Diabetologia (1999) 42: 865±869 Ó Springer-Verlag 1999 Impaired deformability of erythrocytes and neutrophils in children with newly diagnosed insulin-dependent diabetes mellitus O. Linderkamp1,P.Ruef1, E.P. Zilow1, G.F. Hoffmann2 1 Department of Paediatrics, University of Heidelberg, Germany 2 Department of Paediatrics, University of Marburg, Germany Abstract than in healthy children (3 ± 2%). Deformability of passive neutrophils was greatly decreased in the chil- Aims/hypothesis. Abnormal rheological properties of dren with onset diabetes and moderately reduced in erythrocytes, leucocytes and plasma may have a role the diabetic children who were treated with insulin. in the development of diabetic microangiopathy. We Neutrophil deformation (r = ±0.52) and erythrocyte hypothesized that changed haemorrheological vari- deformation at 0.6 Pa (r = ±0.62) were inversely relat- ables may already be found in children with onset di- ed to haemoglobin A1c. Haematocrit and blood vis- abetes. cosity were increased in the untreated children and Methods. Erythrocyte deformation (rheoscope), neu- in the children treated with insulin for 5 to 8 years. trophil deformation (micropipette), erythrocyte ag- Plasma viscosity and erythrocyte aggregation were gregation, blood and plasma viscosity were measured similar in the three groups of children. in 15 children with insulin-dependent diabetes melli- Conclusion/interpretation. Decreased erythrocyte de- tus before initiation of insulin treatment and 4 to formation at low shear force, increased count of ac- 6 weeks later, 15 diabetic children treated with insulin tive neutrophils and impaired deformability of pas- for 5 to 8 years, 15 healthy children and 15 healthy sive neutrophils may increase the risk for acute cere- adults. bro-vascular complications in children with uncon- Results. At a low shear stress of 0.6 Pa, erythrocyte trolled insulin-dependent diabetes mellitus. [Dia- deformation was decreased in the diabetic children betologia (1999) 42: 865±869] before (±28%), after 4 to 6 weeks (±22%) and after 5 to 8 years (±17%) of insulin treatment compared Keywords Blood viscosity, diabetes mellitus, erythro- with healthy children. More active neutrophils were cyte aggregation, erythrocyte deformability, hae- counted in the untreated diabetic children (9 ± 6%) morrheology, neutrophils. Patients with juvenile onset of Type I (insulin-depen- observed. These angiopathic complications usually dent) diabetes mellitus are at high risk of diabetic mi- develop after several years of Type I diabetes. Func- croangiopathy and vascular disease. In children and tional impairments of the macrocirculation and mi- adolescents with Type I diabetes, ischaemic disease crocirculation have, however, been observed at early of the heart [1], retina [2] and intestine [3] have been stages of juvenile Type I diabetes [4, 5]. The development of diabetic angiopathy has been related to abnormal haemorrheological properties as Received: 17 November 1998 and in final revised form: 2 Feb- increased blood viscosity, haematocrit, plasma viscos- ruary 1999 ity and erythrocyte aggregation [6, 7], and decreased erythrocyte [6, 8, 9] and leucocyte deformability Corresponding author: Dr. O. Linderkamp, Department of Paediatrics, University of Heidelberg, D-69 120 Heidelberg, [9±13]. High values of HbA1c correlated with de- Germany creased deformability of erythrocyte [6, 14] and poly- Abbreviations: PMN, Polymorphonuclear neutrophils. morphonuclear neutrophils (PMN) [13] and in- 866 O. Linderkamp et al.: Erythrocyte and leucocyte deformability in diabetic children Table 1. Erythrocyte indices and haemorrheological variables in children with Type I diabetes Onset Type I Children with Type I treated with Insulin for Healthy Healthy before insulin children adults 4±6 weeks 5±8 years Age (years) 10 ± 210± 213± 2b 10 ± 225± 3c Blood glucose (mmol/l) 28.2 ± 6.0c 8.5 ± 2.3c 9.6 ± 2.6c 4.1 ± 0.9 4.5 ± 1.1 c c c Haemoglobin A1c (%) 13.6 ± 3.3 9.8 ± 1.8 7.3 ± 1.7 4.6 ± 1.1 4.2 ± 0.8 Haematocrit (%) 44.4 ± 4.8a 38.6 ± 3.9 43.1 ± 3.5a 39.2 ± 3.6 47.2 ± 5.0a MCV (fl) 88.9 ± 3.2 92.4 ± 3.5 89.5 ± 2.5 90.6 ± 3.3 90.7 ± 4.8 MCH (pg) 29.8 ± 1.9 29.3 ± 1.7 28.9 ± 1.8 28.4 ± 1.6 29.5 ± 1.7 MCHC (g/dl) 33.5 ± 1.2 32.1 ± 1.5 31.9 ± 1.4 32.0 ± 1.2 32.9 ± 1.0 Reticulocyte count (103/ml) 49 ± 23 53 ± 28 78 ± 32a 50 ± 26 52 ± 27 Total plasma protein (g/l) 65 ± 668± 765± 668± 573± 7 Plasma albumin (g/l) 44 ± 342± 443± 345± 348± 5 Plasma fibrinogen (g/l) 2.8 ± 0.5 2.8 ± 0.7 3.0 ± 0.6 2.7 ± 0.6 3.4 ± 0.6a Erythrocyte elongation at 0.6 Pa 13 ± 3b 14 ± 2b 