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Lytvyn Y, Albakr R, Bjornstad P, Lovblom LE, Liu H, Lovshin JA, Boulet G, Farooqi MA, Weisman A, Keenan HA, Brent MH, Paul N, Bril V, Perkins BA, Cherney DZI. Renal hemodynamic dysfunction and neuropathy in longstanding type 1 diabetes: Results from the Canadian study of longevity in type 1 diabetes. J Diabetes Complications 2022; 36:108320. [PMID: 36201892 PMCID: PMC10187942 DOI: 10.1016/j.jdiacomp.2022.108320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 08/29/2022] [Accepted: 09/23/2022] [Indexed: 11/28/2022]
Abstract
AIMS To determine the relationship between renal hemodynamic function and neuropathy in adults with ≥50-years of type 1 diabetes (T1D) compared to nondiabetic controls. METHODS Glomerular filtration rate (GFR, inulin), effective renal plasma flow (ERPF, p-aminohippurate), modified Toronto Clinical Neuropathy Score (mTCNS), corneal confocal microscopy, nerve conduction, and heart rate variability (autonomic function) were measured; afferent (RA) and efferent (RE) arteriolar resistances were estimated using the Gomez equations in 74 participants with T1D and in 75 controls. Diabetic kidney disease (DKD) non-resistors were defined by eGFRMDRD < 60 ml/min/1.73 m2 or 24-h urine albumin excretion >30 mg/day. Linear regression was applied to examine the relationships between renal function (dependent variable) and neuropathy measures (independent variable), adjusted for age, sex, HbA1c, systolic blood pressure, low density lipoprotein cholesterol, and 24-h urine albumin to creatinine ratio. RESULTS Higher mTCNS associated with lower renal blood flow (β ± SE:-9.29 ± 4.20, p = 0.03) and greater RE (β ± SE:32.97 ± 15.43, p = 0.04) in participants with T1D, but not in controls. DKD non-resistors had a higher mTCNS and worse measures of corneal nerve morphology compared to those without DKD. Renal hemodynamic parameters did not associate with autonomic nerve function. CONCLUSIONS Although neurological dysfunction in the presence of diabetes may contribute to impaired renal blood flow resulting in ischemic injury in patients with T1D, early autonomic dysfunction does not appear to be associated with kidney function changes.
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Affiliation(s)
- Yuliya Lytvyn
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rehab Albakr
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada; Division of Nephrology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Petter Bjornstad
- Department of Pediatrics, Division of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Hongyan Liu
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Julie A Lovshin
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Genevieve Boulet
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed A Farooqi
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alanna Weisman
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Michael H Brent
- Department of Ophthalmology and Vision Sciences, Department of Medicine, University of Toronto, Ontario, Canada
| | - Narinder Paul
- Joint Department of Medical Imaging, Division of Cardiothoracic Radiology, University Health Network, Toronto, Ontario, Canada
| | - Vera Bril
- Division of Neurology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Bruce A Perkins
- Department of Medicine, Division of Endocrinology and Metabolism, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David Z I Cherney
- Department of Medicine, Division of Nephrology, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Cosmo E, Midena G, Frizziero L, Bruno M, Cecere M, Midena E. Corneal Confocal Microscopy as a Quantitative Imaging Biomarker of Diabetic Peripheral Neuropathy: A Review. J Clin Med 2022; 11:jcm11175130. [PMID: 36079060 PMCID: PMC9457345 DOI: 10.3390/jcm11175130] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Distal symmetric polyneuropathy (DPN), particularly chronic sensorimotor DPN, represents one of the most frequent complications of diabetes, affecting 50% of diabetic patients and causing an enormous financial burden. Whilst diagnostic methods exist to detect and monitor this condition, they have significant limitations, mainly due to their high subjectivity, invasiveness, and non-repeatability. Corneal confocal microscopy (CCM) is an in vivo, non-invasive, and reproducible diagnostic technique for the study of all corneal layers including the sub-basal nerve plexus, which represents part of the peripheral nervous system. We reviewed the current literature on the use of CCM as an instrument in the assessment of diabetic patients, particularly focusing on its role in the study of sub-basal nerve plexus alterations as a marker of DPN. CCM has been demonstrated to be a valid in vivo tool to detect early sub-basal nerve plexus damage in adult and pediatric diabetic patients, correlating with the severity of DPN. Despite its great potential, CCM has still limited application in daily clinical practice, and more efforts still need to be made to allow the dissemination of this technique among doctors taking care of diabetic patients.
