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Low Serum Bilirubin Levels Contribute to the Presence and Progression of Distal Symmetrical Polyneuropathy in Chinese Patients with Type 2 Diabetes

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Low Serum Bilirubin Levels Contribute to the Presence and Progression of Distal Symmetrical Polyneuropathy in Chinese Patients with Type 2 Diabetes Diabetes & Metabolism 45 (2019) 47–52 Available online at ScienceDirect www.sciencedirect.com Original article Low serum bilirubin levels contribute to the presence and progression of distal symmetrical polyneuropathy in Chinese patients with type 2 diabetes J. Jin a,1, W. Wang a,1,T.Gua,1, C. Chen b, J. Sun a, W. Chen a,Y.Bia,*, D. Zhu a,* a Department of Endocrinology, Drum Tower Hospital Affiliated to Nanjing University Medical School, No. 321, Zhongshan Road, Nanjing, Jiangsu 210008, China b Department of Endocrinology, Drum Tower Clinical Medical College of Nanjing Medical University, Jiangsu, China ARTICLE INFO ABSTRACT Article history: Aim. – To investigate the association between serum bilirubin and distal symmetrical polyneuropathy Received 29 October 2017 (DSPN) in Chinese patients with type 2 diabetes (T2D). Received in revised form 10 February 2018 Methods. – A total of 1800 inpatients with T2D (including 68 with 1-year follow-ups) were Accepted 18 February 2018 consecutively enrolled between June 2014 and March 2017. DSPN was diagnosed according to criteria Available online 22 February 2018 recommended by the Toronto Diabetic Neuropathy Expert Group in 2010. Clinical data were retrospectively collected. Keywords: Results. – Patients with vs. without DSPN had low levels of serum total bilirubin (9.9 Æ 3.1 mmol/L vs. Bilirubin 10.7 2.8 mol/L; P < 0.01) and unconjugated bilirubin (6.7 2.2 mol/L vs. 7.3 2.1 mol/L; P < 0.01), Distal symmetrical polyneuropathy Æ m Æ m Æ m Indicator respectively. Patients in the lowest tertiles of bilirubin had the highest rates of DSPN and slowest nerve Type 2 diabetes conduction velocities (NCVs). After multivariate adjustment, low levels of unconjugated bilirubin were a risk Unconjugated bilirubin factor (OR: 0.696, 95% CI: 0.494–0.981; P = 0.038, highest vs. lowest) for the presence of DSPN. Furthermore, in the 68 patients who had 1-year follow-ups, those with the lowest tertiles of serum bilirubin showed maximum deterioration in NCVs. These changes remained significant even after multivariate adjustment. Conclusion. – Low levels of serum bilirubin, especially unconjugated bilirubin, contributed to the presence and progression of DSPN in Chinese patients with T2D. Thus, serum unconjugated bilirubin may be used as an additional indicator of risk and progression of DSPN. C 2018 Published by Elsevier Masson SAS. Oxidative stress can induce tissue injury in peripheral nerves in Introduction patients with diabetes and, in fact, participates in the pathogenesis of DSPN [6]. Bilirubin is the end product of haem catabolism and is Distal symmetrical polyneuropathy (DSPN) is one of the most an endogenous antioxidant, and the beneficial effects of elevated common chronic complications of diabetes [1], presenting in at serum bilirubin on the cardiovascular system at physiological least 10–15% of newly diagnosed diabetes patients [2,3] and concentrations have recently been reported [7]. In the general possibly reaching 50% in those with diabetes for > 10 years population, low levels of total bilirubin have been correlated with [4]. DSPN is the main contributor to several severe diabetes subclinical atherosclerotic changes [8], and associated with the complications, such as foot ulcers and even amputation [5]. incidence of coronary artery disease, stroke and peripheral artery disease [9]. Abbreviations: DSPN, distal symmetric polyneuropathy; AST, aspartate amino- In patients with type 2 diabetes (T2D), low serum levels of total transferase; ALT, alanine aminotransferase; BMI, body mass index; HbA1c, bilirubin have been reported in association with microvascular glycosylated hemoglobin; TC, total cholesterol; LDL, low-density lipoprotein; SD, complications such as microalbuminuria [10] and retinopathy standard deviation. [11], as well as macrovascular complications such as coronary * Corresponding authors. E-mail addresses: [email protected] (Y. Bi), [email protected] (D. Zhu). heart disease, peripheral vascular disease [12] and higher risk of 1 These authors contributed equally to this work. amputation [13]. Similarly, an inverse relationship between total https://doi.org/10.1016/j.diabet.2018.02.007 1262-3636/ C 2018 Published by Elsevier Masson SAS. 48 J. Jin et al. / Diabetes & Metabolism 45 (2019) 47–52 bilirubin and the presence of DSPN was observed in a Korean stabilized to around 31 8C. The following NCVs were measured on population [14]. However, that study explored only the effect of both sides: total bilirubin on DSPN. Indeed, no prospective study or analysis has yet been conducted to evaluate the effect