How to perform better intervention to prevent and control diabetic retinopathy among patients with type 2 diabetes: A meta-analysis of randomized controlled trials

Factors associated with development of retinopathy in patients with type 2 diabetes mellitus at onset and within three years after diagnosis

OBJECTIVE

To investigate the prevalence of diabetes retinopathy and evaluate the factors influencing its occurrence both at the onset of type 2 diabetes (T2D) and three years into its duration.

DESIGN

Retrospective population-based study.

SETTING

Data was retrieved from Regional Healthcare Information Platform in Region Halland 2016-2020.

SUBJECTS

Patients 35-75 years old in Region Halland receiving first-time diabetes diagnosis according to ICD-code E11-14 in 2016-17. The total cohort consisted of 1659 patients.

MAIN OUTCOME MEASURES

The main outcome measure of the study was the occurrence of diabetes retinopathy at onset and within three years from the diabetes diagnosis. Multivariate logistic regression analysis was conducted for diabetes retinopathy at onset and within three years, adjusted for age, gender, comorbidities, levels of HbA1c, cholesterol, kidney functional and blood pressure.

RESULTS

At onset, there were 12% with diabetes retinopathy and after three years, 32% of the patients had developed diabetes retinopathy. In the study cohort, 71 of patients who were examined with fundus photography within three years after onset, and 8% had had dietary recommendation without pharmacotherapy. High HbA1c levels, blood pressure values and impaired renal function already at onset were associated with development of diabetes retinopathy at onset and this association persisted after three years. The odds ratio for diabetes retinopathy was increased adjusted for HbA1c elevations, renal impairment, and increased blood pressure at index and when adjusted for these variables three years from index.

CONCLUSION

These findings indicate that the risk of developing diabetes retinopathy is present early on at onset and within the first three years of diabetes diagnosis. This highlights the importance of promptly regulating glucose- and blood-pressure levels and follow up kidney dysfunction to mitigate the risk of diabetes retinopathy.

Elucidating glial responses to products of diabetes-associated systemic dyshomeostasis

Diabetic retinopathy (DR) is a leading cause of blindness in working age adults. DR has non-proliferative stages, characterized in part by retinal neuroinflammation and ischemia, and proliferative stages, characterized by retinal angiogenesis. Several systemic factors, including poor glycemic control, hypertension, and hyperlipidemia, increase the risk of DR progression to vision-threatening stages. Identification of cellular or molecular targets in early DR events could allow more prompt interventions pre-empting DR progression to vision-threatening stages. Glia mediate homeostasis and repair. They contribute to immune surveillance and defense, cytokine and growth factor production and secretion, ion and neurotransmitter balance, neuroprotection, and, potentially, regeneration. Therefore, it is likely that glia orchestrate events throughout the development and progression of retinopathy. Understanding glial responses to products of diabetes-associated systemic dyshomeostasis may reveal novel insights into the pathophysiology of DR and guide the development of novel therapies for this potentially blinding condition. In this article, first, we review normal glial functions and their putative roles in the development of DR. We then describe glial transcriptome alterations in response to systemic circulating factors that are upregulated in patients with diabetes and diabetes-related comorbidities; namely glucose in hyperglycemia, angiotensin II in hypertension, and the free fatty acid palmitic acid in hyperlipidemia. Finally, we discuss potential benefits and challenges associated with studying glia as targets of DR therapeutic interventions. In vitro stimulation of glia with glucose, angiotensin II and palmitic acid suggests that: 1) astrocytes may be more responsive than other glia to these products of systemic dyshomeostasis; 2) the effects of hyperglycemia on glia are likely to be largely osmotic; 3) fatty acid accumulation may compound DR pathophysiology by promoting predominantly proinflammatory and proangiogenic transcriptional alterations of macro and microglia; and 4) cell-targeted therapies may offer safer and more effective avenues for DR treatment as they may circumvent the complication of pleiotropism in retinal cell responses. Although several molecules previously implicated in DR pathophysiology are validated in this review, some less explored molecules emerge as potential therapeutic targets. Whereas much is known regarding glial cell activation, future studies characterizing the role of glia in DR and how their activation is regulated and sustained (independently or as part of retinal cell networks) may help elucidate mechanisms of DR pathogenesis and identify novel drug targets for this blinding disease.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Yiqi Tongluo Fang could preventive and delayed development and formation of diabetic retinopathy through antioxidant and anti-inflammatory effects

BACKGROUND

Yiqi Tongluo Fang (YQTLF) is an effective prescription for the treatment of diabetic retinopathy (DR), but its mechanism of action remains unclear.

METHOD

The content of YQTLF was determined using liquid and gas chromatography-mass spectrometry (LC-MS and GC-MS, respectively). Twenty-five Sprague Dawley (SD) rats were randomly selected as the normal control group. One hundred SD streptozotocin-induced diabetes (type 1) rats were randomly divided into diabetic control, diabetic+insulin+ calcium dobesilate (CaD), and diabetic+insulin+ YQTLF groups, with 25 rats in each group. Bodyweight level was measured every 2 weeks. After 12 weeks of gavage, the glucose levels, lipids, oxidative stress, inflammation, retinal histopathology, and the blood-retinal barrier were assessed in each group. The p38 MAPK pathway was changed to explore its internal mechanism. The measurement data were expressed as mean ± standard deviation, and different statistical methods were used according to a normal distribution, square error, or not.

