Diabetic retinopathy is associated with an increased incidence of cardiovascular events in Type 2 diabetic patients

Association between Severity of Diabetic Retinopathy and Cardiac Function in Patients with Type 2 Diabetes

Background

The purpose of this research was to assess the relationship between the severity of diabetic retinopathy (DR) and indexes of left ventricle (LV) structure and function in type 2 diabetes mellitus (T2DM).

Methods

Retrospective analysis of 790 patients with T2DM and preserved LV ejection fraction. Retinopathy stages were classified as no DR, early nonproliferative DR, moderate to severe nonproliferative DR, or proliferative DR. The electrocardiogram was used to assess myocardial conduction function. Echocardiography was used to evaluate myocardial structure and function.

Results

Patients were divided into three groups based on the DR status: no DR group (NDR, n = 475), nonproliferative DR group (NPDR, n = 247), and proliferative DR group (PDR, n = 68). LV interventricular septal thickness (IVST) increased significantly with more severe retinopathy (NDR: 10.00 ± 1.09; NPDR: 10.42 ± 1.21; and PDR: 10.66 ± 1.58; P < 0.001). Multivariate logistic regression analysis showed that the significant correlation of IVST persisted between subjects with no retinopathy and proliferative DR (odds ratio = 1.35, P = 0.026). Indices of myocardial conduction function were assessed by electrocardiogram differences among groups of retinopathy (all P < 0.001). In multiple-adjusted linear regression analyses, the increasing degree of retinopathy was closely correlated with heart rate (β = 1.593, P = 0.027), PR interval (β = 4.666, P = 0.001), and QTc interval (β = 8.807, P = 0.005).

Conclusion

The proliferative DR was independently associated with worse cardiac structure and function by echocardiography. Furthermore, the severity of retinopathy significantly correlated with abnormalities of the electrocardiogram in patients with T2DM.

Targeting mTOR/YY1 signaling pathway by quercetin through CYP7A1-mediated cholesterol-to-bile acids conversion alleviated type 2 diabetes mellitus induced hepatic lipid accumulation

BACKGROUND

Hepatic lipid accumulation was a major promoter for the further development of non-alcoholic fatty liver disease (NAFLD) in type 2 diabetes (T2DM). mTOR/YY1 signaling pathway regulated many metabolic processes in different organs, and played an important role in hepatic lipid metabolism. Thus, targeting mTOR/YY1 signaling pathway might be a novel therapeutic strategy of T2DM-associated NALFD.

PURPOSE

To investigate the effects and the mechanism of quercetin against T2DM-associated NAFLD.

STUDY DESIGN AND METHODS

The combine abilities of 24 flavonoid compounds with mTOR were detected by computer virtual screening (VS) and molecular modeling. mTOR/YY1 signaling pathway was examined in the liver of db/db mice, and high glucose (HG) and free fatty acid (FFA) co-cultured HepG2 cells. YY1 overexpression lentivirus vector and mTOR specific inhibitor rapamycin were used to further identify the indispensable role of mTOR/YY1 signaling pathway in quercetin's amelioration effect of hepatic lipid accumulation in vitro. Clinical studies, luciferase assay and chromatin immunoprecipitation (ChIP) assay were all carried out to investigate the potential mechanisms by which quercetin exerted its amelioration effect of hepatic lipid accumulation.

RESULTS

Quercetin had the strongest ability to combine with mTOR and could competitively occupy its binding pocked. Along with the alleviated hepatic injury by quercetin, mTOR/YY1 signaling pathway was down-regulated in vivo and in vitro. However, the alleviation effect of quercetin against hepatic lipid accumulation was inhibited by YY1 overexpression in vitro. Mechanistically, the down-regulated nuclear YY1 induced by quercetin directly bound to CYP7A1 promoter and activated its transcription, resulting in the restoration of cholesterol homeostasis via the conversion of cholesterol-to-bile acids (BAs).

CONCLUSION

The hepatoprotective effect of quercetin on T2DM-associated NAFLD was linked to the restoration of cholesterol homeostasis by the conversion of cholesterol-to-BAs via down-regulating mTOR/YY1 signaling pathway, leading to the increased CYP7A1 activity.

Same-Day Cancellation is Higher in Outpatient Pars Plana Vitrectomy for Proliferative Diabetic Retinopathy

Purpose

Safety and efficiency of ambulatory pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR) patients is worthy of attention, since patients always have severe systemic diseases. The purpose of this study was to compare the incidence of same-day cancellation of PPV for PDR between outpatients and inpatients and to analyze the causes of cancellations.

Patients and Methods

This is a retrospective review of consecutive PPV procedures for PDR from January 2019 to April 2021 at either the ambulatory or the inpatient surgery center in an academic tertiary referral center. Data on patient surgery plan, same-day surgical cancellation and follow-up were recorded. Differences in cancellation rate and reasons for cancellation (e.g. medical factors, patient reasons and administrative problems) between outpatients and inpatients were compared.

Results

In total, 1810 consecutive PPV procedures of 1367 patients were identified; 1509 (83.4%) were managed as inpatient surgeries and 301 (16.6%) as outpatient surgeries. The total same-day cancellation rate was 5.2% for all patients. Although outpatients were younger (51 years vs 52 years, P < 0.001), had less proportion of hypertension (60.5% vs 74.0%), coronary artery disease (10.0% vs 18.8%), renal insufficiency (9.3% vs 18.0%) and cerebrovascular diseases (1.0% vs 11.4%) (all P < 0.001), had less proportion of patients with ASA III status (14.9% vs 27.4%, P < 0.001), and had higher proportion of regional anesthesia with MAC (19.9% vs 5.0%, P < 0.001), the cancellation proportion was significantly higher for outpatients than inpatients (12.3% vs 3.8%, P < 0.001). Overall, the most common reason for surgical cancellation was medical factors, occurring more frequently in outpatients than inpatients (91.9% vs 68.4%, P = 0.012).

Conclusion

Same-day cancellation is higher in outpatient pars plana vitrectomy for proliferative diabetic retinopathy. To reduce ambulatory surgery cancellations, it is important to strengthen the monitoring of preoperative systemic comorbidities and adjust medication if necessary.

Diabetic retinopathy as a predictor of cardiovascular morbidity and mortality in subjects with type 2 diabetes

This study aimed to evaluate the predictive value of diabetic retinopathy (DR) and its stages with the incidence of major cardiovascular events and all-cause mortality in type 2 diabetes mellitus (T2DM) persons in our large primary healthcare database from Catalonia (Spain). A retrospective cohort study with pseudo-anonymized routinely collected health data from SIDIAP was conducted from 2008 to 2016. We calculated incidence rates of major cardiovascular events [coronary heart disease (CHD), stroke, or both—macrovascular events] and all-cause mortality for subjects with and without DR and for different stages of DR. The proportional hazards regression analysis was done to assess the probability of occurrence between DR and the study events. About 22,402 T2DM subjects with DR were identified in the database and 196,983 subjects without DR. During the follow-up period among the subjects with DR, we observed the highest incidence of all-cause mortally. In the second place were the macrovascular events among the subjects with DR. In the multivariable analysis, fully adjusted for DR, sex, age, body mass index (BMI), tobacco, duration of T2DM, an antiplatelet or antihypertensive drug, and HbA1c, we observed that subjects with any stage of DR had higher risks for all of the study events, except for stroke. We observed the highest probability of all-cause death events (adjusted hazard ratios, AHRs: 1.34, 95% CI: 1.28; 1.41). In conclusion, our results show that DR is related to CHD, macrovascular events, and all-cause mortality among persons with T2DM.

Incidence and risk factors of severe non-proliferative/proliferative diabetic retinopathy: More than a decade follow up in the Tehran Lipids and Glucose Study

AIMS/INTRODUCTION

To examine the incidence rate of severe non-proliferative and proliferative diabetic retinopathy (severe-NPDR/PDR) and determine its potential risk factors.

MATERIALS AND METHODS

The study consisted of 1,169 participants (675 women) with type 2 diabetes mellitus, aged ≥20 years. A trained interviewer collected information about the history of pan-retinal photocoagulation as a result of diabetic retinopathy. Multivariable Cox proportional hazards regression models were applied.

RESULTS

We found 187 cases (126 women) of severe-NPDR/PDR during a median follow-up period of 12.7 years; the corresponding incidence rate was 13.6 per 1,000 person-years. Being overweight (hazard ratio [HR], 95% confidence interval [CI] 0.60, 0.39-0.92) and obese (HR 0.48, 95% CI 0.27-0.83) were associated with lower risk, whereas being smoker (HR 1.75, 95% CI 1.12-2.74), having fasting plasma glucose levels 7.22-10.0 mmol/L (HR 2.81, 95% CI 1.70-4.62), fasting plasma glucose ≥10 mmol/L (HR 5.87, 95% CI 3.67-9.41), taking glucose-lowering medications (HR 2.58, 95% CI 1.87-3.56), prehypertension status (HR 1.65, 95% CI 1.05-2.58) and newly diagnosed hypertension (HR 1.96, 95% CI 1.06-3.65) increased the risk of severe-NPDR/PDR. Among newly diagnosed diabetes patients, being male was associated with a 59% lower risk of severe-NPDR/PDR (HR 0.41, 95% CI 0.21-0.79). Furthermore, patients who had an intermediate level of education (6-12 years) had a higher risk of developing PDR (HR 1.86, 95% CI 1.05-3.30) compared with those who had <6 years of education.

CONCLUSIONS

Among Iranians with type 2 diabetes mellitus, 1.36% developed severe-NPDR/PDR annually. Normal bodyweight, being a smoker, out of target fasting plasma glucose level, prehypertension and newly diagnosed hypertension status were independent risk factors of severe-NPDR/PDR. Regarding the sight-threatening entity of advanced diabetic retinopathy, the multicomponent strategy to control diabetes, abstinence of smoking and tight control of blood pressure should be considered.

