Early risk stratification in pediatric type 1 diabetes

Prevalence and Risk Factors of Retinopathy in Type 1 Diabetes: A Cross-Sectional Study

Introduction Diabetic retinopathy (DR) is a severe complication of diabetes. It remains a major cause of visual impairment and blindness, especially in young people. It is a silent affection that only becomes symptomatic at the onset of complications. Our study aimed to estimate the prevalence of retinopathy in patients with type 1 diabetes mellitus (T1DM) and evaluate the associated risk factors in our population. Materials and methods A descriptive and analytical study, with a cross-sectional study involving 359 patients with type 1 diabetes, was followed up in the Department of Endocrinology, Diabetology, and Nutrition of the University Hospital Center Mohammed VI Oujda, Morocco. Data were collected from medical records and analyzed by binary logistic regression using IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. Results The average age of our patients was 24.2 ± 11.4 years. The mean duration of diabetes was 11.8±4.4 years. The average glycated hemoglobin (HbA1c) at admission was 10.1 ± 2.4%. DR was found in 30% of patients, including 28.6% with minimal non-proliferative diabetic retinopathy (NPDR), 19.1% with moderate NPDR, 19.1% with severe NPDR, and 33.3% with proliferative DR. Patients with diabetic retinopathy appear to have a longer duration of diabetes (13.05±9.05 vs. 10.6±8.07 years). The longer duration of diabetes, neuropathy, and nephropathy was significantly associated with diabetic retinopathy (p=0.02, p=0.002, and p=0.0001, respectively). Conclusion The frequency of diabetic retinopathy increases with age, poor glycemic control, and the duration of diabetes. Therefore, cooperation between diabetologists and ophthalmologists is essential for making an early diagnosis and providing early treatment.

Risk factors associated with retinopathy in young people with type 1 diabetes in Bangladesh

Objectives

Diabetic retinopathy (DR) is the most common microvascular complications seen in children and adolescents with type 1 diabetes. The aim of this study was to evaluate the prevalence of retinopathy and its association with other risk factors in young people with type 1 diabetes.

Methods

This study was a cross-sectional study, which was done as part of the ongoing complication assessment in the paediatric diabetes clinic in BIRDEM (Bangladesh Institute of Research and Rehabilitation of Diabetes Endocrine and Metabolic Disorders), a tertiary care hospital. Children, adolescents and young adults with type 1 diabetes who were having diabetes duration >2 years were included in this study. Retinopathy was detected using fundal photography, and grading was done by National Screening Committee of UK by trained ophthalmologists.

Results

Diabetic retinopathy was observed in 44 (6.6%) patients. Majority (95.4%) of them had early diabetic retinopathy in the form of mild NPDR (nonproliferative diabetic retinopathy) (R1). Patients with retinopathy had higher HbA1c 9.6[8.4-12.3] vs 9.1 [7.9-10.8] (P = .013), longer duration of diabetes 7.6 [5.5-10.7] vs 6.0 [4.5-8.2] years (P = .001) and were older 21.5 [18.0-23.0] vs 18 [16.0-21.0] years (P = .0001) compared with those without retinopathy. On multivariate regression analysis, higher age and median HbA1c were significantly associated with DR.

Conclusions

Higher HbA1c was the only modifiable risk factor for development of DR in our study population. Early detection of DR with improvement of glycaemic control may reduce the risk of progression of severe stages of the disease.

Porcine models for studying complications and organ crosstalk in diabetes mellitus

