Predictors for diabetic retinopathy in normoalbuminuric people with type 2 diabetes mellitus

Incidence of Diabetic Retinopathy and Its Predictors Among Newly Diagnosed Type 1 and Type 2 Diabetic Patients: A Retrospective Follow-up Study at Tertiary Health-care Setting of Ethiopia

BACKGROUND

With an increasing number of diabetes patients in developing countries, the burden of diabetes-related blindness is undoubtedly posing a massive challenge to the sustainable health care system due to the cost of care. Despite this fact, to date, most of the epidemiological research on diabetic retinopathy (DR) in eastern Africa, including Ethiopia, has been limited to survey studies. Thus, we determined the incidence of retinopathy and its predictors among diabetic patients in Jimma University Medical Center, Southwest Ethiopia.

METHODS

A retrospective follow-up study was conducted on 402 randomly selected diabetic patients of aged ≥15 years. A preliminary reviewed checklist was used to obtain information on the demographics, clinical and physiological attributes. Data were entered using EpiData version 4.6 and analyzed using Stata version 14. All variables at P-values less than 0.2 in bivariable analysis were exported to multivariable analysis. Multivariable accelerated failure time (AFT) regression analyses using Weibull distribution were used to examine the predictors of DR at a 5% level of significance.

RESULTS

Throughout a median follow-up period of 5.9 years, the cumulative incidence of DR was 20.15% (95%CI: 16.50-24.37) and the incidence rate was 36.9 per 1000 person years (PY) (95%CI: 29.7-45.9). Multivariable Weibull AFT regression analyses showed that type two diabetes mellitus (T2DM) (adjusted time ratio (ATR) 0.4095%CI: 0.20-0.78), hypertension (HTN) (ATR 0.54; 95%CI: [0.35, 0.82]), low high density lipoprotein cholesterol (HDL-C) (ATR 0.51; 95%CI: 0.36-0.73), and borderline high total cholesterol (TC) (ATR 0.63; 95%CI: 0.42-0.94) were a predictor of time to DR.

CONCLUSION

The overall incidence of DR among patients with diabetes mellitus was estimated to be 20.15% and is becoming a public health burden in Ethiopia. Our results indicate that T2DM, HTN, low HDL-C and borderline high TC independently predicts an increased incidence/decreased survival time of retinopathy among diabetes patients. The low HDL-C, HTN, and high TC are modifiable risk factors that should be managed along with diabetes.

Clinical Predictors of Diabetic Retinopathy Progression; A Systematic Review

OBJECTIVE

This study was conducted to discuss the clinical value of published Diabetic Retinopathy Progression determinants.

METHODS

The data for systematic review was collected from the published studies through PubMed and Medline. These studies discussed the clinical predictors of Diabetic Retinopathy (DR) progression. The common keywords used were diabetic Retinopathy, diabetes mellitus, systolic blood pressure, hemoglobin, and albuminuria.

RESULTS

Diabetic Retinopathy is one of the common causes of irreversible visual impairment among adults. Poor glycemic control, systemic hypertension, diabetes duration, dyslipidemia, and microalbuminuria are the major risk factors for the development and progression of diabetic retinopathy. Recently, increased aortic stiffness has been identified as a prognostic marker of diabetic retinopathy and peripheral neuropathy.

CONCLUSION

Certain groups of diabetic individuals are at higher risk to have progressive diabetic retinopathy and eventually visual impairment. Clinical determinants and predictors are considered as prognostic markers and could help physicians to develop an effective risk-based screening program for this condition.

Synergistic interaction between prolonged increased glycemic exposure and mildly increased urinary albumin excretion on diabetic retinopathy

