Tropical Ophthalmology
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R
ENAL
-
RETINAL
S
YNDROME
D
R
.
F.A.
K
HAIDAROVA
,
P
H
.D.
D
R
.
A
KSHEY
K
HERA
,
D
R
.
N.R.
Y
ANGIEVA
,
P
H
.D.
D
R
.
N.K
H
.
A
BASKHANOVA
,
B.A.
S
ULTANOV
Tashkent Medical Institute of Post
Graduate Study, First Tashkent State Medical Institute
Tashkent, Uzbekistan
Key words:
diabetes mellitus (DM),
complications, diabetic retinopathy (DR), risk
factors, diabetic nephropathy (DN), clinical DN
(CN), and chronic renal insufficiency (CRI).
The late complications of the DM are one of
the basic reasons of premature physical inability
and lethality of the DM patients, which puts
essential harm to the health of the population and
the economy as a whole (2). Proceeding from it in
the foreground of the problem of prophylactics of
the given DM complications is put forward.
For the development of effectual measures of
prophylactics it is necessary to study features of a
course, prevalence and to reveal the factors
promoting the development of the late
complications of the DM.
Recently the association between DN and DR
has being actively discussed in literature.
The purpose of the present work was a study
of the frequent- of the late complications of DM on
the population of the DN patients in Tashkent city
conditions and the study of the risk factors
promoting their development.
The given article is devoted to the analysis of
the received information on the association
between DN and DR and the factors of its
development.
In the City Endocrinology Dispensary a
single time research in the epidemiology of the late
DM complications is performed. Cohort method is
used for selection of observation units. Cohort was
formed in accordance with all basic attributes of
general set: typicalness by sex, age (18-75 years)
and type of DM.
. For processing the selected totality of the
representative group of DM patients the formula of
unrepeated random selection offered by R.N.
Biryukova was used.
All surveyed were interrogated on the
specially developed card. The card is developed on
the basis of an information medical sheet offered
by the European regional bureau of the WHO and
is adapted according to purposes and research
problems.
The card includes the items of information on
the patients, duration of disease and treatment
(diet observance, receptions of tablet sugar reduce
preparations and insulin, duration of reception of
preparations, dose of shortactive and prolonged
forms of insulin, frequency of injections per - day).
Analyzed anthropometrical and biochemical
parameters, the presence and expressivities of
changes on the fundus of the eye, functions of
kidneys, vascular system, nervous and genital
systems as the most often displays of late
complications revealed presence in anamnesis
hereditary history on DM and hypertensive
disease. In women we analyzed the quantity of
pregnancies in anamnesis and
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their results. We determine the common presence
in anamnesis of both hypoglycemic and
hyperglycemic. We estimated the risk factors and
their characters. Found out the level of knowledge
in the patient about DN and the degree of
realization by himself of selfchecking. Diagnostics
and screening of diabetic nephropathy performed
by qualitatively defining proteinuria with the help
of the Phan test of thf' Lachema" firm. The test was
considered positive, if the albumin concentration in
urine was more than 300 mg/ day.
Diagnostics and screening of the peripheral
neuropathy performed on the basis of the
definition of vibrating sensitivity with the help of
the graduated tuning fork. The research was
performed on a horizontal patients condition.
Diabetic retinopathy diagnostics performed
by way of selection data from medical cards and if
necessary examining the fundus of the eye with the
help of the indirect ophthalmoscopy after the
dilation of pupil. Revealed changes classified by
ophthalmoscopic criteria were offered by the E.
Koner and M. Porta.
Ischemic heart disease (IHD), vessels
macroangiopathy of the lower extremities was
established on the basis of combination of the
positive answers on the standard Rouse's
questionnaire with the presence of stenocardia,
myocardial infraction, alternating lameness
syndrome, and, also if necessary on the basis of
ECG and reovasography examinations.
The total number of patients: 1201 persons,
out of the men - 40.5% (486), women - 59.5% (715).
Patients suffering from insulin-dependent DM
(IDDM) - 201, from non-insulin dependent DM
(NIDDM) - 1000.
By the presence of IDDM the greatest number
of patients are registered till 40 years (70.1%), and
with NIDDM - more senior than 50 years Id
(75,6%).