Diabetic Retinopathy as a Predictor of Angiographic Coronary Atherosclerosis Severity in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Diabetic retinopathy (DR) is one of the most prevalent consequences of diabetes mellitus (DM). Much emphasis has been focused on the link between DR and cardiovascular disorders in patients with type 2 diabetes (T2DM). However, there is little information about the relation between the degree of DR and coronary atherosclerosis severity in Egyptian patients.

AIM

To assess the correlation between the degree of DR and the coronary atherosclerosis severity in T2DM.

PATIENTS AND METHODS

This work included 140 diabetic patients with T2DM who underwent diagnostic coronary angiography because of suspected coronary artery disease (CAD). All participants were evaluated by history, fundus assessment, laboratory tests (lipid profile and glycated hemoglobin [HbA1c]), and selective coronary angiography. The severity of coronary artery lesion was detected by Gensini score and vessel score.

RESULTS

Patients with DR had a significantly higher Gensini score (67.86± 44.56 versus 5.93± 9.02, P < 0.001) and a vessel score (2.29± 0.86 versus 0.50± 0.66, P < 0.001). There was a significant relation between the degree of DR, Gensini score (P < 0.001), and vessel score (P < 0.001), as both scores increased according to the severity of DR. The presence and degree of retinopathy were the only independent factors linked to the severity score in multivariate linear regression analyses (P < 0.001).

CONCLUSION

The presence and degree of DR are independent predictors of severe coronary atherosclerosis. Therefore, when evaluating whether a patient with T2DM is at high risk for CAD, the DR degree should be taken into consideration.

Diabetic Retinopathy and Skin Tissue Advanced Glycation End Products Are Biomarkers of Cardiovascular Events in Type 2 Diabetic Patients

Risk of cardiovascular events is not homogeneous in subjects with type 2 diabetes; therefore, its early identification remains a challenge to be met. The aim of this study is to evaluate whether the presence of diabetic retinopathy and accumulation of advanced glycation end-products in subcutaneous tissue can help identify patients at high risk of cardiovascular events. For this purpose, we conducted a prospective study (mean follow-up: 4.35 years) comprising 200 subjects with type 2 diabetes with no history of clinical cardiovascular disease and 60 non-diabetic controls matched by age and sex. The primary outcome was defined as the composite of myocardial infarction, coronary revascularization, stroke, lower limb amputation or cardiovascular death. The Cox proportional hazard multiple regression analysis was used to determine the independent predictors of cardiovascular events. The patients with type 2 diabetes had significantly more cardiovascular events than the non-diabetic subjects. Apart from the classic factors such as age, sex and coronary artery calcium score, we observed that the diabetic retinopathy and advanced glycation end-products in subcutaneous tissue were independent predictors of cardiovascular events. We conclude that the diabetic retinopathy and advanced glycation end-products in subcutaneous tissue could be useful biomarkers for selecting type 2 diabetic patients in whom the screening for cardiovascular disease should be prioritized, thereby creating more personalized and cost-effective medicine.

Macro and microangiopathy related to retinopathy and choroidopathy in type 2 diabetes

PURPOSE

To describe the relationship between diabetic retinopathy (DR) and choroidal thickness (CT), and systemic macro and microangiopathy in patients with type 2 diabetes (T2D).

METHODS

Cross-sectional study enrolling 200 eyes (100 T2D naïve patients) without macular edema. DR was graded and swept-source optical coherence tomography Triton DRI (Topcon) was used to measure CT, which gave automatic measurements in ETDRS grid. An endocrinologist examined all the patients and searched in their medical records for data about macro and microangiopathy: ischemic cardiopathy (IC), cerebrovascular accident (CVA), peripheral artery disease (PAD), nephropathy, and peripheral polyneuropathy (PPN).

RESULTS

Mean age was 67.38 ± 8.15 years, mean axial length was 23.26 ± 0.09 mm, and mean IOP was 16.75 ± 3.06 mmHg. Sixty eyes had no DR, 46 had mild, 64 had moderate, 20 had severe, and 10 had proliferative DR. IC was correlated with horizontal choroidal zones (p < 0.05 and η between 0.16 and 0.21) but not with DR (p = 0.16). CVA was neither correlated with CT (p > 0.05) nor with DR (p = 0.39). PAD was not correlated with CT (p > 0.05) but it was with DR (p = 0.03). The type of nephropathy was correlated both with CT in vertical sectors (p < 0.05 and η between 0.15 and 0.27) and DR (p = 0.01, τ = 0.24). PPN was not correlated with CT (p > 0.05) but it was with DR (p = 0.03).

CONCLUSIONS

DR is correlated with microangiopathy (nephropathy and PPN) but not with macroangiopathy (IC, CVA, and PAD). CT is mildly correlated with nephropathy and IC. Some choroidal regions are more sensitive than others to each diabetic macro and microvascular manifestation.

Proliferative diabetic retinopathy in patients with type 2 diabetes correlates with the presence of atherosclerosis cardiovascular disease

BACKGROUND

Atherosclerosis cardiovascular disease (ASCVD) is the main cause of morbidity and mortality in type 2 diabetes mellitus (T2DM). As most diabetic patients with ASCVD are asymptomatic, it is most neglected in clinical practice. For this reason, identifying high-risk ASCVD population with intensified treatment is very important. In recent years, the relationship between diabetic retinopathy (DR) and ASCVD has caused much academic concern, but the results are inconsistent. Moreover, whether all grades of DR increase the risk of ASCVD remains controversial. Most importantly, very few data can be found in China.

OBJECTIVE

Our aim is to discuss whether all grades of DR increase the risk of ASCVD after adjustment for the traditional cardiovascular risk factors and to assess the independent contribution of DR to cardiovascular events in patients with T2DM, hoping to provide more evidence for early identification of ASCVD.

RESEARCH DESIGN AND METHODS

A total of 425 T2DM patients with complete physical and biochemical data were included in the study. The grade of DR was assessed with two 45 color digital retinal images. Based on the presence of history of ASCVD, 425 T2DM patients were divided into 2 groups: ASCVD group and non-ASCVD group.

RESULTS

ASCVD patients were older and had a significantly higher fasting plasma glucose (FPG) and glycated haemoglobin (HbA1c) and proportion of history of ASCVD. At the same time, they were more likely to be females, and had lower level of alcohol and calculated glomerular filtration rate (eGFR) than non-ASCVD patients. Their trend to develop DR with ASCVD was significantly higher than patients with non-ASCVD (χ² = 5.805, P  = 0.016). DR was an independent statistical indicator of the presence of ASCVD [odds ratio (OR) (95% CI): 2.321 (1.152-4.678), P = 0.018]. Furthermore, when DR was divided into non-proliferative retinopathy (NPDR) and proliferative retinopathy (PDR) according to its severity, only PDR was significantly associated with incident ASCVD [OR (95% CI): 8.333 (1.813-38.304), P = 0.006]. After adjusting for traditional ASCVD risk factors, such an association still existed [OR (95% CI): 7.466 (1.355-41.137), P = 0.021].

CONCLUSION

DR associates strongly with ASCVD in the Chinese population with T2DM. With the increasing severity of DR, the risk of ASCVD also increases. After adjustment for traditional risk factors, PDR is still an independent risk marker for ASCVD.

Clinical Efficacy and Safety of Angiogenesis Inhibitors: Sex Differences and Current Challenges

Vasoactive molecules, such as vascular endothelial growth factor (VEGF) and endothelins, share cytokine-like activities and regulate endothelial cell (EC) growth, migration and inflammation. Some endothelial mediators and their receptors are targets for currently approved angiogenesis inhibitors, drugs that are either monoclonal antibodies raised towards VEGF, or inhibitors of vascular receptor protein kinases and signaling pathways. Pharmacological interference with the protective functions of ECs results in a similar spectrum of adverse effects. Clinically, the most common side effects of VEGF signaling pathway inhibition include an increase in arterial pressure, left ventricular (LV) dysfunction ultimately causing heart failure, and thromboembolic events, including pulmonary embolism, stroke, and myocardial infarction. Sex steroids such as androgens, progestins, and estrogen and their receptors (ERα, ERβ, GPER; PR-A, PR-B; AR) have been identified as important modifiers of angiogenesis, and sex differences have been reported for anti-angiogenic drugs. This review article discusses the current challenges clinicians are facing with regard to angiogenesis inhibitor treatments, including the need to consider sex differences affecting clinical efficacy and safety. We also propose areas for future research taking into account the role of sex hormone receptors and sex chromosomes. Development of new sex-specific drugs with improved target and cell-type selectivity likely will open the way personalized medicine in men and women requiring antiangiogenic therapy and result in reduced adverse effects and improved therapeutic efficacy.

Severity of Diabetic Retinopathy and the Risk of Future Cerebrovascular Disease, Cardiovascular Disease, and All-Cause Mortality

PURPOSE

To determine the relationship between the severity of diabetic retinopathy and the future risk of cerebrovascular accident (CVA), myocardial infarction (MI), congestive heart failure (CHF), and all-cause mortality in patients with type 2 diabetes mellitus.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Patients with type 2 diabetes who underwent diabetic retinopathy screening via fundus photography.

METHODS

The relationship between retinopathy status and the 5-year risk of first-time CVA, MI, CHF, and all-cause mortality was investigated using multivariate Cox proportional hazards regressions that controlled for age, gender, race or ethnicity, hemoglobin A1c, duration of diabetes, high-density lipoprotein level, low-density lipoprotein level, history of hypertension, systolic blood pressure, diastolic blood pressure, tobacco use, statin use, body mass index, urine microalbumin-to-creatinine ratio, and estimated glomerular filtration rate.

MAIN OUTCOME MEASURES

Five-year risk of first-time CVA, MI, CHF, and all-cause mortality.