The association of mild increase in urinary albumin excretion with diabetic retinopathy (DR) in clinical studies is controversial. The aim of this study is to clarify the interaction between increased glycemic exposure and mild increase in urinary albumin excretion on risk of DR.Data were collected from the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2012. Overall, data from 953 participants without microalbuminuria (477 men and 476 women) were assessed. Logistic regression analysis was constructed to evaluate the association between DR and related clinical parameters, including urinary albumin-creatinine ratio (UACR, mg/g creatinine). The biological interaction of glycemic status and UACR on DR was evaluated by 3 indices: RERI, the relative excess risk due to the interaction; AP, the attributable proportion due to the interaction; and S, the additive interaction index of synergy.We found that UACR, glycated hemoglobin (HbA1c), and diabetic duration were deeply associated with increased risk of DR (UACR, odds ratio [OR] = 1.04, 95% confidence interval [CI] = 1.02-1.07; HbA1c, OR = 1.16, 95% CI = 1.04-1.30; diabetic duration, OR = 1.06, 95% CI = 1.04-1.07). Furthermore, our interaction analysis demonstrated that synergistic interaction between HbA1c and UACR on development of DR was prominent in participants with diabetic duration of ≥10 years (adjusted RERI = 0.92, 95% CI = 0.10-1.74; adjusted AP = 0.29, 95% CI = -0.82-1.41; adjusted S = 1.76, 95% CI = 1.27-2.25), but not subjects with shorter diabetic duration.These findings imply that there is the interaction between prolonged hyperglycemic exposure and increased urinary albumin excretion may exert additive synergistic effect on vascular endothelial dysfunction in the eye, even before the appearance of overt diabetic nephropathy.

Normal-to-mildly increased albuminuria predicts the risk for diabetic retinopathy in patients with type 2 diabetes

Albuminuria is closely associated with diabetic retinopathy (DR), but the precise role of the albumin-to-creatinine ratio (ACR) in screening for DR remains to be determined. This study aimed to investigate an ACR threshold for predicting DR in patients with type 2 diabetes. A cross-sectional study was conducted on 1,102 type 2 diabetes patients, aged ≥30 years and recruited from the Korea National Health and Nutrition Examination Survey, 2010–2011. Participants were grouped by stage of DR: mild-to-moderate nonproliferative DR (NPDR), severe NPDR, and proliferative diabetic retinopathy (PDR). An early morning spot urine sample was obtained for ACR measurement. ROC curve analysis revealed that the optimal cut-off value of ACR for predicting DR was 2.26 mg/mmol (20 μg/mg). The prevalence of ACR ≥ 2.26 mg/mmol tended to increase with severity of DR. The risk for DR in patients with ACR ≥ 2.26 mg/mmol was higher than in those with ACR < 2.26 mg/mmol. The risk for severe NPDR and PDR also increased at ACR ≥ 2.26 mg/mmol. Normal-to-mildly increased albuminuria (an ACR of 2.26 mg/mmol) may predict the risk for DR development and progression in patients with type 2 diabetes.

Inpatient screening for albuminuria and retinopathy to predict long-term mortality in type 2 diabetic patients: a retrospective cohort study

BACKGROUND

There is a high hospitalization rate for diabetic patients. Since retinopathy and albuminuria are both important manifestations of microvascular disease in diabetes, our aim was to investigate the effect of retinopathy and albuminuria on long-term mortality in type 2 diabetic inpatients through this observational cohort study.

METHODS

Type 2 diabetic inpatients given a primary diagnosis of poor glucose control were consecutively enrolled during their hospitalization periods. Clinical information was collected through review of each patient's medical records, and mortality data were obtained from the national registry in Taiwan.

RESULTS

A total of 761 type 2 diabetic inpatients were enrolled in the study with a median follow-up period of 6.6 years (interquartile range, 4.0-9.6 years). Patients in the Albuminuria(-)/Retinopathy(+), Albuminuria(+)/Retinopathy(-) and Albuminuria(+)/Retinopathy(+) groups had significantly higher risks of all-cause mortality and cardiovascular mortality than those in the Albuminuria(-)/Retinopathy(-) group. However, among patients with albuminuria, there was no significant difference in cumulative mortality between those with and without retinopathy (P = 0.821). A decrease in the estimated glomerular filtration rate (eGFR), but not retinopathy, was an independent predictor of all-cause mortality (95% CI 0.647‒0.893; P < 0.001) and cardiovascular mortality (95% CI 0.564‒0.921; P = 0.009) in type 2 diabetic inpatients with albuminuria.