The worldwide prevalence of diabetes mellitus and obesity is rapidly increasing not only in adults but also in children and adolescents. Diabetes is associated with macrovascular complications increasing the risk for cardiovascular disease and stroke, as well as microvascular complications leading to diabetic nephropathy, retinopathy and neuropathy. Animal models are essential for studying disease mechanisms and for developing and testing diagnostic procedures and therapeutic strategies. Rodent models are most widely used but have limitations in translational research. Porcine models have the potential to bridge the gap between basic studies and clinical trials in human patients. This article provides an overview of concepts for the development of porcine models for diabetes and obesity research, with a focus on genetically engineered models. Diabetes-associated ocular, cardiovascular and renal alterations observed in diabetic pig models are summarized and their similarities with complications in diabetic patients are discussed. Systematic multi-organ biobanking of porcine models of diabetes and obesity and molecular profiling of representative tissue samples on different levels, e.g., on the transcriptome, proteome, or metabolome level, is proposed as a strategy for discovering tissue-specific pathomechanisms and their molecular key drivers using systems biology tools. This is exemplified by a recent study providing multi-omics insights into functional changes of the liver in a transgenic pig model for insulin-deficient diabetes mellitus. Collectively, these approaches will provide a better understanding of organ crosstalk in diabetes mellitus and eventually reveal new molecular targets for the prevention, early diagnosis and treatment of diabetes mellitus and its associated complications.

Neurophysiological Evidence for a Compensatory Activity during a Simple Oddball Task in Adolescents with Type 1 Diabetes Mellitus

OBJECTIVE

The poor metabolic control in type 1 diabetes mellitus (T1D) has a negative impact on the developing brain. Hyperglycemia and glycemic fluctuations disrupt mainly executive functions. To assess a hypothesized deficit of the executive functions, we evaluated visual processing and reaction time in an oddball task.

METHODS

Oddball visual event-related potentials (ERPs), reaction time, and pattern-reversal visual evoked potentials (VEPs) were examined in a cohort of twenty-two 12- to 18-year-old T1D patients without diabetic retinopathy at normal glycemia and in nineteen 10- to 21-year-old healthy controls.

RESULTS

The P100 peak time of the VEPs was significantly prolonged in T1D patients compared with the control group (p < 0.017). In contrast to the deteriorated sensory response, the area under the curve of the P3b component of the ERPs was significantly larger (p = 0.035) in patients, while reaction time in the same task did not differ between groups (p = 0.713).

CONCLUSIONS

The deterioration on a sensory level, enhanced activity during cognitive processing, and balanced behavioral response support the view that neuroplasticity counterbalances the neural impairment by enhanced cognitive processing to achieve normal behavioral performance in T1D adolescents.

Retinal vascular imaging technology to monitor disease severity and complications in type 1 diabetes mellitus: A systematic review

OBJECTIVE

Type 1 diabetes mellitus (T1DM) is a major disease affecting a large number of young patients. In the recent years, retinal vascular imaging has provided an objective assessment of vascular health in patients with T1DM. Our study aimed to review the current literature on retinal vascular parameters in young patients with T1DM in order to understand the following: (i) How retinal vessels are affected in T1DM (ii) How such vascular changes can be predictive of future diabetic microvascular complications METHODS: We performed a systematic review and extracted relevant data from 17 articles.

RESULTS

We found significant correlations between retinal vessel changes and diabetes-related risk factors (eg, hypertension, hyperlipidemia, and obesity), diabetes-related features (eg, diabetes duration and glycemic control), and diabetes-related microvascular complications (eg, diabetic retinopathy, nephropathy, and neuropathy).

CONCLUSION

Our findings suggest that retinal microvasculature is associated with both disease severity and complications in young patients with T1DM.

Retinopathy with central oedema in an INS C94Y transgenic pig model of long-term diabetes

AIMS/HYPOTHESIS

Diabetic retinopathy is a severe complication of diabetes mellitus that often leads to blindness. Because the pathophysiology of diabetic retinopathy is not fully understood and novel therapeutic interventions require testing, there is a need for reliable animal models that mimic all the complications of diabetic retinopathy. Pig eyes share important anatomical and physiological similarities with human eyes. Previous studies have demonstrated that INS ^C94Y transgenic pigs develop a stable diabetic phenotype and ocular alterations such as cataracts. The aim of this study was to conduct an in-depth analysis of pathological changes in retinas from INS ^C94Y pigs exposed to hyperglycaemia for more than 2 years, representing a chronic diabetic condition.