RESULTS

Seventy-seven thousand three hundred seventy-six patients were included in this study. The average age was 59.8 years with 53.6% male, 31.2% non-Hispanic White, and 41.4% Hispanic patients. Diabetic retinopathy was significantly associated with all outcomes on multivariate analysis. Compared with patients with no retinopathy, those with minimal nonproliferative diabetic retinopathy (NPDR) had a higher risk of CVA (hazard ratio [HR], 1.31; 95% confidence interval [CI], 1.18-1.46), MI (HR, 1.30; 95% CI, 1.15-1.46), CHF (HR, 1.29; 95% CI, 1.19-1.40), and death (HR, 1.15; 95% CI, 1.05-1.25). Similarly, patients with moderate to severe NPDR had a higher risk of each outcome (CVA: HR, 1.56; 95% CI, 1.29-1.89; MI: HR, 1.92; 95% CI, 1.57-2.34; CHF: HR, 1.90; 95% CI, 1.66-2.18, and death: HR, 1.55; 95% CI, 1.32-1.82), as did patients with proliferative diabetic retinopathy (CVA: HR, 2.53; 95% CI, 1.84-3.48; MI: HR, 1.89; 95% CI, 1.26-2.83; CHF: HR, 1.96; 95% CI, 1.47-2.59; and death: HR, 1.87; 95% CI, 1.36-2.56).

CONCLUSIONS

Diabetic retinopathy is significantly associated with future risk of CVA, MI, CHF, and death, with higher degrees of retinopathy appearing to carry a heightened risk for each outcome. Retinal information may provide valuable insights into patients' risk of future vascular disease and death.

Placebo-Controlled, Double-Blind Study of Empagliflozin (EMPA) and Implantable Cardioverter-Defibrillator (EMPA-ICD) in Patients with Type 2 Diabetes (T2DM): Rationale and Design

INTRODUCTION

Type 2 diabetes (T2DM) is associated with cardiovascular death, including sudden cardiac death due to arrhythmias. Patients with an implantable cardioverter-defibrillator (ICD) are also at high risk of developing a clinically significant ventricular arrhythmia. It has been reported that sodium-glucose cotransporter 2 (SGLT2) inhibitors can reduce cardiovascular deaths; however, the physiological mechanisms of this remain unclear. It is, however, well known that SGLT2 inhibitors increase blood ketone bodies, which have been suggested to have sympatho-suppressive effects. Empagliflozin (EMPA) is an SGLT2 inhibitor. The current clinical trial titled "Placebo-controlled, double-blind study of empagliflozin (EMPA) and implantable cardioverter-defibrillator (EMPA-ICD) in patients with type 2 diabetes (T2DM)" was designed to investigate the antiarrhythmic effects of EMPA.

METHODS

The EMPA-ICD study is a prospective, multicenter, placebo-controlled, double-blind, randomized, investigator-initiated clinical trial currently in progress. A total of 210 patients with T2DM (hemoglobin A1c 6.5-10.0%) will be randomized (1:1) to receive once-daily placebo or EMPA, 10 mg, for 24 weeks. The primary endpoint is the number of clinically significant ventricular arrhythmias for 24 weeks before and 24 weeks after study drug administration, as documented by the ICD. The secondary endpoints of the study are the change from baseline concentrations in blood ketone and catecholamine 24 weeks after drug treatment.

CONCLUSION

The EMPA-ICD study is the first clinical trial to assess the effect of an SGLT2 inhibitor on clinically significant ventricular arrhythmias in patients with T2DM and an ICD.

TRIAL REGISTRATION

Unique trial number, jRCTs031180120 ( https://jrct.niph.go.jp/latest-detail/jRCTs031180120 ).

Vascular resistance of carotid and vertebral arteries is associated with retinal microcirculation measured by laser speckle flowgraphy in patients with type 2 diabetes mellitus

AIMS

Evaluation of the retinal microcirculation is key to understanding retinal vasculopathies, such as diabetic retinopathy. Laser speckle flowgraphy (LSFG) has recently enabled us to directly evaluate the vascular resistance in both retinal vessels and capillaries, non-invasively. We therefore assessed whether retinal vessel blood flow and/or the capillary microcirculation are associated with blood flow in the cervical arteries in diabetic patients without severe retinopathy.

METHODS

We enrolled 110 type 2 diabetes patients, with no or mild non-proliferative diabetic retinopathy, in this prospective cross-sectional study. We measured the resistivity indices (RIs) of the retinal vessel and capillaries by LSFG and those of cervical arteries by Doppler ultrasonography, followed by analyzing associations.

RESULTS

The RIs of not only the carotid but also vertebral arteries were associated with those of retinal vessel blood flow and the retinal capillary microcirculation. Multiple regression analyses revealed these associations to be independent of other explanatory variables including age and diabetes duration.

CONCLUSIONS

We obtained novel and direct evidence demonstrating a close association between the retinal microcirculation and cervical artery hemodynamics in diabetic patients. These findings suggest shared mechanisms to underlie micro- and macro-angiopathies. Thus, high vascular resistance of cervical arteries may be a risk of developing retinopathy.

High pulse wave velocity is associated with the severity of diabetic retinopathy in patients with type 2 diabetes

Pulse wave velocity (PWV) is a non-invasive test for assessing arterial stiffness, and brachial-ankle PWV has been used as an index of peripheral arterial stiffness. This study aimed to investigate the association between the PWV value and severity of diabetic retinopathy (DR). 846 patients with type 2 diabetes (T2DM) consecutively underwent brachial-ankle PWV, and the degree of PWV was defined by tertile. The severity of DR was categorized as no diabetic retinopathy (NDR), non-proliferative diabetic retinopathy (NPDR) or proliferative diabetic retinopathy (PDR) based on the Early Treatment Diabetic Retinopathy Study Scale. Multinomial logistic regression analyses were utilized not only to explore the association between the degree of PWV and severity of DR but also to examine the association of a high-tertile PWV with PDR. PWV levels, diabetes duration and blood pressure were all significantly higher in subjects with NPDR or PDR as compared with individuals with NDR. In the univariate analysis, the highest tertile of PWV (>19.6 m/s) was significantly associated with both NPDR (p<0.001) and PDR (p<0.001) as compared with NDR. After adjusting for confounding factors, the highest tertile of PWV remained significantly associated with PDR (p=0.005), but not with NPDR (p=0.107). Furthermore, the highest tertile of PWV was more significantly associated with PDR (OR=6.15, 95%CI 1.38 to 27.38) as compared with the lowest tertile. In our study, an increasing degree of PWV was positively associated with the severity of DR. High PWV was strongly associated with the risk of severe DR, especially PDR.

Presence of Carotid Plaque Is Associated with Rapid Renal Function Decline in Patients with Type 2 Diabetes Mellitus and Normal Renal Function

BACKGROUND

Recent evidences indicate that early rapid renal function decline is closely associated with the development and progression of diabetic kidney disease. We have investigated the association between carotid atherosclerosis and rapid renal function decline in patients with type 2 diabetes mellitus and preserved renal function.

METHODS

In a prospective, multicenter cohort, a total of 967 patients with type 2 diabetes mellitus and preserved renal function were followed for 6 years with serial estimated glomerular filtration rate (eGFR) measurements. Common carotid intima-media thickness (CIMT) and presence of carotid plaque were assessed at baseline. Rapid renal function decline was defined as an eGFR decline >3.3% per year.

RESULTS

Over a median follow-up of 6 years, 158 participants (16.3%) developed rapid renal function decline. While there was no difference in CIMT, the presence of carotid plaque in rapid decliners was significantly higher than in non-decliners (23.2% vs. 12.2%, P<0.001). In multivariable logistic regression analysis, presence of carotid plaque was an independent predictor of rapid renal function decline (odds ratio, 2.33; 95% confidence interval, 1.48 to 3.68; P<0.0001) after adjustment for established risk factors. The model including the carotid plaque had better performance for discrimination of rapid renal function decline than the model without carotid plaque (area under the receiver operating characteristic curve 0.772 vs. 0.744, P=0.016).

CONCLUSION

Close monitoring of renal function and early intensive management may be beneficial in patients with type 2 diabetes mellitus and carotid plaques.

Association of central arterial stiffness with the presence and severity of diabetic retinopathy in Asians with type 2 diabetes

OBJECTIVE

Arterial stiffness has been associated with diabetic retinopathy; however, the information is limited in Asians. We aim to examine the association of central arterial stiffness with the presence and severity of diabetic retinopathy in type 2 diabetes mellitus patients in Singapore.

METHODS

Arterial stiffness was estimated by carotid-femoral pulse wave velocity and augmentation index using applanation tonometry method. Digital colour fundus photographs from 1,203 patients were assessed for diabetic retinopathy. Diabetic retinopathy severity was categorized into non-proliferative diabetic retinopathy and proliferative diabetic retinopathy. Logistic regression model was used to evaluate the associations of diabetic retinopathy with pulse wave velocity and augmentation index.

RESULTS

Diabetic retinopathy was diagnosed in 391 (32.5%) patients, including 271 non-proliferative diabetic retinopathy and 108 proliferative diabetic retinopathy. Diabetic retinopathy have higher pulse wave velocity (11.2 ± 3.3 vs 9.5 ± 2.6 m/s, p < 0.001) and augmentation index (28.4 ± 9.4 vs 26.1 ± 10.6%, p < 0.001) than non-diabetic retinopathy. After multivariable adjustment, pulse wave velocity [odds ratio = 1.11 (95% confidence interval = 1.05-1.17), p < 0.001] and augmentation index [odds ratio = 1.03 (95% confidence interval = 1.01-1.04), p = 0.009] was associated with diabetic retinopathy. In severity analyses, pulse wave velocity was associated with non-proliferative diabetic retinopathy [odds ratio = 1.10 (95% confidence interval = 1.03-1.17), p = 0.002] and proliferative diabetic retinopathy [odds ratio = 1.15 (95% confidence interval = 1.06-1.25), p = 0.001] (p-trend < 0.001). Augmentation index showed significant associations with non-proliferative diabetic retinopathy [odds ratio = 1.02 (95% confidence interval = 1.01-1.04), p = 0.008], but not with proliferative diabetic retinopathy [odds ratio = 1.01 (95% confidence interval = 0.98-1.04), p = 0.36] (p-trend = 0.03).