CONCLUSIONS

Albuminuria in type 2 diabetic inpatients is a strong predictor of long-term mortality after discharge from the hospital. Retinopathy is an independent predictor of mortality in type 2 diabetic inpatients without albuminuria but not in those with albuminuria. A low eGFR is a better predictor of mortality than retinopathy in type 2 diabetic inpatients with albuminuria.

Disability of Hearing Impairment Is Positively Associated With Urine Albumin/Creatinine Ratio in Korean Adults: The 2011-2012 Korea National Health and Nutrition Examination Survey

OBJECTIVES

The aim of this study was to determine whether chronic kidney disease (CKD) is associated with hearing thresholds in the nationwide, large-scaled Korean population.

METHODS

This study analyzed the data of 9,798 subjects of 19 years and older (4,387 males and 5,411 females). Urine albumin-to-creatinine ratio (ACR) was measured from first-voided spot urine samples. The air-conduction hearing threshold was measured at 0.5, 1, 2, 3, 4, and 6 kHz and pure tone audiogram (PTA) average was calculated as the four-frequency average of 0.5, 1, 2, and 4 kHz.

RESULTS

Urine ACR was significantly correlated with the PTA average of better ear in both genders, especially at 3 and 6 kHz in males and at 1, 3, 4, and 6 kHz in females. After adjusting, urine ACR also increased the risk of hearing loss in female, especially if urine ACR was 30 mg/g and more (odds ratio, 1.636-2.229. This study showed that the degree of hearing loss was significantly different according to categories of urine ACR in both genders. Hearing loss without disability was found less but that with bilateral hearing disability was found more as urine ACR increased. In generally, prevalence of hearing loss with disability was higher in males than females.

CONCLUSION

This study demonstrated that urine ACR was significantly correlated with the PTA average of better ear in Korean adults of both genders. This study suggests that clinicians should carefully monitor the hearing level for subjects with elevated urine ACR, even though high urine ACR within the normal range.

Chronic Kidney Disease and Diabetic Retinopathy in Patients with Type 2 Diabetes

Purpose

To explore the relationship between chronic kidney disease (CKD) and diabetic retinopathy (DR) in a representative population of type 2 diabetes mellitus (DM2) patients in Catalonia (Spain).

Methods

This was a population-based, cross-sectional study. A total of 28,344 patients diagnosed with DM2 who had recorded ophthalmologic and renal functional examinations were evaluated. Data were obtained from a primary healthcare electronic database of medical records. CKD was defined as an estimated glomerular filtration ratio (eGFR) of <60 ml/min/1.73m² and/or urine albumin to creatinine ratio (UACR) ≥30 mg/g. DR was categorized as non-vision threatening diabetic retinopathy and vision threatening diabetic retinopathy.

Results

CKD was associated with a higher rate of DR [OR], 95% confidence interval [CI], 1.5 (1.4–1.7). When we analyzed the association between different levels of UACR and DR prevalence observed that DR prevalence rose with the increase of UACR levels, and this association was significant from UACR values ≥10 mg/g, and increased considerably with UACR values ≥300mg/g (Odds ratio [OR], 95% confidence interval [CI], 2.0 (1.6–2.5). This association was lower in patients with eGFR levels 44 to 30 mL/min/1.73m² [OR], 95% confidence interval [CI], 1.3 (1.1–1.6).

Conclusions

These results show that CKD, high UACR and/or low eGFR, appear to be associated with DR in this DM2 population.

Independent correlates of urinary albumin excretion within the normoalbuminuric range in patients with type 2 diabetes: The Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study

AIMS

Within the normoalbuminuric range, low albuminuria (LA, 10-29 mg/24 h) is associated with higher adverse cardiovascular and renal outcomes than normal albuminuria (NA, <10 mg/24 h). This cross-sectional analysis of the cohort from the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicentre Study was aimed at assessing the independent correlates of LA versus NA in patients with type 2 diabetes.

METHODS

This analysis involved 11,538 normoalbuminuric patients (73.2 % of the entire RIACE cohort): 6023 (52.2 %) with NA and 5515 (47.8 %) with LA. Binary logistic regression analysis with backward conditional variable selection was applied to assess the independent correlates of LA versus NA.

