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PUBLISHED DATE: - 09-10-2024
https://doi.org/10.37547/TAJMSPR/Volume06Issue10-03
PAGE NO.: - 13-20
COMPARATIVE STUDY OF
MICROCIRCULATION PARAMETERS IN THE
LOWER EXTREMITIES OF PATIENTS WITH
TYPE 2 DIABETES DEPENDING ON BODY
WEIGHT
J.A. Nazarova
Center for the Development of Professional Qualifications of Medical
Workers under the Ministry of Health of the Republic of Uzbekistan,
Uzbekistan
L.Kh. Mamadinova
Andijan State Medical University, Uzbekistan
L.U. Zakirova
Andijan State Medical University, Uzbekistan
INTRODUCTION
Despite advances in diagnosis and treatment,
complications of diabetes mellitus (DM) remain a
major concern for patients and their families.
Microvascular disease can lead to blindness, renal
failure,
and
limb
amputation
(1,2,3).
Macrovascular complications such as myocardial
infarction and stroke occur at a higher rate in
patients with DM than in the general population
and are the leading cause of death in patients with
this
disease.
Both
microvascular
and
macrovascular complications reduce patients’
quality of life and ability to work, and impose
significant costs on the public health and
healthcare sectors (5,6,7,8).
RESEARCH ARTICLE
Open Access
Abstract
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To assess the state of arterial blood flow in the
lower extremities, attending physicians mainly
prescribe ultrasound of the vessels of the lower
extremities, which, however, does not provide an
idea of the state of the microcirculatory bed. It can
be argued that the range of diagnostic capabilities
for assessing disorders in the microcirculatory bed
of the lower extremities is currently extremely
limited. But it is the detection of early
hemodynamic disorders in small vessels that will
help prevent the development of severe
complications. Currently, there are no specific
clinical recommendations for doctors to identify
hemodynamic disorders in the microcirculatory
bed of the lower extremities, since the
methodology of disorders in the microcirculatory
bed of the lower extremities remains the subject of
scientific debate. Among the existing research
methods
(color
duplex
scanning,
rheolymphovasography,
radionuclide
lymphoscintigraphy,
photon-correlation
spectroscopy, etc.), laser Doppler flowmetry (LDF)
has an undoubted advantage due to its ease of use,
non-invasiveness of the technique, and the absence
of contraindications for use. The ability to identify
microcirculation disorders of
the
lower
extremities characteristic of patients with type 2
diabetes using a simple and relatively inexpensive
diagnostic method will expand the diagnostic
criteria for type 2 diabetes, especially in the early
stages of its development (4). All of the above
became the basis for conducting research work.
Aim of the study
. To study the diagnostic
capabilities of laser Doppler flowmetry in the
diagnosis of lower limb microcirculation disorders
in type 2 diabetes.
Research material
. The study was conducted at
the Andijan State Medical Institute (I, II and III
neurological departments) and the Regional
Endocrinology Dispensary. The criteria for
inclusion of patients in the study were the
presence of verified type II diabetes mellitus (DM-
2); disease duration of at least 5 years; age from 45
to 65 years; absence of focal brain damage
according to MRI data; signing of voluntary
informed consent to participate in the study. The
exclusion criteria were the presence of severe or
unstable concomitant somatic pathology, acute
cerebrovascular accident, myocardial infarction,
alcoholism, substance abuse.
A total of 110 patients diagnosed with type 2
diabetes mellitus (DM-2) were examined, 47
(42.7%) men and 63 (57.3%) women, aged 40 to
79 years, the average age of patients was 52.3+12.9
years. During the study, patients were divided into
two groups.
Table 1
Distribution of patients into groups
Groups
gender
n
%
Group I
male
14
56,0%
n=25 (19,4%)
female
11
44,0%
II group
male
35
41,2%
n=85(65,9%)
female
50
58,8%
Total
male
49
44,5%
n=110 (100,0%)
female
61
55,5%
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The first group consisted of 25 (22.7%) patients
who did not have excess div weight (BMI < 25),
for this group the average BMI was 19.2 + 5.8 and
the HbA1C level was 8.8 + 0.4%. The second group
included 85 (77.3%) patients whose div weight
was above normal (BMI> 25). In this group the
average BMI was - 31.8 + 7.3, and the HbA1C level
was 9.2 + 0.8% (Table 1). The control group (CG)
consisted of 19 individuals (12 women and 7 men,
average age 64.3 ± 7.1) with no history or objective
examination of diabetes, hypertension, or other
cardiovascular diseases, and no other diseases that
impair cognitive functions (TBI, hypothyroidism,
alcoholism, substance abuse). Individuals in the
control group did not complain of decreased
memory, attention, or mental performance (Table
1).
Analyzing the data of patients selected for the
study, the following conclusions can be made:
there were more women among the patients - the
sex index was 1.4 in favor of the female sex; when
analyzing the sex structure depending on age, it
was noted that the percentage of men decreased
with age, and women increased; there was a
significant number of patients with increased div
weight (BMI> 25.0) - 85 people (77.3%).