CONCLUSION

Central arterial stiffness was associated with the presence and severity of diabetic retinopathy in type 2 diabetes mellitus patients, suggesting its etiologic implication in diabetic retinopathy.

Association between diabetic eye disease and other complications of diabetes: Implications for care. A systematic review

The aim of this systematic review was to examine the associations between diabetic retinopathy (DR) and the common micro- and macrovascular complications of diabetes mellitus, and how these could potentially affect clinical practice. A structured search of the PubMed database identified studies of patients with diabetes that assessed the presence or development of DR in conjunction with other vascular complications of diabetes. From 70 included studies, we found that DR is consistently associated with other complications of diabetes, with the severity of DR linked to a higher risk of the presence of, or of developing, other micro- and macrovascular complications. In particular, DR increases the likelihood of having or developing nephropathy and is also a strong predictor of stroke and cardiovascular disease, and progression of DR significantly increases this risk. Proliferative DR is a strong risk factor for peripheral arterial disease, which carries a risk of lower extremity ulceration and amputation. Additionally, our findings suggest that a patient with DR has an overall worse prognosis than a patient without DR. In conclusion, this analysis highlights the need for a coordinated and collaborative approach to patient management. Given the widespread use of DR screening programmes that can be performed outside of an ophthalmology office, and the overall cost-effectiveness of DR screening, the presence and severity of DR can be a means of identifying patients at increased risk for micro- and macrovascular complications, enabling earlier detection, referral and intervention with the aim of reducing morbidity and mortality among patients with diabetes. Healthcare professionals involved in the management of diabetes should encourage regular DR screening.

Diabetic retinopathy as an independent predictor of subclinical cardiovascular disease: baseline results of the PRECISED study

OBJECTIVE

Detection of subclinical cardiovascular disease (CVD) has significant impact on the management of type 2 diabetes. We examined whether the assessment of diabetic retinopathy (DR) is useful for identifying patients at a higher risk of having silent CVD.

RESEARCH DESIGN AND METHODS

Prospective case-control study comprising 200 type 2 diabetic subjects without history of clinical CVD and 60 age-matched non-diabetic subjects. The presence of subclinical CVD was examined using two parameters: (1) calcium coronary score (CACs); (2) composite of CACs >400 UA, carotid plaque ≥3 mm, carotid intima-media thickness ratio >1, or the presence of ECG changes suggestive of previous asymptomatic myocardial infarction. In addition, coronary angio-CT was performed. DR was assessed by slit-lamp biomicroscopy and retinography.

RESULTS

Type 2 diabetic subjects presented higher CACs than non-diabetic control subjects (p<0.01). Age, male gender, and the presence of DR were independently related to CACs >400 (area under the receiver operating characteristic curve (AUROC) 0.76). In addition, an inverse relationship was observed between the degree of DR and CACs <10 AU. The variables independently associated with the composite measurement of subclinical CVD were age, diabetes duration, the glomerular filtration rate, microalbuminuria, and the presence of DR (AUROC 0.71). In addition, a relationship (p<0.01) was observed between the presence and degree of DR and coronary stenosis.

CONCLUSIONS

The presence and degree of DR is independently associated with subclinical CVD in type 2 diabetic patients. Our results lead us to propose a rationalized screening for coronary artery disease in type 2 diabetes based on prioritizing patients with DR, particularly those with moderate-severe degree.

Early vascular parameters in the micro- and macrocirculation in type 2 diabetes

BACKGROUND

Diabetes converts from a metabolic disorder into a predominantly vascular disease, once its duration extends over several years or/and when additional cardiovascular risk factors such as hypertension coexist. In a cross-sectional analysis we analyzed various vascular parameters in the renal, retinal and systemic circulation, with the goal to identify which vascular parameter of early organ damage is the earliest that can be clinically detected.

METHODS

In 111 patients with type 2 diabetes (T2DM) (off any anti-diabetic medication for at least 4 weeks) and 54 subjects without T2DM we compared various parameters of early vascular remodeling in the same patient: urinary albumin creatinine ratio ([UACR], early morning spot urine) and estimated glomerular filtration rate (eGFR), retinal capillary flow (RCF) and intercapillary distance (ICD) as parameters of capillary rarefaction, wall-to-lumen ratio (WLR) of the retinal arterioles [all assessed by Scanning Laser Doppler Flowmetry], and central systolic pressure (cSBP) and central pulse pressure (cPP) [measured by pulse wave analysis, Syphygmocor] both reflecting vascular stiffness of large arteries.

RESULTS

Compared to subjects without T2DM, patients with T2DM (diabetes duration: median 48 months, interquartile range 24-88 months) were older (59.8 ± 7.3 vs 43.4 ± 12.9 years, p < 0.001), more females (33.3 vs 20.4%, p < 0.001), but 24-h systolic and diastolic blood pressure did not differ between the two groups. The analysis adjusted for age, gender and cardiovascular risk factors revealed that ICD (23.9 ± 5.1 vs 20.8 ± 3.5 µm, p value = 0.001) and cPP (41.8 ± 11.7 vs 34.8 ± 10.6 mmHg, p value < 0.001) were significantly higher and eGFR (91.7 ± 9.9 vs 95.9 ± 17.3 ml/min/1.73 m², p value < 0.001) was significantly lower in patients with T2DM than in subjects without T2DM.

CONCLUSION

These data suggest that at similar blood pressure capillary rarefaction in the retinal circulation (ICD), decreased eGFR in the renal circulation and increased central pulse pressure (cPP) of large arteries are earlier detectable than other vascular remodeling parameters of the micro- (WLR, RCF, UACR) and macrocirculation (cSBP) in patients with T2DM. Trial registration Trial registration number: NCT02471963, Date of registration: June 15, 2015, retrospectively registered; Trial registration number: NCT01319357, Date of registration: March 21, 2011, retrospectively registered; Trial registration number: NCT02383238, Date of registration: March 9, 2015, retrospectively registered; Trial registration number: NCT00152698, Date of registration: September 9, 2005, prospectively registered; Trial registration number: NCT00136188, Date of registration: August 26, 2005, prospectively registered.

Prevalence, risk factors and burden of diabetic retinopathy in China: a systematic review and meta-analysis

Background

Diabetic retinopathy (DR), the primary retinal vascular complication of diabetes mellitus (DM), is a leading cause of vision impairment and blindness in working-age population globally. Despite mounting concerns about the emergence of DM as a major public health problem in the largest developing country, China, much remains to be understood about the epidemiology of DR. We aimed to investigate the prevalence of and risk factors for DR, and estimate the burden of DR in China in 2010.

Methods

China National Knowledge Infrastructure (CNKI), Wanfang, Chinese Biomedicine Literature Database (CBM-SinoMed), PubMed, Embase and Medline were searched for studies that reported the prevalence of and risk factors for DR in Chinese population between 1990 and 2017. A random-effects meta-analysis model was adopted to pool the overall prevalence of DR. Variations in the prevalence of DR in different age groups, DM duration groups and settings were assessed by subgroup meta-analysis and meta-regression. Odds ratios (ORs) of major risk factors were pooled using random-effects meta-analysis. The number of people with DR in 2010 was estimated by multiplying the age-specific prevalence of DR in people with DM with the corresponding number of people with DM in China. Finally, the national number of people with DR was distributed into six geographic regions using a risk factor-based model.

Results

A total of 31 studies provided information on the prevalence of DR and 21 explored potential risk factors for DR. The pooled prevalence of any DR, nonproliferative DR (NPDR) and proliferative DR (PDR) was 1.14% (95% CI = 0.80-1.52), 0.90% (95% CI = 0.56-1.31) and 0.07% (95% CI = 0.02-0.14) in general population; In people with DM, the pooled prevalence rates were 18.45% (95% CI = 14.77-22.43), 15.06% (95% CI = 11.59-18.88) and 0.99% (95% CI = 0.40-1.80) for any DR, NPDR and PDR, respectively. The prevalence of any DR in DM patients peaked between 60 and 69 years of age, and increased steeply with the duration of DM. DM patients residing in rural China were at a higher risk to have DR than those in urban areas. In addition, insulin treatment, elevated FBG level and higher HbA1c concentration were confirmed to be associated with a higher prevalence of DR in people with DM, with meta-ORs of 1.99 (95% CI = 1.34-2.95), 1.33 (95% CI = 1.12-1.59) and 1.15 (95% CI = 1.09-1.20) respectively. In 2010, a total of 13.16 million (95% CI = 8.95-18.00) Chinese aged 45 years and above were living with DR, among whom the most were in South Central China and the least were in Northwest China.

Conclusions

DR has become a serious public health problem in China. Optimal screening of and interventions on DR should be implemented. Improved epidemiological studies on DR are still required.

Retinopathy, Neuropathy, and Subsequent Cardiovascular Events in Patients with Type 2 Diabetes and Acute Coronary Syndrome in the ELIXA: The Importance of Disease Duration

INTRODUCTION

We investigated the association of diabetic retinopathy and neuropathy with increased risk of recurrent cardiovascular (CV) events in 6068 patients with type 2 diabetes mellitus (T2DM) and recent acute coronary syndrome (ACS) enrolled in the Evaluation of Lixisenatide in Acute Coronary Syndrome (ELIXA).

METHODS

History of retinopathy and neuropathy as well as duration of T2DM were self-reported at screening. Proportional hazards regression models were used to assess relationships between retinopathy, neuropathy, and recurrent CV events.