METHODS

Eyes from six INS ^C94Ypigs and six age-matched control littermates were analysed via histology and immunohistochemistry. For histological analyses of retinal (layer) thickness, sections were stained with H&E or Mallory's trichrome. For comparison of protein expression patterns and vessel courses, sections were stained with different antibodies in immunohistochemistry. Observed lesions were compared with reported pathologies in human diabetic retinopathy.

RESULTS

INS ^C94Ypigs developed several signs of diabetic retinopathy similar to those seen in humans, such as intraretinal microvascular abnormalities, symptoms of proliferative diabetic retinopathy and central retinal oedema in a region that is cone rich, like the human macula.

CONCLUSIONS/INTERPRETATION

The INS ^C94Ypig is an interesting model for studying the pathophysiology of diabetic retinopathy and for testing novel therapeutic strategies.

Short-term poor glycemic control and retinal microvascular changes in pediatric Type 1 Diabetes patients in Singapore: a pilot study

Background

Poor glycemic control in Type 1 Diabetes (T1D) patients is strongly associated with an increased risk of diabetes-related microvascular complications later in life, but it is unclear whether short period of poor glycemic control in children with T1D can cause evident microvascular morphological changes long before any pathological manifestation. Our study aimed to investigate the longitudinal association between poor glycemic control and subsequent changes in retinal microvasculature, in a pilot study of 55 pediatric T1D patients from Singapore after a one-year follow-up.

Methods

This is a hospital-based, exposure-matched and retrospective longitudinal study. A total of 55 T1D patients were included from Singapore KK Women’s and Children Hospital, 28 of whom had poor glycemic control (average glycated hemoglobin [HbA1c] ≥8% during the year) while the other 27 age- and gender-matched subjects had good glycemic control (HbA1c <8%). Retinal photography was taken at diabetes annual screening and images were graded by trained graders using a semi-automated computer-based program (Singapore I Vessel Assessment [SIVA], version 4.0, Singapore Eye Research Institute, Singapore) and a spectrum of retinal vascular parameters (e.g. caliber, tortuosity, branching angle and fractal dimension) were measured quantitatively from 0.5 to 2.0 disc diameters.

Results

There was no significant difference in ethnicity, duration of T1D, blood pressure, body mass index (BMI) and low-density cholesterol lipoprotein (LDL) between the two groups. Retinal imaging was obtained at the end of 1 year of glycemic control assessment. In multiple linear regression adjusting for ethnicity, BMI, LDL and duration of T1D, patients with poor glycemic control tended to have marginally wider retinal arteriolar caliber (6.0 μm, 95% CI: −0.9, 12.8) and had significantly larger retinal arteriolar branching angle (10.1 degrees, 95% CI: 1.4, 18.9) compared with their age- and gender- matched counterparts with good glycemic control.

Conclusions

Our findings showed that abnormal retinal microvascular morphology was evident in pediatric patients with T1D after one-year’s poor glycemic control. Such morphological abnormalities may lead to future development of microvascular complications among T1D pediatric patients with poor glycemic control.

The role of retinopathy distribution and other lesion types for the definition of examination intervals during screening for diabetic retinopathy

PURPOSE

It has previously been shown that the intervals between screening examinations for diabetic retinopathy can be optimized by including individual risk factors for the development of the disease in the risk assessment. However, in some cases, the risk model calculating the screening interval may recommend a different interval than an experienced clinician. The purpose of this study was to evaluate the influence of factors unrelated to diabetic retinopathy and the distribution of lesions for discrepancies between decisions made by the clinician and the risk model.

METHODS

Therefore, fundus photographs from 90 screening examinations where the recommendations of the clinician and a risk model had been discrepant were evaluated. Forty features were defined to describe the type and location of the lesions, and classification and ranking techniques were used to assess whether the features could predict the discrepancy between the grader and the risk model.

RESULTS

Suspicion of tumours, retinal degeneration and vascular diseases other than diabetic retinopathy could explain why the clinician recommended shorter examination intervals than the model. Additionally, the regional distribution of microaneurysms/dot haemorrhages was important for defining a photograph as belonging to the group where both the clinician and the risk model had recommended a short screening interval as opposed to the other decision alternatives.