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Affiliation(s)
| | | | - Luisa Frizziero
- Department of Neuroscience-Ophthalmology, University of Padova, 35128 Padova, Italy
| | | | | | - Edoardo Midena
- IRCCS—Fondazione Bietti, 00198 Rome, Italy
- Department of Neuroscience-Ophthalmology, University of Padova, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-049-821-2110
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Dhage S, Ferdousi M, Adam S, Ho JH, Kalteniece A, Azmi S, Alam U, Ponirakis G, Petropoulos I, Atkinson AJ, Marshall A, Jeziorska M, Soran H, Malik RA. Corneal confocal microscopy identifies small fibre damage and progression of diabetic neuropathy. Sci Rep 2021; 11:1859. [PMID: 33479291 PMCID: PMC7820596 DOI: 10.1038/s41598-021-81302-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/05/2021] [Indexed: 01/25/2023] Open
Abstract
Accurately quantifying the progression of diabetic peripheral neuropathy is key to identify individuals who will progress to foot ulceration and to power clinical intervention trials. We have undertaken detailed neuropathy phenotyping to assess the longitudinal utility of different measures of neuropathy in patients with diabetes. Nineteen patients with diabetes (age 52.5 ± 14.7 years, duration of diabetes 26.0 ± 13.8 years) and 19 healthy controls underwent assessment of symptoms and signs of neuropathy, quantitative sensory testing, autonomic nerve function, neurophysiology, intra-epidermal nerve fibre density (IENFD) and corneal confocal microscopy (CCM) to quantify corneal nerve fibre density (CNFD), branch density (CNBD) and fibre length (CNFL). Mean follow-up was 6.5 years. Glycated haemoglobin (p = 0.04), low-density lipoprotein-cholesterol (LDL-C) (p = 0.0009) and urinary albumin creatinine ratio (p < 0.0001) improved. Neuropathy symptom profile (p = 0.03), neuropathy disability score (p = 0.04), vibration perception threshold (p = 0.02), cold perception threshold (p = 0.006), CNFD (p = 0.03), CNBD (p < 0.0001), CNFL (p < 0.0001), IENFD (p = 0.04), sural (p = 0.02) and peroneal motor nerve conduction velocity (p = 0.03) deteriorated significantly. Change (∆) in CNFL correlated with ∆CPT (p = 0.006) and ∆Expiration/Inspiration ratio (p = 0.002) and ∆IENFD correlated with ∆CNFD (p = 0.005), ∆CNBD (p = 0.02) and ∆CNFL (p = 0.01). This study shows worsening of diabetic neuropathy across a range of neuropathy measures, especially CCM, despite an improvement in HbA1c and LDL-C. It further supports the utility of CCM as a rapid, non-invasive surrogate measure of diabetic neuropathy.
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Affiliation(s)
- Shaishav Dhage
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Research Group, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Maryam Ferdousi
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Safwaan Adam
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Research Group, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Jan Hoong Ho
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Research Group, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Alise Kalteniece
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Shazli Azmi
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Uazman Alam
- Institute of Cardiovascular and Metabolic Medicine and The Pain Research Institute, University of Liverpool & Liverpool University NHS Hospital Trust, Liverpool, UK
| | - Georgios Ponirakis
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Ioannis Petropoulos
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Andrew J Atkinson
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Andrew Marshall
- Institute of Life Course and Medical Sciences and The Pain Research Institute, University of Liverpool & Liverpool University NHS Hospital Trust, Liverpool, UK
| | - Maria Jeziorska
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Handrean Soran
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Rayaz A Malik
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK.
- Cardiovascular Research Group, University of Manchester, Manchester, UK.
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar.