RESULTS

At screening, retinopathy and neuropathy were reported in 10.7% and 17.5% of patients, respectively, while 5.7% reported both. When adjusted for randomized treatment only, both retinopathy and neuropathy were associated with a primary composite outcome (CV death, nonfatal MI, stroke, or hospitalization for unstable angina) (retinopathy: HR 1.44, 95% CI 1.19-1.75; neuropathy: HR 1.33, 95% CI 1.12-1.57), CV composite (CV death, nonfatal MI, stroke, hospitalization for heart failure (HF)) (retinopathy: HR 1.57, 95% CI 1.31-1.88; neuropathy: HR 1.38, 95% CI 1.19-1.62), myocardial infarction (retinopathy: HR 1.38, 95% CI 1.08-1.76; neuropathy: HR 1.26, 95% CI 1.02-1.54), HF hospitalization (retinopathy: HR 2.03, 95% CI 1.48-2.78; neuropathy: HR 1.71, 95% CI 1.30-2.27), and all-cause mortality (retinopathy: HR 1.65, 95% CI 1.28-2.12; neuropathy: HR 1.43, 95% CI 1.14-1.78). When included in the same model, and adjusted for T2DM duration, there were no independent associations of either with CV outcomes, while T2DM duration remained strongly associated with all outcomes. Addition of demographic characteristics and CV risk factors did not further alter these relationships.

CONCLUSIONS

In patients with T2DM and recent ACS, a history of retinopathy and/or neuropathy and longer T2DM duration could be considered clinical markers for high risk of recurrent CV events. This trial is registered with the ELIXA (Evaluation of Lixisenatide in Acute Coronary Syndrome), ClinicalTrials.gov registration number NCT01147250.

Elevated serum fetuin-A levels are associated with grades of retinopathy in type 2 diabetic patients

PURPOSE

Fetuin-A is a physiological inhibitor of insulin receptor tyrosine kinase and thus associated with insulin resistance, metabolic syndrome, and an increased risk for type 2 diabetes mellitus (T2DM). This study aims to investigate the possible relation between the serum fetuin-A levels and the stages of diabetic retinopathy (DR) in patients with T2DM.

METHODS

This prospective study included 82 patients with T2DM and 19 age- and gender-matched healthy controls (HCs) (group 1). Diabetic patients were subclassified into three groups according to ocular findings: without DR (group 2; n = 26); non-proliferative DR (group 3; n = 29), and proliferative DR (group 4; n = 27). Serum fetuin-A levels were determined by a spectrophotometric technique using an immulite chemiluminescent immunometric assay. The data were analyzed using a Mann-Whitney U test, and the results were expressed as mean ± standard deviation.

RESULTS

Mean fetuin-A values were 256.4 ± 21.3 μg/ml in group 1, 263.5 ± 24.2 μg/ml in group 2, 282.2 ± 31.1 μg/ml in group 3, and 296.3 ± 26.2 μg/ml in group 4. Group 2 had higher mean fetuin-A level compared with group 1, but the difference was not statistically significant (p > 0.05). Serum fetuin-A levels were significantly higher in groups 3 and 4 compared with HCs (both p < 0.05). Compared with group 2, both DR groups had higher fetuin-A levels with a significant difference (both p < 0.05); and patients with proliferative DR had significantly higher serum fetuin-A levels compared with non-proliferative DR (p < 0.05). The mean serum fetuin-A levels increased with the stage of DR, and the highest levels were found in patients with proliferative DR.

CONCLUSION

Our findings suggest an association between fetuin-A levels and DR stage. In diabetic patients, the risk of retinopathy development increases with higher fetuin-A values. Fetuin-A may play an important role in the pathophysiology and progression of DR.

Association of Diabetes Related Complications with Heart Rate Variability among a Diabetic Population in the UAE

Microvascular, macrovascular and neurological complications are the key causes of morbidity and mortality among type II diabetes mellitus (T2DM) patients. The aim of this study was to investigate the alterations of cardiac autonomic function of diabetic patients in relation to three types of diabetes-related complications. ECG recordings were collected and analyzed from 169 T2DM patients in supine position who were diagnosed with nephropathy (n = 55), peripheral neuropathy (n = 64) and retinopathy (n = 106) at two hospitals in the UAE. Comparison between combinations of patients with complications and a control diabetic group (CONT) with no complication (n = 34) was performed using time, frequency and multi-lag entropy measures of heart rate variability (HRV). The results show that these measures decreased significantly (p<0.05) depending on the presence and type of diabetic complications. Entropy, (median, 1st- 3rd interquartile range) for the group combining all complications (1.74,1.37-2.09) was significantly lower than the corresponding values for the CONT group (1.77, 1.39-2.24) with lag-1 for sequential beat-to-beat changes. Odds ratios (OR) from the entropy analysis further demonstrated a significantly higher association with the combination of retinopathy and peripheral neuropathy versus CONT (OR: 1.42 at lag 8) and an even OR for the combination of retinopathy and nephropathy (OR: 2.46 at lag 8) compared to the other groups with complications. Also, the OR of low frequency power to high frequency power ratio (LF/HF) showed a higher association with these diabetic-related complications compared to CONT, especially for the patient group combining all complications (OR: 4.92). This study confirms that the type of microvascular or peripheral neuropathy complication present in T2DM patients have different effects on heart rate entropy, implying disorders of multi-organ connectivity are directly associated with autonomic nervous system dysfunction. Clinical practice may benefit from including multi-lag entropy for cardiac rhythm analysis in conjunction with traditional screening methods in patients with diabetic complications to ensure better preventive and treatment outcomes in the Emirati Arab population.

Reduced serum milk fat globule-epidermal growth factor 8 (MFG-E8) concentrations are associated with an increased risk of microvascular complications in patients with type 2 diabetes

BACKGROUND

The association between serum milk fat globule-epidermal growth factor 8 (MFG-E8) concentrations and vascular complications in T2DM remains unclear.

METHODS

A total of 149 patients with T2DM were included. The serum concentrations of MFG-E8, glycosylated hemoglobin (HbA1c), and high-sensitivity C-reactive protein (hs-CRP) were measured.

RESULTS

There was no significant difference in serum MFG-E8 concentrations between the T2DM group and the T2DM with subclinical atherosclerosis (AS) group (615.49±143.54 vs. 596.22±79.46ng/ml, P=0.365), while the serum concentrations of MFG-E8 in the T2DM with microvascular complications group (446.70±61.53ng/ml) and the T2DM with subclinical AS and microvascular complications group (200.87±38.86ng/ml) were significantly lower than those in the T2DM group (P=0.000 for both). In addition, hs-CRP and HbAlc concentrations were independently associated with serum MFG-E8 concentrations (P=0.024 and P=0.01, respectively), and low serum MFG-E8 concentrations were significantly associated with an increased risk of microvascular complications in T2DM patients.

CONCLUSIONS

Serum concentrations of MFG-E8 were negatively associated with the risk of microvascular complications in patients with T2DM. Thus, it might be a potential candidate biomarker for diabetic microvascular complications.

The Degree of Diabetic Retinopathy in Patients with Type 2 Diabetes Correlates with the Presence and Severity of Coronary Heart Disease

Both diabetic retinopathy (DR) and coronary heart disease (CHD) are clinically significant in diabetic patients. We investigated the correlation between the severity of DR and the presence and severity of CHD among type 2 diabetic patients. A total of 175 patients who were examined at the DR clinic and underwent dual-source computed tomography (DSCT) angiography within 6 months were included. The degree of DR was graded as no DR, nonproliferative DR (NPDR), and proliferative DR (PDR). The severity of CHD and the numbers of significant stenotic coronary artery on DSCT angiography according to DR grade were assessed. The mean Agatston Calcium Score (ACS) in patients with PDR was significantly higher than other groups (P < 0.001). The overall odds of an ACS increase were about 4.7-fold higher in PDR group than in no DR group (P < 0.001). In PDR group, in comparison with in no DR, the odds of having 1 or 2 arterial involvement were 3-fold higher (P = 0.044), and those of having 3 were 17-fold higher (P = 0.011). The c-index, one of the predictability values in regression analysis model, was not significantly increased when PDR was added to classical CHD risk factors (0.671 to 0.706, P = 0.111). Conclusively, patients with PDR develop a greater likelihood of not only having CHD, but being more severe nature. PDR has no additional effect to classical CHD risk factors for predicting CHD.

Beneficial effects through aggressive coronary screening for type 2 diabetes patients with advanced vascular complications

Glycemic control alone does not reduce cardiovascular events in patients with type 2 diabetes (T2D), and routine screening of all T2D patients for asymptomatic coronary artery disease (CAD) is not effective for preventing acute cardiac events. We examined the effectiveness of an aggressive screening protocol for asymptomatic CAD in T2D patients with advanced vascular complications.We designed a 3-year cohort study investigating the effectiveness of the aggressive coronary screening for T2D patients with advanced vascular complications and no known coronary events using propensity score adjusted analysis at a national center in Japan. Eligibility criteria included T2D without known coronary events and with any 1 of the following 4 complications: advanced diabetic retinopathy, advanced chronic kidney disease, peripheral artery disease, or cerebrovascular disease. In the aggressive screening group (n = 122), all patients received stress single photon emission computed tomography and those exhibiting myocardial perfusion abnormalities underwent coronary angiography. In the conventional screening group (n = 108), patients were examined for CAD at the discretion of their medical providers. Primary endpoint was composite outcome of cardiovascular death and nonfatal cardiovascular events.Asymptomatic CAD with ≥70% stenosis was detected in 39.3% of patients completing aggressive screening. The proportions achieving revascularization and receiving intensive medical therapy within 90 days after the screening were significantly higher in the aggressive screening group than in the conventional screening group [19.7% vs 0% (P < 0.001) and 48.4% vs 9.3% (P < 0.001), respectively]. The cumulative rate of primary composite outcome was significantly lower in the aggressive screening group according to a propensity score adjusted Cox proportional hazards model (hazard ratio, 0.35; 95% confidence interval, 0.12-0.96; P = 0.04).Aggressive coronary screening for T2D patients with advanced vascular complications reduced cardiovascular death and nonfatal cardiovascular events.

Microvasular and macrovascular complications in diabetes mellitus: Distinct or continuum?