METHODS
All patients underwent a standard clinical and
neurological examination (analysis of patient
complaints, life history and medical history,
objective examination, including study of
neurological status) and somatic examination.
The initial blood flow and hemodynamic disorders
in the microcirculatory bed of the lower
extremities in patients were assessed using the
laser Doppler flowmetry (LDF) method on a laser
blood microcirculation analyzer for general
practitioners LAKK-OP with 2 recording channels
(manufacturer OOO NPP LAZMA PF, Russia). We
analyzed microcirculation indices at rest in both
lower extremities.
- The microcirculation index is the value of the
average blood flow in the recording time intervals
or the arithmetic mean value of the
microcirculation index, measured in perfusion
units (PU). A change in PM (increase or decrease)
characterizes an increase or decrease in perfusion.
- The parameter RMS is the average fluctuation of
perfusion relative to the average value of blood
flow PM. Since perfusion registration is associated
not only with rhythmic regulatory fluctuations, but
also with random chaotic ones, the standard
deviation is used to average the PM value. RMS
reflects the average change in perfusion
parameters at different registration frequencies.
3. The coefficient of variation reflects the ratio of
the values of PM and SD.
4. Rhythmic components include active and
passive factors of microcirculation control. Based
on the ratio of predominant oscillations in the
amplitude-frequency spectrum, one can draw a
conclusion about the prevalence of one or another
type of microcirculatory bed state.
Hell (passive factor) - respiratory wave, caused by
the dynamics of venous pressure during
pulmonary mechanical activity, the suction action
of the “respiratory pump”. The diagnostic value of
the respiratory wave lies in its connection with the
venular link. However, the respiratory wave does
not directly reflect the blood flow of the venous
sections of the capillaries and venules, it is
associated with its respiratory modulation.
Ac (passive factor)
–
pulse wave, this is a
parameter that changes depending on the state of
tone of resistive vessels.
Ae (active factor)
–
endothelial oscillations, caused
by the functioning of the endothelium. The
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diagnostic value of endothelial oscillations lies in
the assessment of endothelial dysfunction by the
relative change in oscillation amplitudes.
An (active factor)
–
neurogenic oscillations,
associated with sympathetic adrenergic effects on
the smooth muscles of arterioles and arteriolar
sections of arteriole-venular anastomoses.
Am (active factor)
–
myogenic oscillations,
characterize the muscle tone of blood vessels. The
origin of these vasomotions is associated with local
pacemakers inside smooth muscle fibers. The
diagnostic value of myogenic oscillations lies in the
assessment of the state of muscle tone of
precapillaries, regulating the blood flow to the
nutrient channel.
To ensure the accuracy and reliability of the
research results, a thorough statistical analysis
used both parametric and non-parametric
methods. Microsoft Office Excel 2016 spreadsheets
were used to collect, process, systematize and
display the obtained data. For a more in-depth
statistical analysis, IBM SPSS Statistics version 26
software developed by IBM Corporation was used.
This software allowed for complex statistical
calculations and guaranteed high accuracy of data
processing.
RESULTS
The initial blood flow and hemodynamic disorders
in the microcirculatory bed of the lower
extremities in patients of group I were assessed in
comparison with group II. When analyzing the
initial blood flow and the amplitude-frequency
spectrum in patients with varying degrees of
severity of distal diabetic polyneuropathy
depending on the presence of metabolic syndrome,
we obtained the following data, presented in Table
2.
Table 2.
Results of evaluation of microcirculation of lower extremities in groups (Me)
LDF-gram
parameter
Group
I
II
group
KG
Δ I-KG
Δ II-
KG
Δ
I-II
р<
1
2
3
1--2
2--3
1--3
PM, pf.un.
9,7
10,8
12,8
-24,2%
-15,6%
-10,2%
0,005
0,05
RMS, pf.units
1,09
1,15
1,27
-14,2%
-9,4%
-5,2%
0,05
KV
11,8
11,2
10,9
8,3%
2,8%
5,4%
0,005
0,05
Amax Е
0,33
0,31
0,28
17,9%
10,7%
6,5%
0,05
Amax Н
0,35
0,38
0,41
-14,6%
-7,3%
-7,9%
0,05
0,05
0,05
Amax M
0,34
0,31
0,28
21,4%
10,7%
9,7%
0,05
0,05
Amax R
0,25
0,28
0,32
-21,9%
-12,5%
-10,7%
0,05
Amax C
0,81
0,89
0,93
-12,9%
-4,3%
-9,0%
0,05
When analyzing the arithmetic mean (Me) of the
microcirculation index (MI) in group I, significantly
lower perfusion values were found compared to
group II and CG (in group I, Me CG was 24.2%
lower (p>0.005) and compared to group II, it was
15.6% lower (p<0.05)) (Table 2). The standard
deviation (pfd, units) was lower in group I
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compared to CG and group II (Me CG was 14.2%
lower in group I (p>0.05) and compared to group
II, where this indicator was 9.4% lower (p>0.05)).