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Corneal nerves in diabetes-The role of the in vivo corneal confocal microscopy of the subbasal nerve plexus in the assessment of peripheral small fiber neuropathy. Surv Ophthalmol 2020; 66:493-513. [PMID: 32961210 DOI: 10.1016/j.survophthal.2020.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 09/10/2020] [Accepted: 09/14/2020] [Indexed: 02/06/2023]
Abstract
The cornea's intense innervation is responsible for corneal trophism and ocular surface hemostasis maintenance. Corneal diabetic neuropathy affects subbasal nerve plexus, with progressive alteration of nerves' morphology and density. The quantitative analysis of nerve fibers can be performed with in vivo corneal confocal microscopy considering the main parameters such as corneal nerve fibers length, corneal nerve fibers density, corneal nerve branching density, tortuosity coefficient, and beadings frequency. As the nerve examination permits the detection of early changes occurring in diabetes, the invivo corneal confocal microscopy becomes, over time, an important tool for diabetic polyneuropathy assessment and follow-up. In this review, we summarize the actual evidence about corneal nerve changes in diabetes and the relationship between the grade of alterations and the duration and severity of the disease. We aim at understanding how diabetes impacts corneal nerves and how it correlates with sensorimotor peripheral polyneuropathy and retinal complications. We also attempt to analyze the safety of the most common surgical procedures such as cataract and refractive surgery in diabetic patients and to highlight the specific risk factors. We believe that information about the corneal nerve fibers' condition obtained from the in vivo subbasal nerve plexus investigation may be crucial in monitoring peripheral small fiber polyneuropathy and that it will help with decision-making in ophthalmic surgery in diabetic patients.
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Simó R, Frontoni S. Neuropathic damage in the diabetic eye: clinical implications. Curr Opin Pharmacol 2020; 55:1-7. [PMID: 32932105 DOI: 10.1016/j.coph.2020.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 08/11/2020] [Accepted: 08/25/2020] [Indexed: 02/07/2023]
Abstract
In recent years, emerging evidence support that the eye is target of diabetes neuropathy. There are two components of the eye that are mainly involved in the neurodegenerative process induced by diabetes: the retina and the cornea. The study of functional and structural changes in these components of the eye will provide useful information to identify subjects with diabetes at risk of diabetic peripheral neuropathy and dementia. In this review the state of the art regarding the evidence and clinical implications of this emerging concept will be provided. In addition, the relationship between retinal and corneal neurodegeneration with peripheral neuropathy and cognitive decline will be analyzed. Finally, the scientific gaps than need to be covered and will be critically examined.
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Affiliation(s)
- Rafael Simó
- Diabetes and Metabolism Research Unit, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBERDEM (ISCIII), Madrid, Spain.
| | - Simona Frontoni
- Unit of Endocrinology, Diabetes and Metabolism, S. Giovanni Calibita, Fate Bene Fratelli Hospital, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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Lewis EJH, Lovblom LE, Ferdousi M, Halpern EM, Jeziorska M, Pacaud D, Pritchard N, Dehghani C, Edwards K, Srinivasan S, Mintz Shtein R, Efron N, Tavakoli M, Bril V, Malik RA, Perkins BA. Rapid Corneal Nerve Fiber Loss: A Marker of Diabetic Neuropathy Onset and Progression. Diabetes Care 2020; 43:1829-1835. [PMID: 32139385 PMCID: PMC7372054 DOI: 10.2337/dc19-0951] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 11/29/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Corneal nerve fiber length (CNFL) represents a biomarker for diabetic distal symmetric polyneuropathy (DSP). We aimed to determine the reference distribution of annual CNFL change, the prevalence of abnormal change in diabetes, and its associated clinical variables. RESEARCH DESIGN AND METHODS We examined 590 participants with diabetes (399 with type 1 diabetes [T1D] and 191 with type 2 diabetes [T2D]) and 204 control patients without diabetes with at least 1 year of follow-up and classified them according to rapid corneal nerve fiber loss (RCNFL) if CNFL change was below the 5th percentile of the control patients without diabetes. RESULTS Control patients without diabetes were 37.9 ± 19.8 years old, had median follow-up of three visits over 3.0 years, and mean annual change in CNFL was -0.1% (90% CI -5.9% to 5.0%). RCNFL was defined by values exceeding the 5th percentile of 6% loss. Participants with T1D were 39.9 ± 18.7 years old, had median follow-up of three visits over 4.4 years, and mean annual change in CNFL was -0.8% (90% CI -14.0% to 9.9%). Participants with T2D were 60.4 ± 8.2 years old, had median follow-up of three visits over 5.3 years, and mean annual change in CNFL was -0.2% (90% CI -14.1% to 14.3%). RCNFL prevalence was 17% overall and was similar by diabetes type (64 T1D [16.0%], 37 T2D [19.4%], P = 0.31). RNCFL was more common in those with baseline DSP (47% vs. 30% in those without baseline DSP, P = 0.001), which was associated with lower peroneal conduction velocity but not with baseline HbA1c or its change over follow-up. CONCLUSIONS An abnormally rapid loss of CNFL of 6% per year or more occurs in 17% of diabetes patients. RCNFL may identify patients at highest risk for the development and progression of DSP.