Diabetes and related complications are associated with long-term damage and failure of various organ systems. The line of demarcation between the pathogenic mechanisms of microvascular and macrovascular complications of diabetes and differing responses to therapeutic interventions is blurred. Diabetes induces changes in the microvasculature, causing extracellular matrix protein synthesis, and capillary basement membrane thickening which are the pathognomic features of diabetic microangiopathy. These changes in conjunction with advanced glycation end products, oxidative stress, low grade inflammation, and neovascularization of vasa vasorum can lead to macrovascular complications. Hyperglycemia is the principal cause of microvasculopathy but also appears to play an important role in causation of macrovasculopathy. There is thought to be an intersection between micro and macro vascular complications, but the two disorders seem to be strongly interconnected, with micro vascular diseases promoting atherosclerosis through processes such as hypoxia and changes in vasa vasorum. It is thus imperative to understand whether microvascular complications distinctly precede macrovascular complications or do both of them progress simultaneously as a continuum. This will allow re-focusing on the clinical issues with a unifying perspective which can improve type 2 diabetes mellitus outcomes.

Relationship between Altered Platelet Morphological Parameters and Retinopathy in Patients with Type 2 Diabetes Mellitus

Purpose. To investigate whether platelet morphology or function is altered in patients with diabetic retinopathy (DR). Methods. This prospective study enrolled 85 healthy controls (HCs) (group 1) and 262 patients with Type 2 diabetes mellitus (T2DM). Patients were subclassified into three groups according to ocular findings: no DR (group 2; n = 88); nonproliferative DR (group 3; n = 88), and proliferative DR (group 4; n = 86). Mean platelet volume (MPV), platelet distribution width (PDW), platelet large cell ratio (PLCR), plateletcrit (PCT) values, and platelet count were measured in the studied groups. Results. MPV, PDW, and PLCR levels were significantly altered in groups 2-4 compared with HCs (p < 0.05, p < 0.05, p < 0.05). Compared with group 2, both DR groups had higher MPV and PDW levels, with a significant difference between groups 2 and 4 for both MPV (p = 0.036) and PDW (p = 0.006). PLCR correlated with retinopathy stage, but no significant difference was found between the DR groups. Platelet count and PCT values were not significantly different between the groups (p > 0.05). Conclusion. Our findings suggest an association between mean platelet indices (MPI) (i.e., MPV, PDW, and PLCR) and DR stage. Therefore, MPI could be a beneficial prognostic marker of DR in patients with T2DM.

Relationship between increased left atrial volume and microvascular complications in patients with type 2 diabetes

AIMS

We assessed whether left atrial volume index (LAVI) was associated with the presence of microvascular complications in patients with type 2 diabetes, and whether this association was independent of hemodynamic and non-hemodynamic factors.

METHODS

We studied 157 consecutive outpatients with type 2 diabetes with no previous history of ischemic heart disease, chronic heart failure and valvular diseases. A transthoracic echocardiography and myocardial perfusion scintigraphy were performed in all participants. Presence of microvascular complications was also recorded.

RESULTS

Overall, 51 patients had decreased estimated glomerular filtration rate and/or abnormal albuminuria, 24 had diabetic retinopathy, 22 had lower-extremity sensory neuropathy, and 67 (42.7%) patients had one or more of these microvascular complications (i.e., combined endpoint). After stratifying patients by LAVI, those with LAVI ≥32 ml/m(2) had a greater prevalence of microvascular complication, lower left ventricular (LV) ejection fraction, higher LV mass index and higher E/e' ratio than those with LAVI <32 ml/m(2). Logistic regression analyses revealed that microvascular complications (singly or in combination) were associated with increased LAVI, independently of age, sex, diabetes duration, hemoglobin A1c, hypertension, LV-ejection fraction, LV mass index and the E/e' ratio.

CONCLUSIONS

These results indicate that microvascular diabetic complications are associated with increased LAVI in well-controlled type 2 diabetic patients with preserved systolic function and free from ischemic heart disease, independently of multiple potential confounders.

Association Between Diabetic Macular Edema and Cardiovascular Events in Type 2 Diabetes Patients: A Multicenter Observational Study

Diabetic macular edema (DME) is the main cause of visual loss associated with diabetes but any association between DME and cardiovascular events is unclear.This study aims to describe the possible association between DME and cardiovascular events in a multicenter cross-sectional study of patients with type 2 diabetes.Two thousand eight hundred seven patients with type 2 diabetes were recruited from diabetes and nephrology clinical institutional centers participating in the DIAB 2 NEPHROGENE study focusing on diabetic complications. DME (presence/absence) and diabetic retinopathy (DR) classification were based on ophthalmological report and/or on 30° color retinal photographs. DR was defined as absent, nonproliferative (background, moderate, or severe) or proliferative. Cardiovascular events were stroke, myocardial infarction, and lower limb amputation.Details regarding associations between DME and cardiovascular events were evaluated.The study included 2807 patients with type 2 diabetes, of whom 355 (12.6%) had DME. DME was significantly and independently associated with patient age, known duration of diabetes, HbA1c, systolic blood pressure, and DR stage. Only the prior history of lower limb amputation was strongly associated with DME in univariate and multivariate analyses, whereas no association was found with regard to myocardial infarction or stroke. Moreover, both major (n = 32) and minor lower limb (n = 96) amputations were similarly associated with DME, with respective odds ratio of 3.7 (95% confidence interval [CI], 1.77-7.74; P = 0.0012) and of 4.29 (95% CI, 2.79-6.61; P < 0.001).DME is strongly and independently associated with lower limb amputation in type 2 diabetic patients.

Effects of predisposing, reinforcing and enabling factors on self-care behaviors of the patients with diabetes mellitus in the Minoodasht city, Iran

Background

To control diabetes mellitus (DM) it is necessary to make overall changes in the life style of the patients. The aim of this study was to determine the effects of predisposing, reinforcing and enabling factors on self-care behaviors of the patients with DM in the Minoodasht city, Iran in 2012.

Methods

In this quasi-experimental study, 78 people with DM were selected by convenience sampling method. In the first stage of study, the educational program was compiled and executed on six information sessions. To present the informative content, a video projector and different lecturing methods including questions and answers, dynamic group discussion and different educational materials such as pamphlets and CDs were employed. After one month, the efficiency of the educational program was determined by using the same questioner. Data were analyzed using paired sample T-test and McNemar test.

Results

The mean age of participants was 49 (SD: 3.27.) years old, 87.2% were married, and 19.2% were illiterate. The results showed that the enabling factors like adopting to go on a diet and the educational classes facilitated by the staff had significant effects on health care behavior of the patients. Furthermore 69.2% of the participants adopted to go on a diet before the educational sessions; that figure increased to 94.9% after the educational sessions. According to the results the mean scores for the knowledge, attitude, and behavior, reinforcement factors and enabling factors increased significantly after of the educational intervention (p- value >0.001).

Conclusion

Predisposing, enabling and reinforcement factors affected in taking self-care behavior in the patient with DM.

High prevalence of lower extremity peripheral artery disease in type 2 diabetes patients with proliferative diabetic retinopathy

Little is known about the relationship between lower extremity peripheral arterial disease (PAD) and proliferative diabetic retinopathy (PDR) in type 2 diabetes (T2D). Here, we explored the relationship between sight-threatening PDR and PAD. We screened for diabetic retinopathy (DR) and PAD in hospitalized patients with T2D. Patients with a diabetic duration of more than 10 years, HbA1c ≥7.5%, eGFR ≥60mL/min/1.73m2 and with PDR or with no diabetic retinopathy (NDR) were eligible for this cross-sectional study. Severities of DR were graded by digital retinal photographs according to the Early Treatment Diabetic Retinopathy Study (ETDRS) scale. We assessed PAD by measuring Ankle Brachial Index (ABI), Toe Brachial Index (TBI) and Doppler ultrasound. Statistical analyses were performed using SPSS 17.0 software. Of the 1544 patients, 169 patients with extreme eye (57 PDR and 112 NDR) phenotypes met the inclusion criteria. Patients with PDR had a significantly higher proportion of low ABI (≤0.99) and high ABI (≥1.3) than patients with NDR (28.1% and 15.8% vs. 14.3% and 6.2% respectively, P<0.05). PDR patients also had lower TBI than NDR patients (0.56±0.09 vs. 0.61±0.08, P<0.01). The proportion of patients with abnormal duplex ultrasound was higher in PDR than in NDR (21.1% vs. 9.8%, P<0.001). This showed that PDR associated with PAD could be defined in multiple ways: abnormal ABI (≤0.9) (OR = 3.61, 95% CI: 1.15–11.26), abnormal TBI (OR = 2.84, 95% CI: 1.19–6.64), abnormal duplex (OR = 3.28, 95% CI: 1.00–10.71), and critical limb ischemia (OR = 5.52, 95% CI: 2.14–14.26). Moreover, PDR was a stronger independent correlation factor for PAD than a diabetic duration of 10 years. In conclusion, PAD is more common in PDR than in NDR. It implies that PDR and PAD are mostly concomitant in T2D. We should focus on screening PAD in patients with PDR in clinical practice.

Relationship of diabetic retinopathy with coronary artery disease in Asian Indians with type 2 diabetes: the Chennai Urban Rural Epidemiology Study (CURES) Eye Study--3

OBJECTIVES

This study assessed the relationship between diabetic retinopathy (DR) and coronary artery diseases (CAD) in Asian Indians, who are known to be at high risk of CAD and diabetes but have lower prevalence of DR.

SUBJECTS AND METHODS

Type 2 diabetes subjects (n=1,736) were selected from the urban component of the population-based Chennai Urban Rural Epidemiology Study Eye Study. Four-field stereo retinal color photography was done, and DR when present was classified according to the Early Treatment Diabetic Retinopathy Study grading system. Among the 1,723 subjects with gradable fundus photographs, 12-lead electrocardiogram (ECG) was performed in 1,602 individuals, and analysis was restricted to this group. CAD was diagnosed based on documented medical history of CAD or Minnesota coding of ECGs.