of serum bilirubin, median nerve, and both motor and sensory branches; including total bilirubin, unconjugated bilirubin and conjugated ulnar nerve, and both motor and sensory branches; bilirubin, on progression of DSPN. peroneal nerve; Thus, the aim of the present study was to investigate the roles of tibial nerve; the different components of serum bilirubin in the presence and superficial peroneal nerve; progression of DSPN (diagnosed according to nerve conduction sural nerve. studies and neurological assessment) in Chinese patients with T2D. If three or more of the tested NCVs were abnormal, then nerve conduction was considered abnormal and diagnosed on the basis Material and methods of reference values specific to the Chinese population [18]. The presence of abnormal nerve conduction and symptoms or signs of Subjects neuropathy was defined as DSPN [19]. Our study consisted of two parts: a cross-sectional study; and a Clinical assessment retrospective follow-up study. For the cross-sectional part, a total of 1800 patients with T2D were enrolled from among inpatients at Patients’ clinical data were collected by reviewing their Drum Tower Hospital, Nanjing, China, between June 2014 and electronic medical records. Data included demographic informa- March 2017. T2D was diagnosed according to American Diabetes tion, diabetes duration, body mass index (BMI) scores, glycosylated Association (ADA) criteria, using both fasting and 2-h plasma haemoglobin (HbA1c), fasting blood glucose, fasting C-peptide, glucose from an oral glucose tolerance test (OGTT) [15]. Inclusion postprandial C-peptide, triglycerides, total cholesterol (TC), high- criteria were: confirmed T2D; and patients aged 18–75 years. density lipoprotein (HDL), low-density lipoprotein (LDL), AST, ALT, Exclusion criteria were: total bilirubin, conjugated bilirubin, unconjugated bilirubin, history of hypertension and/or coronary heart disease, and the patients with chronic liver disease, renal disease, arrhythmias, presence of diabetic complications, including diabetic retinopathy, malignant disease, severe respiratory disease, heart failure and diabetic nephropathy and cardiovascular autonomic neuropathy. infection; Serum levels of total and conjugated bilirubin were measured by patients with serum bilirubin levels above the upper limit of the oxidation method [Zhuhai Senlo (Senlong) Biotech Co., Ltd., normal (ULN; total bilirubin > 20.5 mmol/L, conjugated biliru- Zhuhai, China] and analyzed using an automated biochemistry bin > 6.8 mmol/L); analyzer (Beckman Coulter, Inc., Indianapolis, IN, USA). Diabetic patients with abnormal liver function tests [defined as complications were diagnosed by senior doctors according to aspartate aminotransferase (AST) or alanine aminotransferase the standard definitions in the relevant guidelines. Diabetic (ALT) 2 times the ULN]; nephropathy (DN) was defined according to ADA criteria [15] patients with stroke, hypothyroidism, alcohol addiction based on the presence of albuminuria (urinary albumin-to- ( 21 standard drinks containing 10–12 g of pure alcohol/week creatinine ratio 30 mg/g) and the absence of signs or symptoms in the past 12 months) [16] and any causes of neuropathy other of other primary causes of kidney damage. Cardiovascular than diabetes. autonomic neuropathy (CAN) was defined as having two or more abnormalities in four reflex tests: heart rate variation during deep For the retrospective follow-up study, 68 patients who under- breathing; Valsalva manoeuvre; lying-to-standing test; and blood went two tests of nerve conduction velocity (NCV) respectively pressure variability in response to standing. Each test was before and after a 1-year interval were selected from the compared against normative values in a previous report [20]. 1800 enrolled subjects. These 68 patients were assessed for diabetic complications annually at our hospital, and NCV tests were routinely Statistical analysis and annually performed in the T2D inpatients at our hospital. The study protocol was approved by the ethics committee of Data are presented as means Æ standard deviation (SD) for Drum Tower Hospital (No. 2017-006-01), and all patients gave continuous variables and as percentages for dichotomous variables. their informed consent to participate. All analyses were performed with IBM SPSS version 22.0 software (IBM Corp., Armonk, NY, USA). For continuous variables, Student’s Neurological symptoms and examination t-test was used for normal distributions and the Wilcoxon rank-sum test for abnormal distributions (fasting C-peptide, postprandial All enrolled patients had a complete history of neurological C-peptide). The Chi2 or Fisher’s exact test was used for dichotomous symptoms and examination. Symptoms were documented using a variables. Linear regression analysis was used for continuous neuropathy symptom scoring system [17] that included feelings of variables, with logistic regression for dichotomous
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