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The Association Between Insulin Resistance and Proliferative Retinopathy in Type 1 Diabetes

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The Association Between Insulin Resistance and Proliferative Retinopathy in Type 1 Diabetes The association between insulin resistance and proliferative retinopathy in type 1 diabetes IRINA DUŢĂ1,2, SIMONA FICA2,3, DANIELA ADRIANA ION2 1“Prof. N. C. Paulescu” National Instititute of Diabetes, Nutrition and Metabolic Diseases, Bucharest, Romania 2“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 3“Elias” Emergency Hospital, Bucharest, Romania Introduction. Little is known about the relationship between insulin resistance and proli- ferative diabetic retinopathy in type 1 diabetes. The aim of this article is to explore the relationship between sight-threatening proliferative diabetic retinopathy and insulin resistance. Methods. This was a cross-sectional study that included 167 type 1 diabetes patients. Insulin resistance was assessed using eGDR (estimated glucose disposal rate) formula. Diabetic retinopathy was assessed by ophthalmoscopy using Early Treatment Diabetic Retinopathy classification. The association between eGDR and proliferative diabetic retinopathy was assessed in uni- and multivariate models using stepwise logistic regression of covariates. The contribution of individual predictors in the final regresion model was examined using Wald statistic. Results. Significantly lower eGDR’s values were observed in patients with proliferative diabetic retinopathy: 5.5 vs. 7 (p = 0.002). The results remained significant (p < 0.001) after adjusting for multiple covariates (sex, diabetes duration, body mass index, HDL cholesterol, LDL cholesterol, triglycerides, smoking). eGDR variable was retained in the final model of stepwise logistic regression (p < 0.001) and showed the strongest association with proliferative diabetic retinopathy (Wald = 12.73). Conclusions. In type 1 diabetes patients insulin resistance was the most important independent risk factor associated with diabetic proliferative retinopathy. Key words: type 1 diabetes, insulin resistance, estimated glucose disposal rate, proliferative diabetic retinopathy. INTRODUCTION micro- (nephropathy, neuropathy and retinopathy) and macro- (coronary artery disease and peripheral With 70-100% of patients being affected, vascular disease) vascular complications [11-15]. retinopathy is the most common type 1 diabetes The purpose of this article was to assess insulin (T1D) complication [1]. resistance in T1D patients stratified according to Diabetic retinopathy lesions are divided into the presence or absence of PDR. For our secondary two large categories: nonproliferative (NPDR) and aim we hypothesized that in T1D patients insulin proliferative (PDR). Almost all T1D patients have resistance, quantified using the estimated glucose NPDR. The more severe form of retinopathy, PDR, disposal rate (eGDR) formula, would be associated affects 15-50% of T1D patients over 15-20 years of with PDR. disease duration [2, 3]. It usually progresses to visual impairment. In developed countries diabetic retinopathy is the main cause of blindness in MATERIALS AND METHODS working age group [4]. Identifying patients at risk of ocular impairment is a concern for clinicians. Study design was cross-sectional. We included Elements of metabolic syndrome such as patients with type 1 diabetes who underwent medical hyperglycemia [5-7], hypertension [8], dyslipidemia checkups in “N.C. Paulescu” Institute during a one [9, 10] and abdominal obesity [10] are known to be year period (from January to December 2012). A risk factors for the occurrence of diabetic retino- total of 167 patients with type 1 diabetes were pathy. Insulin resistance is the physio-pathological included in the study. substrate for the metabolic syndrome. Insulin Inclusion criteria. Type 1 diabetes mellitus resistance is a key element in the pathogenesis of was defined as: diabetes onset before the age of T2D. It has been suggested that insulin resistance is 35 years with permanent insulin treatment initiated also present in T1D. It appears that in T1D patients within the first year after diagnosis. Eligibility for insulin resistance is an independent risk factor for inclusion in the study was based on the clinical ROM. J. INTERN. MED., 2015, 53, 3, 261–266 262 Irina Duţă et al. 2 diagnosis of type 1 diabetes. Confirmation, by Assessment of diabetic retinopathy. Retino- determining serum C peptide level (< 0.3 nmol/l), pathy was assessed following ophthalmological was available only for the subset of patients in examination. The eye with the most severe which there were doubts regarding T1D diagnosis. involvement was used for categorization of ocular The study included either patients with chronic involvement. Early Treatment Diabetic Retinopathy kidney disease stages 4 (urinary albumin