RESULTS

The prevalence of CAD was significantly higher among subjects with DR compared with those without (11.3% vs. 6.7%; P=0.007). A significant association was observed between DR and CAD in subjects with glycated hemoglobin (HbA1c) levels >7% (P=0.002). After controlling for age and gender, only hard exudates were associated with CAD (P=0.032). Logistic regression analysis revealed that even after adjusting for age, gender, HbA1c, mean arterial blood pressure, smoking, serum cholesterol, triglyceride, and low-density lipoprotein cholesterol levels, DR was significantly associated with CAD among the study subjects (odds ratio [OR]=1.58; 95% confidence interval [CI], 1.00-2.49; P=0.049) and those subjects with duration of diabetes >10 years (OR=4.06; 95% CI, 1.55-10.60; P=0.004).

CONCLUSIONS

This cross-sectional study shows a significant association between DR and CAD in South Indian subjects with type 2 diabetes.

Arterial stiffness in diabetes mellitus

Arterial stiffness is an age-related process that is a shared consequence of numerous diseases including diabetes mellitus (DM), and is an independent predictor of mortality both in this population and in the general population. While much has been published about arterial stiffness in patients with DM, a thorough review of the current literature is lacking. Using a systematic literature search strategy, we aimed to summarize our current understanding related to arterial stiffness in DM. We review key studies demonstrating that, among patients with established DM, arterial stiffness is closely related to the progression of complications of DM, including nephropathy, retinopathy, and neuropathy. It is also becoming clear that arterial stiffness can be increased even in pre-diabetic populations with impaired glucose tolerance, and in those with the metabolic syndrome (METS), well before the onset of overt DM. Some data suggests that arterial stiffness can predict the onset of DM. However, future work is needed to further clarify whether large artery stiffness and the pulsatile hemodynamic changes that accompany it are involved in the pathogenesis of DM, and whether interventions targeting arterial stiffness are associated with improved clinical outcomes in DM. We also review of the potential mechanisms of arterial stiffness in DM, with particular emphasis on the role of advanced glycation endproducts (AGEs) and nitric oxide dysregulation, and address potential future directions for research.

The degree of retinopathy is equally predictive for renal and macrovascular outcomes in the ACCORD Trial

AIMS

Diabetic retinopathy (DR) is associated with a higher risk of renal and cardiovascular events. We sought to compare the risk for renal versus cardiovascular (CV) outcomes, stratified by retinopathy severity.

METHODS

ACCORD was a randomized trial of people with type 2 diabetes, at high-risk for CV disease. A subgroup (n=3,369 from 71 clinics) had stereoscopic fundus photographs graded centrally. Participants were stratified at baseline to moderate/severe DR or no/mild DR and were monitored for renal and CV outcomes at follow-up visits over 4 years. The composite renal outcome was composed of serum creatinine doubling, macroalbuminuria, or end-stage renal disease. The composite CV outcome was the ACCORD trial primary outcome. Competing risk techniques were used to estimate the relative risk (RR) of renal versus CV composite outcomes within each DR stratum.

RESULTS

The hazards ratio for doubling of serum creatinine and incident CV event in the moderate/severe DR versus no/mild DR strata were: 2.31 (95% CI: 1.25-4.26) and 1.98 (95% CI: 1.49-2.62), respectively. The RR of the two composite outcomes was highly similar in the no/mild DR stratum (adjusted RR at 4 years for CV versus renal events=0.96, 95% CI: 0.72-1.28) and the moderate/severe DR stratum (adjusted RR=0.92, 95% CI: 0.64-1.31).

CONCLUSIONS

Thus, in people with type 2 diabetes at high risk for cardiovascular disease, incident CV versus renal events was similar, irrespective of the severity of the DR. Further evaluation of the specificity of DR for microvascular versus macrovascular events in other populations is warranted.

Subclinical cardiovascular disease in type 2 diabetes mellitus: To screen or not to screen

The prevalence of type 2 diabetes mellitus (T2DM) has risen in recent decades, and cardiovascular disease remains the leading cause of death in this population. Several clinical trials have demonstrated the benefit of tight control of risk factors on the incidence and mortality of cardiovascular disease. However, in clinical practice, few patients achieve the therapeutic goals. The current diagnostic procedures for subclinical cardiovascular disease in T2DM patients have not been shown to improve prognosis or mortality, probably because they do not categorize cardiovascular risk. Thus, clinical practice guidelines do not systematically recommend screening for subclinical atherosclerosis in these patients, although it is known that patients with extra-coronary atherosclerosis, microangiopathy and poorly-controlled cardiovascular risk factors are at high risk for cardiovascular disease. Improvements in the reliability of diagnostic tests, with fewer side effects and better cost efficiency, may better help to stratify cardiovascular risk in this group of patients, and further evaluation on this topic should be considered.

Insulin resistance and hyperglycaemia in cardiovascular disease development

The prevalence of diabetes mellitus will likely increase globally from 371 million individuals in 2013 to 552 million individuals in 2030. This epidemic is mainly attributable to type 2 diabetes mellitus (T2DM), which represents about 90-95% of all cases. Cardiovascular disease is the leading cause of mortality among individuals with diabetes mellitus, and >50% of patients will die from a cardiovascular event-especially coronary artery disease, but also stroke and peripheral vascular disease. Classic risk factors such as elevated levels of LDL cholesterol and blood pressure, as well as smoking, are risk factors for adverse cardiovascular events in patients with type 1 diabetes mellitus (T1DM) and T2DM to a similar degree as they are in healthy individuals. Patients with T1DM develop insulin resistance in the months after diabetes mellitus diagnosis, and patients with T2DM typically develop insulin resistance before hyperglycaemia occurs. Insulin resistance and hyperglycaemia, in turn, further increase the risk of adverse cardiovascular events. This Review discusses the mechanisms by which T1DM and T2DM can lead to cardiovascular disease and how these relate to the risk factors for coronary artery disease.

Incidence of stroke according to presence of diabetic nephropathy and severe diabetic retinopathy in patients with type 1 diabetes

OBJECTIVE

Type 1 diabetes is associated with a markedly increased risk of stroke, but only a few studies on the incidence of stroke in type 1 diabetes exist. Therefore, we assessed the incidence of stroke in patients with type 1 diabetes and studied the impact of diabetic nephropathy (DN) and severe diabetic retinopathy (SDR) on this risk.

RESEARCH DESIGN AND METHODS

We studied 4,083 patients with type 1 diabetes from the Finnish Diabetic Nephropathy Study. Mean age was 37.4 ± 11.8 years, duration of diabetes was 21.6 ± 12.1 years, and 52% were men. Strokes were identified from medical records, death certificates, and the National Hospital Discharge Register and classified based on medical files and brain images.

RESULTS

During 36,680 person-years of follow-up, 149 (4%) patients suffered an incident stroke (105 infarctions and 44 hemorrhages). Of the infarctions, 58 (55%) were lacunar. The incidence of stroke, cerebral infarction, and cerebral hemorrhage was 406 (95% CI 344-477), 286 (234-347), and 120 (87-161) per 100,000 person-years, respectively. In an adjusted analysis, microalbuminuria increased the risk of stroke with a hazard ratio (HR) of 3.2 (1.9-5.6), macroalbuminuria 4.9 (2.9-8.2), and end-stage renal disease 7.5 (4.2-13.3), and SDR increased the risk with an HR of 3.0 (1.9-4.5). The risk of cerebral infarction, cerebral hemorrhage, and lacunar infarction increased in a similar manner. The proportion of lacunar versus nonlacunar infarction did not change across DN groups.

CONCLUSIONS

The presence of SDR and DN, independently, increases the risk of stroke, cerebral infarction, and cerebral hemorrhage in patients with type 1 diabetes.

Four-year incidence of diabetic retinopathy in a Spanish cohort: the MADIABETES study

Objective

To evaluate the incidence of diabetic retinopathy in patients with Type 2 Diabetes Mellitus, to identify the risk factors associated with the incidence of retinopathy and to develop a risk table to predict four-year retinopathy risk stratification for clinical use, from a four-year cohort study.

Design

The MADIABETES Study is a prospective cohort study of 3,443 outpatients with Type 2 Diabetes Mellitus, sampled from 56 primary health care centers (131 general practitioners) in Madrid (Spain).

Results

The cumulative incidence of retinopathy at four-year follow-up was 8.07% (95% CI = 7.04–9.22) and the incidence density was 2.03 (95% CI = 1.75–2.33) cases per 1000 patient-months or 2.43 (95% CI = 2.10–2.80) cases per 100 patient-years. The highest adjusted hazard ratios of associated risk factors for incidence of diabetic retinopathy were LDL-C >190 mg/dl (HR = 7.91; 95% CI = 3.39–18.47), duration of diabetes longer than 22 years (HR = 2.00; 95% CI = 1.18–3.39), HbA1c>8% (HR = 1.90; 95% CI = 1.30–2.77), and aspirin use (HR = 1.65; 95% CI = 1.22–2.24). Microalbuminuria (HR = 1.17; 95% CI = 0.75–1.82) and being female (HR = 1.12; 95% CI = 0.84–1.49) showed a non-significant increase of diabetic retinopathy. The greatest risk is observed in females who had diabetes for more than 22 years, with microalbuminuria, HbA1c>8%, hypertension, LDL-Cholesterol >190 mg/dl and aspirin use.

Conclusions

After a four-year follow-up, the cumulative incidence of retinopathy was relatively low in comparison with other studies. Higher baseline HbA1c, aspirin use, higher LDL-Cholesterol levels, and longer duration of diabetes were the only statistically significant risk factors found for diabetic retinopathy incidence. This is the first study to demonstrate an association between aspirin use and diabetic retinopathy risk in a well-defined cohort of patients with Type 2 Diabetes Mellitus at low risk of cardiovascular events. However, further studies with patients at high cardiovascular and metabolic risk are needed to clarify this issue.

Diabetic retinopathy, its progression, and incident cardiovascular events in the ACCORD trial

OBJECTIVE

Both the presence of diabetic retinopathy and its severity are significantly associated with future cardiovascular (CV) events. Whether its progression is also linked to incident CV outcomes hasn't been assessed.