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Affiliation(s)
- Evan J H Lewis
- Division of Endocrinology, Leadership Sinai Centre for Diabetes, University of Toronto, Toronto, Canada
| | - Leif E Lovblom
- Division of Endocrinology, Leadership Sinai Centre for Diabetes, University of Toronto, Toronto, Canada
| | - Maryam Ferdousi
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K
| | - Elise M Halpern
- Division of Endocrinology, Leadership Sinai Centre for Diabetes, University of Toronto, Toronto, Canada
| | - Maria Jeziorska
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K
| | - Daniele Pacaud
- Alberta Children's Hospital, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada
| | - Nicola Pritchard
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Cirous Dehghani
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Katie Edwards
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Sangeetha Srinivasan
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Roni Mintz Shtein
- Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, MI
| | - Nathan Efron
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Mitra Tavakoli
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K.,Institute of Health Research, University of Exeter Medical School, Exeter, U.K
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Disorders, Division of Neurology, University Health Network, University of Toronto, Toronto, Canada
| | - Rayaz Ahmed Malik
- Institute of Cardiovascular Medicine, University of Manchester, Manchester, U.K.,Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Bruce A Perkins
- Division of Endocrinology, Leadership Sinai Centre for Diabetes, University of Toronto, Toronto, Canada
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Yan A, Issar T, Tummanapalli SS, Markoulli M, Kwai NCG, Poynten AM, Krishnan AV. Relationship between corneal confocal microscopy and markers of peripheral nerve structure and function in Type 2 diabetes. Diabet Med 2020; 37:326-334. [PMID: 30897245 DOI: 10.1111/dme.13952] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2019] [Indexed: 01/03/2023]
Abstract
AIMS To investigate changes in corneal nerve morphology in Type 2 diabetes and to establish relationships between in vivo corneal confocal microscopy and markers of peripheral nerve structure and function. PARTICIPANTS AND METHODS We recruited 57 participants with Type 2 diabetes and 26 healthy controls of similar age and sex distribution. We also recruited a disease control group of 54 participants with Type 1 diabetes. All participants were assessed for distal symmetrical polyneuropathy using the Total Neuropathy Score. In vivo corneal confocal microscopy was used to assess corneal nerve fibre length, corneal nerve fibre density, corneal nerve branch density and inferior whorl length. Peripheral nerve structure was assessed using median nerve ultrasonography. Large fibre function was assessed according to median nerve axonal excitability. Small fibre function was assessed using SudoscanTM and the Survey of Autonomic Symptoms. RESULTS Corneal nerve fibre length, fibre density and branch density and inferior whorl length were significantly lower in individuals with Type 2 diabetes compared to controls (P<0.001 for all). In the Type 2 diabetes cohort, correlations were observed between neuropathy severity and corneal nerve fibre density (P=0.004), corneal nerve branch density (P=0.003), corneal nerve fibre length (P=0.002) and inferior whorl length (P=0.01). Significant correlations were observed between corneal confocal outcomes and axonal excitability measurements. No association was found between corneal confocal microscopy and median nerve cross-sectional area, Sudoscan measurements or the Survey of Autonomic Symptoms. CONCLUSIONS This study demonstrated significant changes in corneal nerves in individuals with Type 2 diabetes. Reductions in corneal nerve measures correlated with increasing neuropathy severity. Associations were found between corneal confocal microscopy and markers of voltage-gated potassium channel function.