excretion Study classification was used to assess the severity rate - AER > 300 mg/24h) and 5 (end stage renal of retinopathy. NPDR was diagnosed if any of disease – predialysis/dialysis/renal transplant) microaneurysms, hemorrhages, hard exudates, venous according to Mogensen classification or patients congestion, cotton wool spots or intraretinal mico- with at least 15 years duration of diabetes, eGFR vascular abnormalities were present. PDR was (estimated glomerular filtration rate) between 90- 2 registered when new vessels, glial proliferation, 130 ml/min/1.73 m and AER < 30 mg/24h. T1D preretinal hemorrhage, vitreous hemorrhage, scars patients that had AER = 30-300 mg/24 h and any of photocoagulation (known to have been directed other condition that might interfere with albumin at new vessels) and/or retinal detachment were excretion (hyperglycaemia, uncontrolled hyper- found. Patients with none of these abnormalities tension, heart failure or urinary tract infection) were classified as not having retinopathy. were re-examined. Ethical considerations. Patient enrollment Exclusion criteria. Patients were excluded complied with the Declaration of Helsinki. The from the study in the case of any doubt about type 1 study was approved by the local ethics committee. diabetes diagnosis (even after determining the Statistical analysis.Continuous variables with serum C peptide level) or if any evidence of non- normal distribution are presented as mean ± SD. diabetic renal disease. Continuous variables with non-normal distribution Patients were stratified according to the are presented as median and interquartile range.The presence or absence of PDR. distribution of continuous variables was tested for Clinical parameters. Registration of: diabetes- normality using Kolmogorov-Smirnov and Shapiro- related data, anthropometric indices, blood pressure, smoking status, alcohol intake, family history, Wilk tests. Categorical variables are presented as diabetes-related complications data was done. Supine frequencies (%). Between-group comparisons were systolic (SBP) and diastolic (DBP) blood pressure made using Student’s t test (for normally distributed was measured in both arms after 10 minutes of rest. variables), Mann-Whitney U test (for non-normally We used the arithmetic mean of the values obtained. distributed variables) and χ2 test (for categorical Hypertension was defined as a BP> 140/90 mm Hg variables). and/or use of antihypertensive treatment. Patients were stratified according to the presence Laboratory parameters. Fasting blood samples or absence of PDR. were collected for assessment of HbA1c (glycated The association between insulin resistance hemoglobin), C-peptide, fasting glucose, lipids (total (quantified using eGDR) and PDR was assessed in cholesterol, HDL cholesterol, triglycerides) and uni and multivariate logistic regression models. serum creatinine. HbA1c level was measured by a Initially, we analyzed the association between standardized DCCT (Diabetes Control and Compli- eGDR and PDR in univariate logistic regression cations Trial) method. C-peptide levels were measured models and then regression was adjusted for duration using an ELISA technique. Glucose, lipids and of diabetes and sex. creatinine and were assessed using enzymatic methods. To assess the contribution of insulin resistance The glomerular filtration rate was estimated using (quantified using eGDR) and potential confounders the CKD-EPI formula (Chronic Kidney Disease to PDR we conducted a multivariate analysis (logistic Epidemiology Collaboration). Urine samples were regression) where the dependent variable was the collected in order to determine AER/24 h. appearance of PDR (noted as presence / absence) Assessment of insulin resistance. Insulin and the independent variables are the risk factors resistance was assessed using the eGDR formula. studied (eGDR, sex, duration of diabetes, BMI, HDL eGDR is an equation derived from hyper- cholesterol, LDL cholesterol, triglycerides and smoking insulinemic euglycemic clamp studies [16]. eGDR status). Backward stepwise procedure was used. (ml/kg/min) is based on clinical parameters and is Statistical analyses were performed using SPSS calculated as follows: eGDR = 24.31 - (12.22 x version 20.0. P-values < 0.05 were considered WHR) - (3.29 X BP) - (0.57 X HbA1C), where statistically significant. Variables that did not meet WHR – waist to hip ratio, BP - history of hyper- this criterion were removed from the model. The tension (yes = 1, no = 0), HbA1c - glycated hemo- contribution of individual predictors in the final globin A1C. regression model was examined using Wald statistic. 3 Insulin resistance and proliferative retinopathy in type 1 diabetes 263 RESULTS significance. HbA1c values (p = 0.44), fasting plasma glucose (p = 0.80) and BMI (p = 0.11) had Characteristics of patients. The study included similar
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