The distribution of those surveyed on the
duration of DM has shown, that greatest quantity
of the patients was with the disease duration of 6-
10 years.
On a compensation degree patients were
distributed as follows
-
with IDDM:
1.
with the compensated course -2.5%,
2.
with the subcompensated course - 39.3%,
3.
with decompensated course - 58.2%.
With NIDD1C accordingly:
1.
13.3%,
2.
47.8%,
3.
38.9%.
In the examinees with diabetes mellitus the
DN - DP combination was found in 44.7% of
patients with type I diabetes mellitus and in 31,9%
of those with type II diabetes mellitus. The direct
correlation was observed between DN phase and
DR clinical implication (Table 1). In clinical DN and
chronic renal insufficiency (CRI) diabetic
retinopathy was registered in all examinees,
absence of changes in the fundus of eye being
typical of the examinees without renal changes.
Comparison of the fundus vessels in
groups of patients with renal changes, that is, those
having diabetic retinopathy with nephropathy
with those without diabetic nephroangiopathy
showed that in patients with type II diabetes
mellitus and proteinuria preproliferative (DRII)
and proliferative diabetic (DRIH) retinopathies
were diagnosed 2.5 more frequently than in those
without diabetic nephropathy, in 60.4% and 25.0%
of cases, respectively. In type I diabetes mellitus the
ratio was
III
and 29.4% (P<0.001).
It should be noted that there were 2 times
more persons with the disease duration longer than
10 years among the diabetics (regardless of
diabetes type) with the combination of DR and DN,
as compared with those without diabetic
nephroangiopathy
(Table
2,3),
sub-
and
decompensated diabetes mellitus being observed 2
times more frequently (Table 4).
Confidently high systolic arterial pressure
Table 1
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Diabetic nephroangiopathy incidence dependence on diabetic retinopathy severity
(%)
Diabetic
retinopathy
Severity
Type I diabetes mellitus
Type II diabetes mellitus
No. of patients CN
CRI
No. of patients CN
CRI
DR I
79
36.7+2.7
-
470
29.3+2.6
-
DR
П
65
76.6+2.7
4.6+1.2
284
61.2+2.8
3.5+1.2
DR III
14
4.28+2.6
57.1+2.3
38
28.9+2.5
Total
158
50.0+2.8
6.9+1.6
792
40.7+2.7
Table 2
Renal-retinal syndrome incidence dependence on type I diabetes mellitus duration and DR severity (%)
Disease
duration
No
DR without nephropathy
Total
DR with nephropathy
Total
DR I
DR
П
DRIII
DRI
DRII
DRIII
Less than a
year
22
9.0+0.8
-
-
9.0+0.8
-
-
-
-
1-5
years
47
29.7+1.3
6.3+1.7
-
36.1+1.5
12.7+1.0
4.2+1.0
-
17.0+1.2
6-10
years
51
43.1+1.5
13.7+1.0
-
56.8+1.2
25.4+1.3
15.6+1.6
-
41.1+1.5
11-15
years
39
20.5+1.7
17.9+1.7
-
38.4+1.9
17.9+1.7
38.4+1.7
5.1+0.7
61.5+1.2
16 and
more
years
42
9.5+0.7
2.3+1.0
-
11.9+1.2
7.1+1.2
52.3+1.2
28.5+1.4
88.0+1.4
Total
201
2.4+1.0
6.9+0.8
-
33.8+1.0
14.4+1.2
23.3
6.9+0.7
44.0+1.4
Table 3
Renal-retinal syndrome incidence dependence on type II diabetes mellitus duration and DR severity
(%)
Disease
duration
No.
DR without nephro
jathy
Total
DR with nephropathy
Total
DR I
DR
П
DRIII
DRI
DRII
DRIII
Less than a
year
161
18.6+1.2
0.62+0.62
-
19.0+1.2
5.5+1.7
-
-
5.5+1.7
1-5 years
221
31.2+1.4
65.8+1.5
0.45+0.4
37.5+1.6
23.0+1.3
1.8+0.8
-
24.8+1.9
6-10 years
235
56.1+1.6
9.3+1.8
0.85+0.5
66.3+1.6
19.1+1.5
12.7+1.1
-
31.9+1.2
11-15 years
201
23.6+1.3
-
0.99+0.7
54.2+1.5
14.4+1.7
28.3+1.7
28.3+1.7
50.7+1.5
16 and
more years
182
29.6+1.3
2.1+1.0
3.2+1.3
35.1+1.5
2.1+1.0
51.0+1.7
11.5+1.3
64.8+1.5
Total
1000
33.2+1.4
10.0+0.9
1.1+0.3
44.3±1.5
13.8+1.0
18.4+1.2
2.7+0.5
34.0+1.5
Table 4
Tropical Ophthalmology
I
T2.