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Affiliation(s)
- A Yan
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - T Issar
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - S S Tummanapalli
- School of Optometry and Vision Science, University of New South Wales, Sydney, NSW, Australia
| | - M Markoulli
- School of Optometry and Vision Science, University of New South Wales, Sydney, NSW, Australia
| | - N C G Kwai
- School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia
| | - A M Poynten
- Department of Endocrinology, Prince of Wales Hospital, Sydney, NSW, Australia
| | - A V Krishnan
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
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Boulton AJM. The 2017 Banting Memorial Lecture The diabetic lower limb - a forty year journey: from clinical observation to clinical science. Diabet Med 2019; 36:1539-1549. [PMID: 30659650 DOI: 10.1111/dme.13901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2019] [Indexed: 11/29/2022]
Abstract
A series of clinical research projects conducted over the past 40 years, all of which were informed by clinical observation or discussions with people with diabetes and staff colleagues are described in this review. A study of necrobiosis lipoidica diabeticorum confirmed that this rare skin complication occurs predominantly in young women with Type 1 diabetes and other microvascular complications. Biopsies of necrobiotic lesions showed destruction of superficial nerve fibres by inflammatory tissue, which likely causes the sensory loss in lesions that is pathognomonic of the condition. The development of corneal confocal microscopy as a new non-invasive surrogate marker of peripheral neuropathy in diabetes is described next and several small studies of the use of this new technique in clinical research are reported. The influence of blood glucose instability on the genesis of neuropathic pain is then explained, with results suggesting that the stability of glycaemic control may be more important than the level of control achieved. Lastly, in neuropathy, studies of gustatory sweating are discussed, including the observation that sweating in the head and neck region is more common in people with end-stage diabetic nephropathy than in those with neuropathy. The disappearance of gustatory sweating after renal transplantation suggests a metabolic cause and for those with troublesome sweating, use of the anticholinergic, anti-muscarinic, topical cream glycopyrrolate is confirmed in a randomized control trial. In the area of diabetic foot research, distended dorsal foot veins were observed to be a clinical sign of sympathetic autonomic neuropathy: raised venous Po2 and Doppler abnormalities of blood flow are highly suggestive of arteriovenous shunting. A series of studies of the abnormalities of pressures and loads under the neuropathic diabetic foot are described: high dynamic plantar pressures are highly predictive of subsequent ulceration in the neuropathic foot. Lastly, a number of recent studies on unsteadiness and gait abnormalities when climbing and descending stairs are described. It is hoped that the art of clinical observation survives in the highly technological 21st century.
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Affiliation(s)
- Andrew J M Boulton
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, UK
- Manchester Royal Infirmary, Manchester, UK
- Diabetes Research Institute, University of Miami, Miami, FL, USA
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9
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Tummanapalli SS, Willcox MD, Issar T, Yan A, Pisarcikova J, Kwai N, Poynten AM, Krishnan AV, Markoulli M. Tear film substance P: A potential biomarker for diabetic peripheral neuropathy. Ocul Surf 2019; 17:690-698. [DOI: 10.1016/j.jtos.2019.08.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/14/2019] [Accepted: 08/29/2019] [Indexed: 01/17/2023]
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Zilliox LA, Russell JW. Physical activity and dietary interventions in diabetic neuropathy: a systematic review. Clin Auton Res 2019; 29:443-455. [PMID: 31076938 PMCID: PMC6697618 DOI: 10.1007/s10286-019-00607-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/09/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE Diabetic neuropathy is a common and disabling disorder, and there are currently no proven effective disease-modifying treatments. Physical activity and dietary interventions in patients with diabetes and diabetic neuropathy have multiple beneficial effects and are generally low risk, which makes lifestyle interventions an attractive treatment option. We reviewed the literature on the effects of physical activity and dietary interventions on length-dependent peripheral neuropathy and cardiac autonomic neuropathy in diabetes. METHODS The electronic database PubMed was systematically searched for original human and mouse model studies examining the effect of either dietary or physical activity interventions in subjects with diabetes, prediabetes, or metabolic syndrome. RESULTS Twenty studies are included in this review. Fourteen studies were human studies and six were in mice. Studies were generally small with few controlled trials, and there are no widely agreed upon outcome measures. CONCLUSIONS Recent research indicates that dietary interventions are effective in modifying diabetic neuropathy in animal models, and there are promising data that they may also ameliorate diabetic neuropathy in humans. It has been known for some time that lifestyle interventions can prevent the development of diabetic neuropathy in type 2 diabetes mellitus subjects. However, there is emerging evidence that lifestyle interventions are effective in individuals with established diabetic neuropathy. In addition to the observed clinical value of lifestyle interventions, there is emerging evidence of effects on biochemical pathways that improve muscle function and affect other organ systems, including the peripheral nerve. However, data from randomized controlled trials are needed.
