Diabetic microangiopathy in patients with pancreatitic diabetes mellitus

Screening attendance, prevalence and severity of diabetic retinopathy (DR) in a cohort of patients with diabetes mellitus secondary to chronic pancreatitis (DMsCP) in Northern Ireland

INTRODUCTION

This study investigated Northern Ireland Diabetic Eye Screening Programme (NIDESP) attendance and diabetic retinopathy (DR) prevalence/severity in patients with diabetes mellitus secondary to chronic pancreatitis (PwDMsCP).

RESEARCH DESIGN AND METHODS

Medical/NIDESP records for all PwDMsCP attending the pancreatic diabetes clinic were analyzed in 2017 (n=78) and 2019 (n=94).

RESULTS

Between 2017 and 2019, those without DR decreased (76% to 63%); mild non-proliferative DR (NPDR), severe NPDR and PDR were found in 30%, 2% and 5%, respectively (previously 18%, 4%, 2%); diabetic maculopathy (DMac) was present in 12% (previously 10%). There was no significant difference between worst-eye DR/DMac grade and HbA1c, gender, body mass index, pancreatitis etiology and screening attendance (p>0.05). Patients with proliferative DR had longer diabetes and pancreatitis duration than DR-free patients (both p=0.001).

CONCLUSIONS

DR prevalence was similar in PwDMsCP and patients with type 2 diabetes of similar disease duration. This work demonstrates the importance of reaching all patients for establishing DR severity reliably and to provide accessible, equitable care to PwDMsCP.

Epidemiological study of pancreatic diabetes in Japan in 2005: a nationwide study

OBJECTIVES

There have been few epidemiological studies on pancreatic diabetes. In this study, we determined the incidence and pathology of pancreatic diabetes in Japan.

METHODS

We examined the epidemiology of pancreatic diabetes in Japan in 2005 by using a nationwide stratified random-sampling method. Especially, we focused on newly developed diabetes in association with the occurrence of pancreatic disease (true pancreatic diabetes).

RESULTS

A total of 19,500 individuals received treatment for true pancreatic diabetes, accounting for 0.8% of patients with diabetes. Prevalence was estimated to be 15.2 per 100,000 with an annual onset incidence of 1.1 per 100,000. With regard to the complications in true pancreatic diabetes, the incidence of retinopathy was lower than that in types 1 and 2 diabetes. Among true pancreatic diabetes with chronic pancreatitis, alcoholic pancreatitis was found in the largest sector. Furthermore, as many as 53.7% were continuous drinkers, and 66.7% received insulin therapy. The frequency of hypoglycemia was high in regular drinkers treated with insulin. Hypoglycemia was a major cause of death in patients who were on insulin and continuous drinkers.

CONCLUSION

We clarified the epidemiology of pancreatic diabetes in Japan. Patients with chronic pancreatitis-associated pancreatic diabetes should receive lifestyle guidance focused on drinking cessation.

Endocrine pancreatic insufficiency in chronic pancreatitis

Chronic pancreatitis (CP) is considered to be a rare cause of diabetes mellitus. However, in both the developed and developing world, there is an increasing number of patients suffering from pancreatitis probably due to lifestyle changes, which is partially associated with both social factors and the poor health status of immigrants. Owing to these circumstances, CP has evolved with one of the possible causes of diabetes in a selected group of patients and should be included in the differential diagnosis of diabetes. Several studies have shown that the long-term rate of diabetic complications in patients with CP and insulin-dependent diabetes is similar to that in patients with type 1 diabetes of equal duration. The hypothesis that early diagnosis of CP should result in better prognosis is not validated and may complicate the issue, since the risk of diabetes has been shown to increase significantly only once pancreatic calcification has developed. Accumulative evidence suggests that the risk of diabetes is not influenced by elective pancreatic surgical procedures other than distal pancreatectomy. The lack of contemporary data points to the urgent need for large prospective studies in order to accurately evaluate the special characteristics of disorders in glucose homeostasis in patients with CP.

Natural course of chronic pancreatitis

Although the three leading symptoms of chronic pancreatitis, pain, exocrine and endocrine pancreatic insufficiency, are well known, only a few long-term studies have correlated these symptoms with the natural course of the disease. Besides these symptoms, numerous pancreatic complications and/or pancreatitis-associated diseases may affect the course and determine the prognosis of chronic pancreatitis. Their influence, however, has not been studied in detail. This review has two major aims: The first one is to give an up-to-date survey of present knowledge on the natural course of the disease with a view to the leading symptoms under special consideration of how the duration of the disease, continual alcohol abuse as well as endoscopic procedures and surgical treatment affect pain. Included is also what is known about chronic pancreatitis as a precondition of pancreatic and extrapancreatic carcinoma. The effect of chronic pancreatitis on the socio-economic status of patients is discussed and the mortality rate of the disease. The second aim of this review is to stimulate pancreatologists from different centers to consolidate resources in order to perform larger controlled studies than any one single center can undertake and work out common criteria for the diagnosis of chronic pancreatitis and follow-up of its course.