CONCLUSIONS

Features unrelated to diabetic retinopathy and the regional distribution of retinal lesions may affect the recommendation of the examination interval during screening for diabetic retinopathy. The development of automated computerized algorithms for extracting information about the type and location of retinal lesions could be expected to further optimize examination intervals during screening for diabetic retinopathy.

Ophthalmic Screening Patterns Among Youths With Diabetes Enrolled in a Large US Managed Care Network

Importance

Ophthalmic screening to check for diabetic retinopathy (DR) is important to prevent vision loss in persons with diabetes. The American Academy of Ophthalmology recommends that ophthalmic screening for DR occur beginning at 5 years after initial diabetes diagnosis for youths with type 1 diabetes; the American Diabetes Association recommends screening of youths with type 2 diabetes at the time of initial diagnosis. To our knowledge, it is unknown to what extent youths with diabetes obtain eye examinations in accordance with these guidelines.

Objective

To assess the rate of obtaining ophthalmic examinations and factors associated with receipt of eye examinations for youths with diabetes.

Design, Setting, and Participants

This retrospective, longitudinal cohort study examined youths 21 years or younger with newly diagnosed diabetes enrolled in a US managed care network from January 1, 2001, through December 31, 2014.

Main Outcomes and Measures

Kaplan-Meier survival curves estimated the time from initial diabetes diagnosis to first eye examination by an ophthalmologist or optometrist. Multivariable Cox proportional hazards regression models identified factors associated with receiving an ophthalmic examination after initial diabetes diagnosis.

Results

Among 5453 youths with type 1 diabetes (median age at initial diagnosis, 11 years; interquartile range, 8-15 years; 2972 male [54.5%]; 4505 white [82.6%]) and 7233 youths with type 2 diabetes (median age at initial diagnosis, 19 years; interquartile range, 16-22 years; 1196 male [16.5%]; 5052 white [69.9%]), 64.9% of patients with type 1 diabetes and 42.2% of patients with type 2 diabetes had undergone an eye examination by 6 years after initial diabetes diagnosis. Black youths (1367 [10.8%] of the sample) had an 11% and Latino youths (1450 [11.4%] of the sample) had an 18% decreased hazard of undergoing an eye examination by 6 years compared with white youths (black youths: adjusted hazard ratio [HR], 0.89; 95% CI, 0.79-0.99; Latino youths: HR, 0.82; 95% CI, 0.73-0.92). As household net worth increased, youths were increasingly more likely to undergo an eye examination by 6 years after initial diabetes diagnosis (net worth of ≥$500 000 vs <$25 000: HR, 1.50; 95% CI, 1.34-1.68).

Conclusions and Relevance

Despite possessing health insurance, many youths with diabetes are not receiving eye examinations by 6 years after initial diagnosis to monitor for DR. These data suggest that adherence to clinical practice guidelines is particularly challenging for racial minorities and youths from less affluent families.

Noninvasive Retinal Markers in Diabetic Retinopathy: Advancing from Bench towards Bedside

The retinal vascular system is the only part of the human body available for direct, in vivo inspection. Noninvasive retinal markers are important to identity patients in risk of sight-threatening diabetic retinopathy. Studies have correlated structural features like retinal vascular caliber and fractals with micro- and macrovascular dysfunction in diabetes. Likewise, the retinal metabolism can be evaluated by retinal oximetry, and higher retinal venular oxygen saturation has been demonstrated in patients with diabetic retinopathy. So far, most studies have been cross-sectional, but these can only disclose associations and are not able to separate cause from effect or to establish the predictive value of retinal vascular dysfunction with respect to long-term complications. Likewise, retinal markers have not been investigated as markers of treatment outcome in patients with proliferative diabetic retinopathy and diabetic macular edema. The Department of Ophthalmology at Odense University Hospital, Denmark, has a strong tradition of studying the retinal microvasculature in diabetic retinopathy. In the present paper, we demonstrate the importance of the retinal vasculature not only as predictors of long-term microvasculopathy but also as markers of treatment outcome in sight-threatening diabetic retinopathy in well-established population-based cohorts of patients with diabetes.