RESULTS

Compared with NA subjects, LA patients were more frequently males, older and with family history of hypertension, had longer diabetes duration, lower HDL cholesterol, and higher haemoglobin (Hb) A1c, triglycerides, and blood pressure (BP), use of anti-hyperglycaemic and anti-hypertensive drugs, and prevalence of metabolic syndrome, retinopathy, chronic kidney disease, any cardiovascular disease, myocardial infarction, and coronary and peripheral events. Men with LA were also more frequently current or former smokers and had higher body mass index, waist circumference, and non-HDL cholesterol. Independent correlates of LA were age (OR 1.018), family history of hypertension (OR 1.321), smoking status (former, OR 1.158; current, OR 1.237), HbA1c (OR 1.062), waist circumference (OR 1.050), triglycerides (OR 1.001), and diastolic BP (OR 1.014), together with use of anti-hyperglycaemic and anti-hypertensive agents.

CONCLUSIONS

Several risk factors are associated with increased albuminuria within the normoalbuminuric range. As most of these factors are potentially modifiable, treating them aggressively might reduce the excess risk associated with LA.

TRIAL REGISTRATION

NCT00715481; www.ClinicalTrials.gov .

High normal albuminuria is associated with arterial stiffness and carotid atherosclerosis in Korean patients with type 2 diabetes

BACKGROUND AND AIMS

Current evidence suggests that high normal albuminuria is significantly associated with increased cardiovascular risk. This study investigated the association between urine albumin-to-creatinine ratio (ACR) within the normal range and subclinical atherosclerosis in Korean patients with type 2 diabetes.

METHODS AND RESULTS

This cross-sectional study involved 521 type 2 diabetic patients with normoalbuminuria. Brachial-ankle pulse wave velocity (baPWV) measurement and ultrasound assessment of carotid atherosclerosis was done. Subclinical atherosclerosis was assessed by the presence of high baPWV (>1682 cm/s), carotid atherosclerosis (intima-media thickness >0.8 mm or the presence of plaques), and carotid stenosis (≥50% of luminal narrowing). Across the tertiles of ACR, there was a trend for an increasing prevalence of high baPWV (16.8%, 20.0%, and 38.2%, P < 0.001), carotid atherosclerosis (46.9%, 55.4%, and 64.7%, P < 0.001), and carotid stenosis (12.7%, 16.0%, and 30.1%, P < 0.001). In multivariate analysis, patients in the highest ACR tertile had an odds ratio of 2.05 (95% confidence interval [CI], 1.13-3.72, P = 0.019) for high baPWV, 1.78 (95% CI, 1.08-2.93, P = 0.024) for carotid atherosclerosis, and 2.72 (95% CI, 1.44-5.11, P = 0.002) for carotid stenosis compared to those in the lowest tertile. The relation of ACR with carotid atherosclerosis and stenosis remained significant even in patients without diabetic retinopathy.

CONCLUSION

High normal albuminuria was significantly associated with atherosclerotic vascular changes, independent of retinopathy and other cardiovascular risk factors. High normal albuminuria may be an early marker for subclinical atherosclerosis in type 2 diabetes.

Corneal confocal microscopy detects neuropathy in patients with type 1 diabetes without retinopathy or microalbuminuria

Objective

Corneal innervation is increasingly used as a surrogate marker of human diabetic peripheral neuropathy (DPN) however its temporal relationship with the other microvascular complications of diabetes is not fully established. In this cross-sectional, observational study we aimed to assess whether neuropathy occurred in patients with type 1 diabetes, without retinopathy or microalbuminuria.

Materials and Methods

All participants underwent detailed assessment of peripheral neuropathy [neuropathy disability score (NDS), vibration perception threshold (VPT), peroneal motor nerve conduction velocity (PMNCV), sural sensory nerve conduction velocity (SSNCV) and in vivo corneal confocal microscopy (IVCCM)], retinopathy (digital fundus photography) and albuminuria status [albumin: creatinine ratio (ACR)].