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Affiliation(s)
- Lindsay A Zilliox
- Department of Neurology, School of Medicine, University of Maryland, 3S-129, 110 South Paca Street, Baltimore, MD, 21201-1595, USA
- Maryland VA Healthcare System, Baltimore, MD, USA
| | - James W Russell
- Department of Neurology, School of Medicine, University of Maryland, 3S-129, 110 South Paca Street, Baltimore, MD, 21201-1595, USA.
- Maryland VA Healthcare System, Baltimore, MD, USA.
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Early Alterations of Corneal Subbasal Plexus in Uncomplicated Type 1 Diabetes Patients. J Ophthalmol 2019; 2019:9818217. [PMID: 31341662 PMCID: PMC6636466 DOI: 10.1155/2019/9818217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/17/2019] [Indexed: 12/18/2022] Open
Abstract
Purpose The purpose of our study is to describe the in vivo corneal confocal microscopy characteristics of subbasal nerve plexus in a highly selected population of patients affected by type 1 diabetes mellitus (T1DM) without any microvascular diabetes complications. Methods We included 19 T1DM patients without diabetic peripheral neuropathy, diabetic autonomic neuropathy, diabetic retinopathy, and microalbuminuria. All patients underwent in vivo corneal confocal microscopy and blood analysis to determine subbasal nerve plexus parameters and their correlation with clinical data. We compared the results with 19 healthy controls. Results The T1DM group showed a significant decrease of the nerve fiber length (P=0.032), the nerve fiber length density (P=0.034), the number of fibers (P=0.005), and the number of branchings (P=0.028), compared to healthy subjects. The nerve fiber length, nerve fiber length density, and number of fibers were directly related to the age at onset of diabetes and inversely to the duration of DM. BMI (body mass index) was highly related to the nerve fiber length (r = −0.6, P=0.007), to the nerve fiber length density (r = −0.6, P=0.007), and to the number of fibers (r = −0.587, P=0.008). No significant correlations were found between the corneal parameters and HbA1c. Conclusions Early subclinical fiber corneal variation could be easily detected using in vivo corneal confocal microscopy, even in type 1 diabetes without any microvascular diabetes complications, including diabetic peripheral neuropathy, diabetic autonomic neuropathy, diabetic retinopathy, and microalbuminuria.
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12
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Early corneal nerve fibre damage and increased Langerhans cell density in children with type 1 diabetes mellitus. Sci Rep 2019; 9:8758. [PMID: 31217448 PMCID: PMC6584636 DOI: 10.1038/s41598-019-45116-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/31/2019] [Indexed: 01/08/2023] Open
Abstract
Corneal confocal microscopy (CCM) has been used to identify corneal nerve damage and increased Langerhans cell (LC) density in adults with Type 1 diabetes mellitus (T1DM). The purpose of this study was to evaluate whether corneal confocal microscopy can identify early corneal nerve damage and change in LC density in children and adolescents with T1DM. 64 participants with T1DM (age-14.6 ± 2.5 years, duration of diabetes-9.1 ± 2.7 years, HbA1c-75.66 ± 2.53 mmol/mol [9.1 ± 1.8%]) and 48 age-matched healthy control subjects underwent CCM. Sub-basal corneal nerve morphology and the density of mature and immature LCs was quantified. Corneal nerve fibre length and branch density were lower, whilst fibre density and tortuosity did not differ and both immature and mature LC density was significantly higher in T1DM compared to control subjects. There was no association between HbA1c and duration of diabetes with nerve fibre parameters or LC's density. Children and adolescents with T1DM demonstrate early immune activation and nerve degeneration.
