate
Multicenter design and large
sample strengthened
reliability, although residual
confounding could not be
excluded.
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DISCUSSION
This
systematic
review
synthesises
recent
observational
evidence
showing
that
diabetes-related
complications
remain
common
across
general
medicine
and
routine-care
settings.
The
most
persistent
pattern
was
the
repeated
documentation
of
microvascular
disease
particularly
nephropathy/chronic
kidney
disease,
neuropathy,
and
retinopathy
alongside
clinically
important
macrovascular and peripheral vascular outcomes. The
evidence
also
indicates
that
complications
frequently
coexist,
supporting
a
multisystem
rather
than
organ-
isolated
view
of
diabetes
morbidity.
The
review
should not be interpreted as demonstrating a universal
prevalence
hierarchy
between
microvascular
and
macrovascular
complications.
Studies
diered
substantially
in
which
complications
they
actively
screened
for,
how
outcomes
were
dened,
and
whether ascertainment relied on clinical examination,
laboratory
data,
patient
records,
or
administrative
coding. Among studies that evaluated both categories,
microvascular
complications
were
often
numerically
more common, while macrovascular disease remained
a major source of morbidity and long-term risk. Poor
glycemic
control
was
the
most
recurrent
modifiable
correlate
of
complication
burden.
This
nding
is
consistent
with
external
evidence
showing
that
inadequate
glycemic
control
is
common
in
type
2
diabetes
and
is
associated
with
a
broad
range
of
clinical
and
behavioural
factors.
31,32
The
reviewed
studies
also
repeatedly
implicated
hypertension,
obesity,
dyslipidemia,
and
longer
diabetes
duration,
emphasising that complication prevention depends on
comprehensive
cardiometabolic
risk
management
rather
than
glucose
control
alone.
The
temporal
dimension
is
also
clinically
important.
The
large
US
cohort
demonstrated
that
a
substantial
proportion
of
patients already had complications at the time of type
2
diabetes
diagnosis
and
that
new
complications
developed
within
only
a
few
years.
11
Similarly,
Bonora
et
al.
documented
chronic
complications
among
newly
diagnosed
patients.
7
These
ndings
support
early
screening
at
diagnosis
and
sustained
surveillance thereafter. Diabetes-related complications
rarely occur in isolation. Large-scale network data and
clinical
cohorts
demonstrate
clustering
of
kidney
disease,
neuropathy,
retinopathy,
cardiovascular
disease,
hypertension,
obesity,
dyslipidemia,
and
peripheral vascular disease.
18,33,34,35
Pető et al. reported
relationships
between
distal
sensorimotor
polyneuropathy
and
age,
HbA1c,
albuminuria,
retinopathy,
and
cardiovascular
complications
(),
while
Roostaei
et
al.
described
interrelationships
among
neuropathy,
retinopathy,
and
nephropathy.
33,34
These patterns support integrated risk stratication and
coordinated
care
pathways
rather
than
sequential,
organ-specic management. Peripheral arterial disease
and
diabetic
foot
morbidity
were
less
consistently
reported
than
nephropathy,
neuropathy,
and
retinopathy, but they remain
clinically
consequential.
External
evidence
indicates
that
at-risk
diabetic
foot
status
is
associated
with
higher
all-cause
and
cardiovascular
mortality,
and
that
deep
or
infected
diabetes-related
foot
ulcers
are
associated
with
increased major adverse cardiovascular-event risk.
36,37
Neuropathy
may
be
present
early
in
type
2
diabetes
and
can
contribute
to
loss
of
protective
sensation,
ulceration,
infection,
and
disability.
38
These
ndings
reinforce
the
value
of
routine
foot
examination,
neuropathy
assessment,
vascular
evaluation,
and
prompt
management
of
high-risk
lesions.
The
synthesis supports a pragmatic, integrated surveillance
model in which glycemic assessment is combined with
periodic
renal,
retinal,
neurologic,
cardiovascular,
peripheral
vascular,
and
foot
evaluation.