Incidence and Risk Factors for Developing Diabetic Retinopathy among Youths with Type 1 or Type 2 Diabetes throughout the United States

PURPOSE

Despite the increasing prevalence of type 2 diabetes mellitus (T2DM) among children and adolescents, little is known about their risk of developing diabetic retinopathy (DR). We sought to identify risk factors for DR in youths with diabetes mellitus, to compare DR rates for youths with type 1 diabetes mellitus (T1DM) and those with T2DM, and to assess whether adherence to DR screening guidelines promoted by the American Academy of Ophthalmology, American Academy of Pediatrics, and American Diabetes Association adequately capture youths with DR.

DESIGN

Retrospective observational longitudinal cohort study.

PARTICIPANTS

Youths aged ≤21 years with newly diagnosed T1DM or T2DM who were enrolled in a large US managed-care network.

METHODS

In this study of youths aged ≤21 years with newly diagnosed T1DM or T2DM who were under ophthalmic surveillance, we identified the incidence and timing of DR onset. Kaplan-Meier survival curves assessed the timing of initial diagnosis of DR for participants. Multivariable Cox proportional hazard regression modeling identified factors associated with the hazard of developing DR. Model predictors were age and calendar year at initial diabetes mellitus diagnosis, sex, race/ethnicity, net worth, and glycated hemoglobin A1c fraction (HbA1c).

MAIN OUTCOME MEASURES

Hazard ratios (HRs) with 95% confidence intervals (CIs) for developing DR.

RESULTS

Among the 2240 youths with T1DM and 1768 youths with T2DM, 20.1% and 7.2% developed DR over a median follow-up time of 3.2 and 3.1 years, respectively. Survival curves demonstrated that youths with T1DM developed DR faster than youths with T2DM (P < 0.0001). For every 1-point increase in HbA1c, the hazard for DR increased by 20% (HR = 1.20; 95% CI 1.06-1.35) and 30% (HR = 1.30; 95% CI 1.08-1.56) among youths with T1DM and T2DM, respectively. Current guidelines suggest that ophthalmic screening begin 3 to 5 years after initial diabetes mellitus diagnosis, at which point in our study, >18% of youths with T1DM had already received ≥1 DR diagnosis.

CONCLUSIONS

Youths with T1DM or T2DM exhibit a considerable risk for DR and should undergo regular screenings by eye-care professionals to ensure timely DR diagnosis and limit progression to vision-threatening disease.

Retinal Vascular Caliber and Kidney Function in Children and Adolescents with Type 1 Diabetes

PURPOSE

To evaluate the relationship between retinal vascular caliber and kidney function in a cohort of Australian children and adolescents with type 1 diabetes.

METHODS

This was a cross-sectional study of 483 children and adolescents with type 1 diabetes, aged 7-18 years. An audit of medical files of participants who attended the Royal Children's Hospital, Melbourne, between January 2009 and March 2014 was performed. Albumin to creatinine ratio (ACR) was acquired through spot urine samples and microalbuminuria was classified as ACR >3.5 mg/mmol in females and >2.5 mg/mmol in males. Retinal vascular caliber was measured using a standardized protocol and later summarized as central retinal arteriolar equivalent (CRAE) and central retinal venular equivalent (CRVE).

RESULTS

CRAE was significantly narrower in participants with microalbuminuria compared to those with normo-albuminuria in crude analysis (mean ± standard deviation 159.07 ± 9.90µm vs 164.49 ± 12.45 µm; p = 0.006). After adjustment for key confounders and known or potential mediators of microalbuminuria (age, sex, ethnicity, hemoglobin A1c, systolic blood pressure, total cholesterol, body mass index, duration of diabetes and CRVE) the association between narrower CRAE and microalbuminuria was attenuated and was no longer significant (95% confidence interval 0.94-1.02, p = 0.222). No significant associations between CRVE or arteriole-to-venule ratio and microalbuminuria were observed in univariate or multivariate models.