RESULTS

A total of 1024 valid peaks were identified in YQTLF using GC-MS. YQTLF significantly lowered the fasting blood glucose levels in diabetic rats. YQTLF early inhibited changes in retinal histology, capillaries, cells, and tight junction proteins (such as ZO-1, occludin, claudin-5, and VE-cadherin) before the formation and development of DR. These findings correlated with the alleviation of glucolipid metabolism, inflammation, and oxidative stress. The lncRNA MALAT1 and the PRC 2/p38 MAPK-related pathway, such as the expression of EZH2, SUZ12, EED, p38 MAPK, MMP-9, and VEGFR, were also correlated.

CONCLUSION

We have demonstrated the molecular and cellular mechanisms underlying the preventive and delayed development and formation of DR. YQTLF prevents changes in dyslipidemia, retinal histology, capillaries, cells, and tight junction proteins. These protective effects appear to be linked to its antioxidant and anti-inflammatory effects, which prevent the activation of intracellular signaling pathways, such as the lncRNA MALAT1 and PRC 2/p38 MAPK-related pathway.

The Risk of Nephropathy, Retinopathy, and Leg Amputation in Patients With Diabetes and Hypertension: A Nationwide, Population-Based Retrospective Cohort Study

Purpose

To compare the risks of chronic kidney disease (CKD), end-stage renal disease (ESRD), sight-threatening retinopathy, and leg amputation between patients with diabetes or hypertension.

Methods

From January 1, 2000, to December 31, 2015, we identified 28943 matched pairs of patients with diabetes with and without subsequent hypertension, 89102 pairs of patients with hypertension with and without subsequent diabetes, and 145294 pairs of patients with coexisting diabetes and hypertension with a previous history of diabetes or hypertension from Taiwan's National Health Insurance Research Database. Cox proportional-hazard models were used for calculating the risks of CKD, sight-threatening retinopathy, and leg amputation.

Results

The mean follow-up time of this study in different cohorts was between 3.59 and 4.28 years. In diabetes patients with vs. without subsequent hypertension, hypertension patients with vs. without subsequent diabetes, and comorbid diabetes and hypertension patients with previous diabetes vs. with previous hypertension, the adjusted HRs (95% CIs) for CKD were 2.77 (2.61-2.94), 1.73 (1.68-1.77), and 1.04 (1.02-1.07); for ESRD were 42.38 (22.62-79.4), 2.76 (2.43-3.13), and 0.72 (0.66-0.79); for sight-threatening retinopathy were 2.07 (1.85-2.3), 3.41 (3.14-3.71), and for leg amputation were 1.51 (1.43-1.58); and 4.74 (3.02-7.43), 6.27(4.72-8.31), and 1.19(1.03-1.38).

Conclusions

This study demonstrated that both diabetes and hypertension are risk factors for the development of CKD, retinopathy, and amputation. Tracing subsequent diabetes for patients with hypertension, and hypertension for patients with diabetes are important in clinical settings.

Population-based cross-sectional prevalence survey of diabetes and diabetic retinopathy in Sohag-Egypt, 2019

OBJECTIVES

To determine the prevalence of diabetes mellitus (DM), prevalence of diabetic retinopathy (DR) and sight-threatening conditions among persons with DM aged 50 years and older in Sohag governorate in Upper Egypt.

DESIGN

Population-based, cross-sectional survey using the standardised Rapid Assessment of Avoidable Blindness with the addition of the Diabetic Retinopathy module methodology.

SETTINGS

Sohag governorate in Egypt where 68 clusters were selected using probability proportional to population size. Households were selected using the compact segment technique.

PARTICIPANTS

4078 people aged 50 years and older in 68 clusters were enrolled, of which 4033 participants had their random blood sugar checked and 843 examined for features of DR.

PRIMARY AND SECONDARY OUTCOMES

The prevalence of DM and DR; secondary outcome was the coverage with diabetic eye care.

RESULTS

The prevalence of DM was 20.9% (95% CI 19.3% to 22.5%). The prevalence in females (23.8%; 95% CI 21.4% to 26.3%) was significantly higher than in males (18.9%; 95% CI 17.1% to 20.7%) (p=0.0001). Only 38.8% of persons diagnosed with diabetes had good control of DM. The prevalence of DR in the sample was 17.9% (95% CI 14.7% to 21.1%). The prevalence in females was higher (18.9%; 95% CI 14.0% to 23.8%) than in males (17.1%; 95% CI 13.0% to 21.2%). Up to 85.3% of study participants have never had eye examination. Sight-threatening DR (R4 and/or M2) was detected in 5.2% (95% CI 3.4% to 7.0%) with only 2.3% having had laser treatment.

CONCLUSION

The prevalence of uncontrolled DM in Sohag governorate in Egypt is higher than the national prevalence. There is a high prevalence of sight-threatening retinopathy and/or maculopathy with few people having access to diabetic eye care. A public health approach is needed for health promotion, early detection and management of DR.