Renal-retinal syndrome incidence in dependence on diabetes mellitus control (%,+m)
Control
Type I diabetes mellitus
Type
П
diabetes mellitus
No.
DR without
nephropathy
DR with
nephropathy
No.
DR without
nephropathy
DR with
nephropathy
Compensated
5
-
20.0±0.4
133
33.0±1.3
8.2±0.8
Subcompensated
79
39.2±1.4
3.9+1.3
478
42.2±1.4
Decompensated
117
33.9±1.3
53.8±1.5
389
50.6±1.6
49.3±1.5
(regardless of diabetes type) was observed in
patients with DR and nephropathy as compared to
those without nephropathy. Mean systolic arterial
pressure in patients with type I diabetes mellitus
and DR without nephropathy was 131.75+23
mmHg, in the group with DR and renal changes it
was 149.88±26.1 mm Hg. Upon type П
diabetes
mellitus the values were 136.09±21 mm Hg and
155,46±25 mm Hg, respectively. Diastolic arterial
pressure upon type I diabetes mellitus in the group
of patients with DR and nephropathy was 92.6+12
mm Hg, in the group of persons with DR without
nephropathy 71,50±14 mm Hg. Upon type Ц,
diabetes mellitus the values were 97.47±14 mm Hg
and 84,84±12 mm Hg, respectively. It should be
noted that upon DR with nephropathy the arterial
hypertension family burden was higher than the
one in the group of patients with DR without
nephropathy (upon type I diabetes mellitus being
56.0% and 19.5%, upon type
П
diabetes mellitus
50.6% and 34.8%, respectively).
The "DM family burden" and "obesity"
factors were found insignificant in patients with
the DR - DN combination (P>0.05).
The findings confirm the opinion that both
insufficient
compensation
of
carbohydrate
metabolism and arterial hypertension play a
significant role in DN pathogenesis, DR reflecting
the general increase of endothelium barriers
permeability for blood plasma proteins.
The analysis of mean blood serum cholesterol
showed that in patients with the DR and DN
combination as compared with those without renal
changes the total cholesterol is higher. Upon type I
diabetes mellitus in patients with the DR - DN
combination mean cholesterol was 5.9±lmmol/l, in
persons with DR without nephroangiopathy it was
3.4±1.7mmol/l, upon type П
diabetes mellitus the
values being 7.7±1.2mmol/l and 5.7±1.0mmol/l,
respectively.
Thus, the findings show that 44.5% of
patients with type I diabetes mellitus and 31.9% of
those with type II diabetes mellitus had the DR -
DN combination to be the evidence for renal-
retinal syndrome in the patients of the kind.
L
ITERATURE
1.
Contribution of hypertension to the development
of diabetic retinopathy: an epidemiological
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Giom. It. Di. Diabetol. - 1995 - V. 15. P. 25-28.
2.
David M. Nathan. Long Term complications of
diabetes mellitus The New Engl. J. Med., 1993. -
V. 10. P. 1676-1683.
3.
Development of diabetic retinopathy and its
associated risk factors in type II diabetes
patients in Osaka district. Japan: a long
-
term
prospective.
4.
Glucose control and the renal and retinal
complications of insulin-dependent diabetes.
Chase H.P., Jackson W.E., Hoops S.L., et al.
JAMA
-
1989 - V. 261. - P. 1155-1160.
5.
Lee E.T., Keen H., Bennett P.H. et al. Follow - up
of the multinational study of vascular disease in
diabetes: general description and morbidity
Diabetologia
-
2001. - 44
-
P.3-13.
6.
Picup J.C., Williams G. Textbook of Diabetes.
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