CONCLUSIONS

After adjustment for potential confounding variables, retinal vascular caliber was not significantly associated with microalbuminuria in this sample of children and adolescents with type 1 diabetes. Future prospective longitudinal research is warranted to further evaluate these findings.

Effect of Axial Eye Length on Retinal Vessel Parameters in 6 to 12-Year-Old Malay Girls

PURPOSE

Retinal vessel analysis is affected by both systemic and ocular factors. Malays are the major ethnicity in South East Asia. Data on the retinal microvasculature in Malays is limited, especially among children. We aim to evaluate the influence of ocular biometry on retinal vessel parameters in young Malay girls.

METHODS

This was a cross-sectional, hospital-based study involving 86 Malay girls aged 6 to 12 years old in Hospital Universiti Sains Malaysia from 2015-2016. Ocular examination, refraction, biometry, retinal photography, and anthropometric measurements were performed. The central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE) and overall fractal dimension (Df) were measured using validated computer-based methods (Singapore I vessel analyzer, SIVA version 3.0, Singapore). The associations of ocular biometry and CRAE, CRVE and Df were analyzed using multivariable analysis.

RESULTS

The mean CRAE, CRVE and Df in Malay girls were 171.40 (14.40) um, 248.02 (16.95) um and 1.42 (0.05) respectively. Each 1 mm increase in axial length was associated with a reduction of 4.25 um in the CRAE (p = 0.03) and a reduction of 0.02 in the Df (p = 0.02), after adjustment for age, blood pressure and body mass index. No association was observed between axial length and CRVE. Anterior chamber depth and corneal curvature had no association with CRAE, CRVE or Df.

CONCLUSION

Axial length affects retinal vessel measurements. Narrower retinal arterioles and reduced retinal fractal dimension were observed in Malay girls with longer axial lengths.

Dietary patterns and retinal vascular calibre in children and adolescents with type 1 diabetes

PURPOSE

To examine the association between dietary patterns and retinal vascular calibre in children and adolescents with type 1 diabetes.

METHODS

A hospital-based cross-sectional study of 83 children and adolescents with type 1 diabetes was conducted over an 8-month period. Dietary patterns were extracted using principal components analysis from completed food frequency questionnaires. Retinal vascular calibre was measured by a trained grader using a standardized protocol and later summarized as central retinal artery equivalent (CRAE) and central retinal vein equivalent (CRVE) using a semi-automated computer program.

RESULTS

Three major dietary patterns were identified as follows: (1) processed foods, (2) plant-based foods and (3) vegetable/fish avoidance pattern. The processed pattern had high component loadings for processed meats and high fat takeaway foods. The plant-based pattern had high component loadings for a number of fruits including, but not limited to, pineapple, grapes oranges and mangos as well as a smaller number of vegetables, including beans and leeks. The vegetable and fish avoidance pattern had high inverse component loadings for canned and fresh fish as well as a number of vegetables including, but not limited to, pumpkin, green beans, broccoli, sweet potato and cabbage. Adjusted regression analysis revealed the 'vegetable/fish avoidance' dietary pattern was associated with a wider CRVE (ExpB = 3.67, 95% CI = 0.11/7.24, p = 0.039). After multivariable adjustments, a vascular risk profile that included: older age, higher BMI, higher systolic blood pressure, greater gestational age, longer screen viewing time, lower maternal education level, lower physical activity levels and lower high-density lipoproteins concentrations were more likely to display narrower CRAE (ExpB = -2.43, 95% CI = -4.92/0.06, p = 0.041).

CONCLUSIONS

This study provides the first evidence for a diet-calibre relationship in children and adolescents with type 1 diabetes. This outcome has potential public health implications, as promotion of healthy eating patterns in children and adolescents might attenuate changes in microvasculature that have been related to an increased risk of microvascular disease, such as retinopathy, in adulthood. Additional studies are warranted to explore and validate this novel finding.