Results

53 patients with Type 1 diabetes with (n=37) and without retinopathy (n=16) were compared to control subjects (n=27). SSNCV, corneal nerve fibre (CNFD) and branch (CNBD) density and length (CNFL) were reduced significantly (p<0.001) in diabetic patients without retinopathy compared to control subjects. Furthermore, CNFD, CNBD and CNFL were also significantly (p<0.001) reduced in diabetic patients without microalbuminuria (n=39), compared to control subjects. Greater neuropathic severity was associated with established retinopathy and microalbuminuria.

Conclusions

IVCCM detects early small fibre damage in the absence of retinopathy or microalbuminuria in patients with Type 1 diabetes.

Risk factors for development and progression of nonproliferative retinopathy in normoalbuminuric patients with type 1 diabetes

BACKGROUND

The aim of this study was to evaluate risk factors for development and progression of nonproliferative retinopathy (NPR) in normoalbuminuric patients with type 1 diabetes mellitus (T1DM).

METHODS

A total of 223 T1DM with normal renal function and normoalbuminuria were included in this study and followed for 48 months. Photodocumented retinopathy status was made according to the EURODIAB protocol. Urinary albumin excretion rate (UAE) was measured from at least two 24-h urine samples. Possible risk factors for development or progression of NPR were examined in backward stepwise Cox's multiple regression analysis.

RESULTS

The majority of patients (70%) had no retinopathy while 67 (30%) had NPR at baseline. Patients with NPR were older, had longer duration of diabetes, higher systolic blood pressure, BMI, resting heart rate, UAE and lower estimated glomerular filtration rate (p ≤ 0.04 for all). After 48 months 24 patients (10.7%) developed NPR or progressed to proliferative retinopathy. Systolic blood pressure (HR 1.03, CI 1.01-1.05, p=0.02), UAE (HR 1.14, CI 1.07-1.21, p<0.001), and resting heart rate (HR 1.05, CI 1.01-1.09, p=0.006) were significantly associated with development or progression of NPR.

CONCLUSIONS

Our results suggest that retinopathy is present and may progress in T1DM even when coexisting renal disease is excluded. Normoalbuminuric T1DM requires close monitoring for the early detection of retinopathy, especially if they have a higher UAE, systolic blood pressure and resting heart rate.

A study of diabetes complications in an endogamous population: an emerging public health burden

AIM

The aims of this study were to determine the prevalence of diabetic complications namely neuropathy, nephropathy, and retinopathy among Qatari's DM patients; and to find associations between these complications and socio-demographic and clinical characteristics in a highly consanguineous population.

DESIGN

It is an observational cohort study.

SETTING

The survey was carried out at the Hamad General Hospital and Primary Health Care (PHC) centers in the State of Qatar.

SUBJECTS

The study was conducted from May 2011 to January 2013 among Qatari nationals above 20 years of age. Of the 2346 registered with diagnosed diabetes attending Hamad General Hospital and PHC centers, 1633 (69.3%) agreed and gave their consent to take part in this study.

METHODS

Questionnaire included socio-demographic variables, body mass index (BMI), consanguinity, lifestyle habits, family history of diabetes, blood pressure and development of diabetes complications such as retinopathy, nephropathy, and neuropathy were collected at regular intervals throughout the follow-up. Univariate and multivariate statistical analysis were performed.

RESULTS

Out of 1633 diabetic patients, 842 (51.6%) were males. The prevalence of diabetic nephropathy 12.4% and retinopathy was 12.5% followed by neuropathy 9.5% among diabetic population. The proportion of diabetic neuropathy and nephropathy were significantly higher among diabetic patients with age 60 years and above as compared to younger age groups (p=0.010). Nephropathy was significantly higher among male diabetic (p=0.014) and smokers (p<0.001) while diabetic neuropathy was more common among diabetic hypertensive patients (p=0.028). Multivariate logistic regression showed that Age (p=0.025), being male (p=0.045), and having high blood pressure (p=0.006) were significant predictors of diabetic neuropathy. For diabetic retinopathy, family history of DM (p<0.001), consanguinity (p=0.010), having high blood pressure (p=0.042) and physical activity (p<0.001) were significant predictors of diabetic retinopathy. Meanwhile, for diabetic nephropathy, age (p<0.001), smoking (p=0.045), physical activity (p<0.001) hypertension (p<0.001) and gender (p=0.012) were the significant predictors.