Blood-
pressure
management,
lipid
control,
weight
management,
medication
adherence,
smoking-risk
reduction
where
relevant,
and
regular
follow-up
should
be
considered
alongside
glucose-lowering
therapy. The evidence also supports multidisciplinary
coordination
across
primary
care,
internal
medicine,
endocrinology,
nephrology,
ophthalmology,
cardiology, vascular/foot services, diabetes education,
and
other
disciplines
according
to
the
patient’s
risk
prole.
Future
studies
should
use
standardised
definitions
for
microvascular
and
macrovascular
outcomes,
report
complication-screening
methods
explicitly,
provide
comparable
HbA1c
and
cardiometabolic-risk
data,
and
distinguish
prevalent
from
incident
complications.
Prospective
multicenter
cohorts
are
particularly
important
for
establishing
temporality
and
quantifying
progression.
Future
systematic
reviews
would
benet
from
protocol
registration,
reproducible
database-specic
search
strategies,
independent
duplicate
screening
and
extraction,
design-specific
risk-of-bias
tools,
and
meta-analysis
where
clinically
and
methodologically
appropriate.
LIMITATIONS
Several
limitations
require
consideration.
Most
included
studies
were
observational,
and
many
were
cross-sectional,
limiting
temporal
and
causal
inference.
Study
populations,
screening
practices,
diagnostic denitions, HbA1c thresholds, and outcome
measures
were
heterogeneous,
precluding
defensible
meta-analysis and direct prevalence comparison. Many
studies
used hospital or referral-centre samples, which
may
overrepresent
patients
with
more
advanced
disease. Residual confounding
was common,
and the
Patterns of Diabetes-Related Complications and Clinical Outcomes
161
J Gandhara Med Dent Sci
October - December 2026
CONCLUSIONS
Diabetes-related
complications
remain
a
substantial
and heterogeneous clinical burden in general medicine
and routine-care settings. Nephropathy/chronic kidney
disease,
neuropathy,
and
retinopathy
were
the
most
consistently
reported
microvascular
complications,
while cardiovascular disease, cerebrovascular disease,
peripheral
vascular
disease,
and
diabetic
foot
morbidity
contributed
important
macrovascular
and
mixed
outcomes.
Poor
glycemic
control,
longer
diabetes duration, hypertension, obesity, dyslipidemia,
older age, suboptimal adherence, and irregular follow-
up
were
recurrently
associated
with
greater
complication burden. The evidence supports early and
repeated
multisystem
screening
together
with
sustained
control
of
modiable
metabolic
and
cardiovascular
risk
factors.
Because
of
marked
heterogeneity
across
the
included
studies,
these
findings should guide clinical pattern recognition and
risk-based surveillance rather than be
interpreted as a
single pooled estimate of complication prevalence.
CONFLICT OF INTEREST:
None
FUNDING SOURCES:
None
source
review
used
a
qualitative
composite
appraisal
rather than consistently applying design-specic risk-
of-bias
tools
item
by
item.
No
formal
certainty-of-
evidence
framework
was
applied,
so
conclusions
should
be
interpreted
as
a
structured
qualitative
synthesis
rather
than
a
graded
estimate
of
eect
or
prevalence.
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Patterns of Diabetes-Related Complications and Clinical Outcomes
AUTHORS CONTRIBUTION
The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.
Shumaila
Ali
Nasir
-
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript; Critical Revision; Final Approval
Sara
Malik
-
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical Revision; Final Approval
Sadaf Fatima
-
Concept &
Design; Data Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical Revision; Final Approval
Anjum
Raza
-
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical Revision; Final Approval
Talat
Aslam
-
Concept & Design; Data
Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript;
Critical Revision; Final Approval
Aamena
Gardazi
-
Concept
&
Design;
Data
Acquisition;
Data
Analysis/Interpretation;
Drafting
Manuscript; Critical Revision; Final Approval