A comparative study of microvascular complications in patients with secondary and type 1 diabetes

The prevalence of retinopathy, albuminuria, and neuropathy were assessed in 25 patients with insulin-requiring diabetes secondary to chronic pancreatitis and in 25 patients with Type 1 (insulin-dependent) diabetes, matched for age at diabetes onset (secondary, 39 +/- 11 (+/- SD) years vs Type 1, 38 +/- 11 years) and duration of diabetes (10 +/- 6 vs 10 +/- 7 years). The prevalence of retinopathy was significantly higher in Type 1 diabetic patients (52%) than those with secondary diabetes (20%) (p less than 0.02). Median urinary excretion of albumin was 9 (range 1-206) mg 24-h-1 in patients with Type 1 diabetes and 7 (1-90) mg 24-h-1 in patients with secondary diabetes (NS). One secondary diabetic patient and five Type 1 diabetic patients had microalbuminuria (NS). Vibration perception threshold (measured at the big toe) was identical in the two groups of patients, and no patient had a threshold indicating somatic neuropathy (biothesiometry greater than 20 V). Retinopathy is more frequent in patients with Type 1 diabetes than in patients with insulin-requiring diabetes secondary to chronic pancreatitis. Retinopathy is so frequent in the latter group, however, that regular ophthalmoscopic examination is still required.

Diabetic retinopathy in chronic pancreatitis

Using fluorescein angiography, we studied the prevalence and characteristics of diabetic retinopathy in 40 patients with chronic pancreatitis complicated by diabetes and in 40 type 1 diabetics with comparable duration of diabetes. Retinopathy was found in 19 pancreatitis patients (47.5%) and in 20 type 1 diabetic patients (50%); it was background, minimal, or mild to moderate, without impairment of visual function, in all 19 pancreatitis patients and in 17 of the 20 type 1 diabetics. In the remaining three idiopathic diabetics, retinopathy was background of severe degree in two and proliferative, with impairment of vision, in one. No differences between patients with and without retinopathy were observed in fasting blood glucose, glycosylated hemoglobin, serum cholesterol, or triglyceride levels. The only significant difference (p less than 0.001) was the greater duration of diabetes in patients with retinopathy when compared with those without it (10.8 +/- 5.7 vs. 5.2 +/- 3.9 yr in pancreatitis patients; 11.2 +/- 5.0 vs. 5.1 +/- 3.5 yr in type 1 diabetics; mean +/- SD). Contrary to what is generally believed, the results indicate that the risk of retinopathy and the characteristics of this complication in patients with chronic pancreatitis and secondary diabetes are similar to those in patients with idiopathic diabetes.

Diabetic microangiopathy, genetics, environment, and treatment

As the major cause of disability and death in insulin-dependent diabetes, microangiopathy is obviously of major concern to diabetologists. Unlike macroangiopathy, which can readily be prevented by means that are currently on hand, the origin and treatment of microangiopathy remain far more problematical. The complexity of this lesion is indicated by the findings in this laboratory that hyperglycemia induced by the rodenticide, vacor, can cause microangiopathy independent of genetic diabetes, yet significant microangiopathic lesions can be detected in genetic diabetic patients before the appearance of hyperglycemia. Further, there is now intriguing evidence based both on basement membrane measurements from our laboratory and on clinical studies showing that significant microangiopathy only rarely occurs prior to the onset of puberty. The evidence that control or even normalization of blood glucose levels does not influence the course of established microangiopathy is becoming increasingly convincing. Five prospective, randomized studies over the past five years have shown that strict regulation of glucose has no consistent benefit on, and in some studies may, at least transiently, accelerate, the retinopathy of diabetes. Moreover, the first controlled study of successful pancreatic transplantation to achieve normalization of blood glucose levels has again demonstrated that established retinopathy is neither prevented nor even delayed by normal glucose levels. This review, therefore, emphasizes that, though hyperglycemia is required for clinically significant microangiopathy to occur, clearly other factors, genetic, environmental, or both, must play major roles in determining the course of microangiopathy. It is toward these nonglycemic factors in the development of diabetic microangiopathy that future research should increasingly be directed.

Recent developments in the understanding and management of diabetic retinopathy

The natural history of diabetic retinopathy, one of the leading causes of visual impairment in the United States, is well described; its pathogenesis, however, is poorly understood. The Diabetic Retinopathy Study and the Early Treatment of Diabetic Retinopathy Study have demonstrated that timely intervention with photocoagulation prevents visual loss. However, recent studies demonstrate that many diabetic patients are not being referred to ophthalmologists for timely treatment. Suggested management and referral strategies are presented in this article.

Muscle capillary basement membrane width in patients with vacor-induced diabetes mellitus

Muscle capillary basement membrane width is a sensitive marker for the presence of diabetic microangiopathy. Studies have indicated that genetic factors and alterations in glucose metabolism influence muscle capillary basement membrane width. To define the role of these factors we have measured muscle capillary basement membrane thickness in controls, insulin dependent diabetics, and individuals with diabetes secondary to the ingestion of Vacor, a rat poison, which results in hyperglycemia. Hemoglobin A1 concentrations were increased in both diabetic groups, but hemoglobin A1 levels and the duration of diabetes were similar in the two diabetic groups. The muscle capillary basement membrane width was increased to a similar extent in the insulin-dependent diabetics (control, 1,781 +/- 46 vs. IDD, 2,287 +/- 144 A, P less than 0.001) and in the Vacor diabetic group (2,320 +/- 149 A, P less than 0.001). In the insulin-dependent diabetic group, 63% of the patients had a muscle capillary basement membrane width greater than two standard deviations above the mean of the controls, while in the Vacor diabetic group this figure was 56%. Despite the relatively short duration of diabetes (6.2 +/- 0.3 yr), 44% of the Vacor diabetic patients had retinopathy and 28% had proteinuria. The present study provides strong evidence that even in the absence of genetic diabetes mellitus, hyperglycemia or some other abnormality related to insulin lack can cause microvascular changes.