CONCLUSION

Diabetes exerts a significant burden in Qatar, and this is expected to increase. Many diabetic patients face significant challenges accessing diagnosis and treatment, which contributes to the high morbidity and mortality and prevalence of complications observed. The significant interactions between diabetes and associated complications highlight the need and opportunity for health planners to develop integrated responses to communicable and non-communicable diseases.

Predictors of diabetic retinopathy in patients with type 2 diabetes who have normoalbuminuria

Background:

Microalbuminuria is an independent predictor of retinopathy, so absence of microalbuminuria may tend clinician not to screen for diabetic retinopathy (DR).

Aim:

The aim of our study was to estimate prevalence of DR in patients with type 2 diabetes who have normoalbuminuria, and to study predictors for DR, which can identify these high-risk individuals.

Subjects and Methods:

In a prospective cross-sectional study that included patients with type 2 DM and normoalbuminuria. Diagnosis of DR was made by a trained ophthalmologist based on the presence of clinical features in the fundus of both eyes following the International Clinical DR guidelines. The statistical analyses were performed using Statistical Package for the Social Sciences 15.0 version software (Chicago, IL, USA). The continuous variables expressed as means (SD and Student's t-test or Mann–Whitney test were used, as appropriate, to determine differences in them. Categorical variables were presented as percentage. The Pearson's Chi-square test or Fisher's exact test, as appropriate, was used to determine the differences in them.

Results:

A total of 226 patients with type 2 DM and normoalbuminuria were enrolled in the study that included 110 males (48.6%), and 116 females (51.4%) Mean (SD) duration of diabetes was 8.2 (5.6) years. DR of any grade was present in 49/226 (22%) patients. Of the patients with DR of any grade, 31/49 (63%) had mild non-proliferative diabetic retinopathy (NPDR) 10/49 (22%) had moderate to severe NPDR and 8/49 (15%) had PDR. Duration of diabetes (OR 1.01, 95% CI, 0.86-2.2, P = 0.04), higher systolic blood pressure (OR 2.2, 95% CI, 1.6-4.5, P = 0.01), low hemoglobin (OR 1.4, 95% CI, 0.45-2.9, P = 0.01), and a higher tertile of urinary albumin excretion rate (OR 4.12, 95% CI, 1.92-7.57, P = 0.001) had independently significant association with DR.

Conclusion:

The risk of DR exists in patients with type 2 diabetes even in normoalbuminuric individuals. Close monitoring is particularly needed if patients have longer duration of diabetes, hypertension, anemia, or high normal albuminuria.

Resting heart rate is associated with nonproliferative retinopathy in normoalbuminuric type 1 diabetic patients

Previous studies have reported that retinopathy might be already present in the normoalbuminuric state in type 1 diabetic patients. The aim of this study was to evaluate the prevalence and predictors of nonproliferative retinopathy in normoalbuminuric type 1 diabetic patients. The study included 312 normoalbuminuric type 1 diabetic patients with normal renal function before any interventions with statins, angiotensin-converting enzyme inhibitors, or angiotensin II receptor blockers. Diagnosis of nonproliferative retinopathy was made by fundoscopy after pupillary dilatation. Urinary albumin excretion (UAE) rate was measured from at least two 24-hour urine samples. Nonproliferative retinopathy was present in 36% of normoalbuminuric patients. Patients with nonproliferative retinopathy were older and had longer duration of diabetes, higher hemoglobin A1c , daily insulin dose, and higher resting heart rate (RHR) (P≤.01 for all). Patients in the 4th quartile of RHR were older and had longer duration of diabetes, higher hemoglobin A1c , daily insulin dose, serum creatinine, UAE, and a significantly higher prevalence of nonproliferative retinopathy compared with subjects in the 2nd, 3rd, and 4th quartiles (P<.05). In logistic regression analysis, after adjustment for risk factors, higher RHR was significantly associated with risk of nonproliferative retinopathy in patients (P<.001), with odds ratios of 1.02 to 1.08. These data suggest that RHR is independently associated with nonproliferative retinopathy in normoalbuminuric type 1 diabetic patients.