15 ± 2a 18 ± 217± 3 Erythrocyte elongation at 8.5 Pa 41 ± 442± 541± 444± 343± 6 Erythrocyte aggregation 8.7 ± 2.1 9.5 ± 2.6 9.3 ± 2.3 8.9 ± 1.8 10.3 ± 2.5 Plasma viscosity (mPa × s) 1.2 ± 0.2 1.3 ± 0.2 1.2 ± 0.1 1.2 ± 0.1 1.3 ± 0.1 Blood viscosity (mPa × s) 3.0 ± 0.4a 2.6 ± 0.4 3.0 ± 0.5a 2.5 ± 0.5 3.4 ± 0.6a Leucocyte count ( 109/l) 12.5 ± 3.7c 7.3 ± 2.4 6.8 ± 1.8 6.5 ± 1.4 6.1 ± 1.3 Neutrophil count ( 109/l) 9.2 ± 3.3c 4.5 ± 1.3 3.6 ± 1.0 3.0 ± 0.7 3.2 ± 0.6 Neutrophil volume (fl) 396 ± 61 358 ± 42 369 ± 44 360 ± 46 348 ± 50 Active neutrophils (%) 9 ± 6b 6 ± 4a 5 ± 33± 24± 3 Neutrophil tongue length (mm; at 60 s) 5.8 ± 1.0c 6.9 ± 1.2b 7.7 ± 1.3a 9.5 ± 1.4 9.1 ± 1.5 Diabetic children and healthy adults were compared with healthy children (a p < 0.05; b p < 0.01; c p < 0.001) MCH, mean corpuscular volume; MCHC, mean corpuscular haemoglobin; MCV, mean corpuscular haemoglobin concentration creased plasma fibrinogen [15], the major determi- diabetes and severe ketoacidosis before commencing nant of plasma viscosity and erythrocyte aggregation insulin treatment and during insulin treatment. These [7]. variables included blood and plasma viscosity, aggre- During the initial presentation, children with Type gation and deformability of erythrocytes and deform- I diabetes frequently show severe hyperglycaemia ability of neutrophils. Moreover, activated neutro- and HbA1c values greater than 10% [4, 16, 17]. Brain phils were counted. swelling is a serious complication of new onset Type I diabetes in children [17, 18]. Brain swelling may oc- cur before treatment with fluids and insulin, suggest- Subjects and methods ing that severe hyperglycaemia and ketoacidosis themselves contribute to the development of cerebral Patients. The studies were undertaken in accordance with the oedema [18]. Although animal experiments have ethical standards laid down in the Declaration of Helsinki. In- shown that acute hyperglycaemia induces consider- formed consent of the blood donors or their parents was given able cerebral blood flow disturbances and impaired and the approval of the ethics committee of the Department cerebrovascular reactivity [19], it is not clear whether of Paediatrics was obtained. We studied 4 groups (Table 1) vascular changes are involved in cerebral complica- each of which comprised 15 subjects: (1) children with Type I diabetes (aged 7 to 12 years) studied before and 4 to 6 weeks tions of patients with uncontrolled Type I diabetes. after initiation of insulin treatment; (2) children with Type I di- Moreover, it is not known whether onset Type I dia- abetes (10 to 15 years old) who had been treated with insulin betes is associated with abnormal haemorrheological for 5 to 8 years; (3) healthy children (7 to 12 years old); and properties. In particular, PMN could play a part in the (4) healthy non-obese men (21 to 29 years old). Children and pathogenesis of cerebral complications during onset adults with a family history or manifestation of hypertension of Type I diabetes, since PMN have been shown to or hyperlipoproteinaemia and those who reported active or passive smoking, alcohol or drug consumption were excluded. have an important role in the production of hypoxic- The healthy children were patients of the Department of Pae- ischaemic brain injury in adult and neonatal animal diatric Surgery who had had minor selective operations (e.g. models [20, 21]. Studies on diabetic rats showed in- inguinal hernia, phimosis). In the children with onset Type I di- creased counts of PMN at the time of overt onset of di- abetes, blood sugar was 21 to 36 mmol/l, HbA1c 10 to 19%, abetes [22] and of active PMN in circulating blood at 2 plasma osmolality 302 to 356 mosmol/kg, arterial pH 7.05 to to 9 months of diabetes [23]. The rise ± in active PMN, 7.22, bicarbonate 7 to 16 mmol/l, base excess ±25 to ±13 mmol/l and pCO 21 to 41 mmHg at admission. All infants which are extremely rigid [24] ± was associated with 2 with newly diagnosed Type I diabetes had subtle central ner- capillary occlusions by leucocytes [23]. vous system signs such as dizziness, headaches or sleepiness Our study was designed to determine several but none developed obvious symptoms of severe brain swelling haemorrheological variables in children with Type I such as severe deterioration in neurological or vital status. In O. Linderkamp et al.: Erythrocyte and leucocyte deformability in diabetic children 867 group 1, blood was taken immediately prior to treatment with insulin and again 4 to 6 weeks later when blood gases were nor- mal and blood sugar was less than 10 mmol/l.