RESEARCH DESIGN AND METHODS

The relationship between retinopathy, its 4-year progression, and CV outcomes (CV death or nonfatal myocardial infarction or stroke) was analyzed in participants in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial who also participated in the ACCORD Eye Study. Retinopathy was classified as either none, mild, moderate, or severe, and worsening was classified as a <2-step, 2-3-step, or >3-step change (that included incident laser therapy or vitrectomy).

RESULTS

Participants (n = 3,433) of mean age 61 years had baseline retinal photographs (seven stereoscopic fields). Compared with no retinopathy, the adjusted HRs (95% CI) for the CV outcome rose from 1.49 (1.12-1.97) for mild retinopathy to 2.35 (1.47-3.76) for severe retinopathy. A subset of 2,856 was evaluated for progression of diabetic retinopathy at 4 years. The hazard of the primary outcome increased by 38% (1.38 [1.10-1.74]) for every category of change in retinopathy severity. Additional adjustment for the baseline and follow-up levels of A1C, systolic blood pressure, and lipids either individually or together rendered the relationships between worsening and CV outcomes nonsignificant.

CONCLUSIONS

Both the severity of retinopathy and its progression are determinants of incident CV outcomes. The retina may provide an anatomical index of the effect of metabolic and hemodynamic factors on future CV outcomes.

Prognostic significance of silent myocardial infarction in newly diagnosed type 2 diabetes mellitus: United Kingdom Prospective Diabetes Study (UKPDS) 79

BACKGROUND

We aimed to determine the prevalence of silent myocardial infarction (SMI) in people with newly diagnosed type 2 diabetes mellitus and its relationships to future myocardial infarction (MI) and all-cause mortality.

METHODS AND RESULTS

We examined data from the 5102 patients in the 30-year UK Prospective Diabetes Study (UKPDS) and used Cox proportional hazards regression to examine outcomes by SMI status. Of 1967 patients with complete baseline data, 326 (16.6%) had ECG evidence of SMI (Minnesota codes 1.1 or 1.2) at enrollment. Those with SMI were more likely to be older, female, sedentary, and nonsmokers compared with those without SMI. Their mean blood pressure was greater despite more intensive antihypertensive treatment; they were more likely to be taking aspirin and lipid-lowering therapy; and they had a greater prevalence of microangiopathy. Fully adjusted hazard ratios for those with versus those without SMI in multivariate models that included UKPDS Risk Engine variables were 1.58 (95% confidence interval, 1.22-2.05) for fatal MI and 1.31 (95% confidence interval, 1.10-1.56) for all-cause mortality. Hazard ratios for first fatal or nonfatal MI and for first nonfatal MI were nonsignificant. The net reclassification index showed no improvement when SMI was added to these models, and the integrated discrimination index showed that SMI marginally improved the prediction of fatal MI and all-cause mortality.

CONCLUSIONS

About 1 in 6 UKPDS patients with newly diagnosed type 2 diabetes mellitus had evidence of SMI, which was independently associated with an increased risk of fatal MI and all-cause mortality. However, identification of SMI does not add substantively to current UKPDS Risk Engine predictive variables.

CLINICAL TRIAL REGISTRATION

URL: http://www.controlled-trials.com. Identifier: ISRCTN number 75451837.

Relationship between coronary artery disease and retinopathy in patients with type 2 diabetes mellitus

OBJECTIVE

To examine risk factors for coronary artery disease (CAD) and retinopathy in patients with type 2 diabetes mellitus (DM) and assess the relationship between CAD and retinopathy.

METHODS

A total of 1,003 outpatients with type 2 DM (578 men and 425 women) were classified into two groups according to the presence (based on ischemic findings on a resting electrocardiogram or a history of angina or myocardial infarction) or absence of CAD and four retinopathy stages based on the International Clinical Classification of Diabetic Retinopathy.

RESULTS

Stepwise multiple regression analyses showed that independent risk factors for CAD were age, the triglyceride (TG) level and smoking, while those for retinopathy included age, age of DM diagnosis, the HbA1c level and a female gender. The prevalence of CAD increased in association with the progression of retinopathy (p<0.01).

CONCLUSION

Since it is difficult to distinguish macrovascular and microvascular diseases, diabetic vascular disorders require comprehensive approaches to assessment and treatment.

The association between regional arterial stiffness and diabetic retinopathy in type 2 diabetes

OBJECTIVES

Although several studies have reported that PWV is associated with diabetic retinopathy, it remains controversial as to which segment provides the PWV that might best reflect the presence of retinopathy. The aim of this study was to determine the pulse wave velocity (PWV) of arterial segments that is most closely associated with diabetic retinopathy in subjects without a history of macrovascular complications.

METHODS

After excluding subjects with a history of ischemic heart disease, peripheral artery disease, ischemic stroke, renal insufficiency, overt proteinuria, and other nondiabetic ophthalmic lesions or insufficient retinal examinations, a total of 494 subjects were analyzed by cross-sectional study. The central PWVs, including the heart-femoral (hf), heart-carotid (hc), heart-ankle (ha), and carotid-brachial (cb) segments, and the peripheral PWVs, including brachial-ankle (ba) and femoral-ankle (fa), were measured for each subject.

RESULTS

The group with diabetic retinopathy exhibited significantly higher hfPWV, hcPWV, haPWV and baPWV, but notcbPWV, faPWV or augmentation index (AI). Age, duration of diabetes, systolic and diastolic BP and pulse pressure were all positively associated with hfPWV, hcPWV, haPWV and baPWV. Quartiles of hfPWV were significantly associated with diabetic retinopathy after adjustment for covariates and known risk factors of diabetic retinopathy (P for trend = 0.023). Conversely, all quartiles of haPWV, hcPWV and baPWV lost significance after adjustment.

CONCLUSIONS

We found that diabetic retinopathy was most closely associated with hfPWV, suggesting the most reliable index of regional arterial stiffness index in retinopathy.

Diabetic retinopathy: a new predictor in patients on regular hemodialysis

BACKGROUND

Data evaluating the presence and impact of diabetic retinopathy (DR) in patients on regular hemodialysis (HD) are scarce.

OBJECTIVE

To assess prevalence and outcomes of DR in HD patients.

METHODS

Data were collected from 252 consecutive HD-dependent patients who underwent eye examination for detection of DR in 2007. Patients were divided into two groups (DR vs. no-DR) and followed up for 3 years. Demographic and clinical profiles were analyzed and compared. Multivariate logistic regression was used to find out the predictors of DR, morbidity and mortality.

RESULTS

DR was diagnosed in 113 patients (45%). In comparison to no-DR, DR patients were older and more likely to have high prevalence of dyslipidemia, coronary artery disease and cerebrovascular accidents. Duration of DM was longer in DR patients (p = 0.02). There was significant correlation between DR and nephropathy (r = 0.38; p = 0.001) and PAD (r = 0.27; p = 0.001). Hemoglobin A1c, serum calcium and total cholesterol were higher while serum albumin and phosphorus were lower in DR in comparison to no-DR group. The rates of renal transplant, coronary artery disease and cerebrovascular accidents were comparable in the two groups. Peripheral arterial disease (PAD) was associated with 4-fold increase in the presence of DR (Adjusted OR 3.9; p = 0.009). DR was independent predictor for PAD (adjusted OR 2.2; p = 0.01). Age-sex adjusted DR was independent predictor of 3-year mortality (OR 2.04; p = 0.03).

LIMITATIONS

The main issue with a cross-sectional study such as this, is differentiating cause and effect from simple association. Also, the current study did not specify the severity of DR.

CONCLUSION

Prevalence of DR is high among HD patients and associated with high mortality. DR is an independent predictor for PAD and not for transplantation. Early detection of DR is highly recommended among HD population for risk-stratification and counseling. Further randomized controlled studies are needed to support our finding.

Hospitalized cardiovascular events in patients with diabetic macular edema

Background

Microvascular and macrovascular complications in diabetes stem from chronic hyperglycemia and are thought to have overlapping pathophysiology. The aim of this study was to investigate the incidence rate of hospitalized myocardial infarctions (MI) and cerebrovascular accidents (CVA) in patients with diabetic macular edema (DME) compared with diabetic patients without retinal diseases.

Methods

This was a retrospective cohort study of a commercially insured population in an administrative claims database. DME subjects (n = 3519) and diabetes controls without retinal disease (n = 10557) were matched by age and gender. Healthcare claims were analyzed for the study period from 1 January 2002 to 31 December 2005. Incidence and adjusted rate ratios of hospitalized MI and CVA events were then calculated.

Results

The adjusted rate ratio for MI was 2.50 (95% CI: 1.83-3.41, p < 0.001) for DME versus diabetes controls. Predictors of MI events were heart disease, history of acute MI, and prior use of antiplatelet or anticoagulant drugs. The adjusted rate ratio for CVA was 1.98 (95% CI: 1.39-2.83, p < 0.001) for DME versus diabetes controls. Predictors of CVA events were cardiac arrhythmia, Charlson comorbidity scores, history of CVA, hyperlipidemia, and other cerebrovascular diseases.

Conclusion

Event rates of MI or CVA were higher in patients with DME than in diabetes controls. This study is one of few with sufficient sample size to accurately estimate the relationship between DME and cardiovascular outcomes.

Microcirculation on a large scale: techniques, tactics and relevance of studying the microcirculation in larger population samples

The role of microcirculatory dysfunction is increasingly being recognized in the etiopathogenesis of cardiovascular disease. Whilst the importance of detailed mechanistic studies to determine the exact nature of these disturbances is without question, it was large-scale population-based studies that first identified the associations between deranged microvascular perfusion, autoregulation or structure, and subsequent target organ damage. This is the subject of considerable studies to establish whether there is a causal effect in either direction, or simply represents shared risk factors, although it is most likely to be a complex combination of bidirectional interactions. The techniques for investigating microcirculatory function have evolved almost exponentially over the last 75 years: So too have the strategies for investigation. Current epidemiological studies are focusing on attempting to untangle the inter-relationship between risk factors and pathological mechanisms to attempt to determine whether these represent therapeutic targets or simple markers of unmeasured risk. We plan to review the techniques used for these population-based studies, the advances made, and the clinical implications derived.