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Lewis EJH, Perkins BA, Lovblom LE, Bazinet RP, Wolever TMS, Bril V. Effect of omega-3 supplementation on neuropathy in type 1 diabetes: A 12-month pilot trial. Neurology 2017; 88:2294-2301. [PMID: 28515269 DOI: 10.1212/wnl.0000000000004033] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 03/21/2017] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To test the hypothesis that 12 months of seal oil omega-3 polyunsaturated fatty acids (ω-3 PUFA) supplementation will stop the known progression of diabetic sensorimotor polyneuropathy (DSP) in type 1 diabetes mellitus (T1DM). METHODS Individuals with T1DM and evidence of DSP as determined by a Toronto Clinical Neuropathy Score ≥1 were recruited to participate in a single-arm, open-label trial of seal oil ω-3 PUFA supplementation (10 mL·d-1; 750 mg eicosapentaenoic acid, 560 mg docosapentaenoic acid, and 1,020 mg docosahexaenoic acid) for 1 year. The primary outcome was the 1-year change in corneal nerve fiber length (CNFL) measured by in vivo corneal confocal microscopy, with sensory and nerve conduction measures as secondary outcomes. RESULTS Forty participants (53% female), aged 48 ± 14 years, body mass index 28.1 ± 5.8 with diabetes duration of 27 ± 18 years, were enrolled. At baseline, 23 participants had clinical DSP and 17 did not. Baseline CNFL was 8.3 ± 2.9 mm/mm2 and increased 29% to 10.1 ± 3.7 mm/mm2 (p = 0.002) after 12 months of supplementation. There was no change in nerve conduction or sensory function. CONCLUSIONS Twelve months of ω-3 supplementation was associated with increase in CNFL in T1DM. CLINICALTRIALSGOVIDENTIFIER NCT02034266. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with T1DM and evidence of DSP, 12 months of seal oil omega-3 supplementation increases CNFL.
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Affiliation(s)
- Evan J H Lewis
- From the Department of Nutritional Sciences (E.J.H.L., R.P.B., T.M.S.W.), Faculty of Medicine, University of Toronto; Leadership Sinai Centre for Diabetes (B.A.P., L.E.L.), Mount Sinai Hospital, Toronto; and Ellen and Martin Prosserman Centre for Neuromuscular Diseases (V.B.), Division of Neurology, University Health Network, Toronto, Canada.
| | - Bruce A Perkins
- From the Department of Nutritional Sciences (E.J.H.L., R.P.B., T.M.S.W.), Faculty of Medicine, University of Toronto; Leadership Sinai Centre for Diabetes (B.A.P., L.E.L.), Mount Sinai Hospital, Toronto; and Ellen and Martin Prosserman Centre for Neuromuscular Diseases (V.B.), Division of Neurology, University Health Network, Toronto, Canada
| | - Leif E Lovblom
- From the Department of Nutritional Sciences (E.J.H.L., R.P.B., T.M.S.W.), Faculty of Medicine, University of Toronto; Leadership Sinai Centre for Diabetes (B.A.P., L.E.L.), Mount Sinai Hospital, Toronto; and Ellen and Martin Prosserman Centre for Neuromuscular Diseases (V.B.), Division of Neurology, University Health Network, Toronto, Canada
| | - Richard P Bazinet
- From the Department of Nutritional Sciences (E.J.H.L., R.P.B., T.M.S.W.), Faculty of Medicine, University of Toronto; Leadership Sinai Centre for Diabetes (B.A.P., L.E.L.), Mount Sinai Hospital, Toronto; and Ellen and Martin Prosserman Centre for Neuromuscular Diseases (V.B.), Division of Neurology, University Health Network, Toronto, Canada
| | - Thomas M S Wolever
- From the Department of Nutritional Sciences (E.J.H.L., R.P.B., T.M.S.W.), Faculty of Medicine, University of Toronto; Leadership Sinai Centre for Diabetes (B.A.P., L.E.L.), Mount Sinai Hospital, Toronto; and Ellen and Martin Prosserman Centre for Neuromuscular Diseases (V.B.), Division of Neurology, University Health Network, Toronto, Canada
| | - Vera Bril
- From the Department of Nutritional Sciences (E.J.H.L., R.P.B., T.M.S.W.), Faculty of Medicine, University of Toronto; Leadership Sinai Centre for Diabetes (B.A.P., L.E.L.), Mount Sinai Hospital, Toronto; and Ellen and Martin Prosserman Centre for Neuromuscular Diseases (V.B.), Division of Neurology, University Health Network, Toronto, Canada
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