Lower flux values obtained as a result of our work
in patients in group I may be due to less intensive
functioning of the mechanisms of active control of
microcirculation, a decrease in cardiac and
respiratory rhythms due to a smaller number of
erythrocytes entering the arterioles (Table 2).
When analyzing blood flow in patients in group I,
the median values for the coefficient of variation
(CV) did not differ significantly from those in group
II (Me in group I was 5.4% higher than Me in group
II (p>0.05)).
Blood pressure (passive factor)
–
Amax R -
respiratory wave: lower blood pressure values in
patients of group I compared to the values in the
control group may indicate an increase in
microcirculatory pressure (Me in group I is 10.7%
less than Me in group II (p>0.05)).
Ac (passive factor)
–
Amax C - pulse wave:
significantly reduced Ac values in patients of group
I, together with reduced or normal PM values, may
indicate a decrease in the inflow of arterial blood
into the microcirculatory bed of the lower
extremities (Me of group I is 4.3% less than Me of
group II (p <0.05)).
Ae (active factor)
–
Amax E - endothelial
fluctuations: significantly elevated Ae values in
patients of group I (Me in group I is 6.5% higher
than Me in group II (p <0.05)) indicate the
presence of endothelial dysfunction, and in
patients with high-amplitude pulse rhythm
–
indicate dilation of small arteries and large
arterioles.
An (active factor)
–
Amax H - neurogenic
fluctuations: reduced An values in patients of
group II (Me in group I is 7.9% less than Me in
group II (p> 0.05)) indicate increased neurogenic
tone, and are also an indicator of increased
arteriolar resistance, which can be used in the
diagnosis of peripheral polyneuropathy in these
patients.
Am (active factor)
–
Amax M- myogenic
fluctuations: median values did not differ
significantly from those in healthy volunteers (Me
in group I was 9.7% higher than Me in group II
(p>0.05)).
Table 3.
Results of the evaluation of microcirculation of the lower extremities in groups
depending on gender (Me)
Group I
increase Δ
р<
LDF-gram parameter
men
women
KG
m/KG
w/kg
1
2
1--2
PM, pf.un.
10,2
10,0
12,9
-
20,9% -22,5%
RMS, pf.units
1,11
1,13
1,28
-
13,3% -11,7%
КV
11,8
11,7
10,8
9,3%
8,3%
Amax Е
0,32
0,3
0,29
10,3%
3,4%
0,05
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Amax Н
0,41
0,35
0,42
-2,4%
-16,7%
0,005
Amax M
0,33
0,29
0,28
17,9%
3,6%
0,05
Amax R
0,28
0,26
0,31
-9,7%
-16,1%
0,005
Amax C
0,9
0,84
0,92
-2,2%
-8,7%
0,05
II group
increase Δ
р<
LDF-gram parameter
men
women
KG
m/KG
w/kg
3
4
3--4
PM, pf.un.
11,6
12,2
12,9
-
10,1%
-5,4%
0,05
RMS, pf.units
1,17
1,21
1,28
-8,6%
-5,5%
КV
10,8
11,2
10,8
0,0%
3,7%
Amax Е
0,28
0,32
0,29
-3,4%
10,3%
0,05
Amax Н
0,39
0,43
0,42
-7,1%
2,4%
0,05
Amax M
0,27
0,31
0,28
-3,6%
10,7%
0,05
Amax R
0,26
0,32
0,31
-
16,1%
3,2%
0,005
Amax C
0,87
0,93
0,92
-5,4%
1,1%
We also assessed the initial blood flow and
hemodynamic disorders in the microcirculatory
bed of the lower extremities in patients of group I
and group II depending on gender. When analyzing
the initial blood flow and the amplitude-frequency
spectrum in patients with varying degrees of
severity in patients in subgroups, we obtained the
following data, presented in Table 3.
When analyzing the arithmetic mean value of the
microcirculation index (MI) in group I, lower
perfusion values were found in men compared to
women and the CG (p<0.05).
RMS (pfd, units) was lower in men (group I)
compared to the CG and women (group I) (Me men
(group I) by 13.3% less Me CG and Me women
(group I) by 11.7% less Me CG (p>0.05 reliability
not revealed), Lower flux values obtained as a
result of our work in male patients (group I) may
be due to less intensive functioning of the
mechanisms of active control of microcirculation, a
decrease in cardiac and respiratory rhythms due to
a smaller number of erythrocytes entering the
arterioles (Table 3).
When analyzing blood flow in male patients (group
I), the median values for the coefficient of variation
(CV) did not differ significantly from those of
women (group I) (Me of men (group I) was 9.3%
higher than Me of CG and Me of women (group I)
was 8.3% higher than Me of KG, no significance
was found).
Blood pressure (passive factor)
–
Amax R -
respiratory wave: lower blood pressure values in
patients of group I compared to the values in the
control group may indicate an increase in
microcirculatory pressure (Me in men (group I) is
9.7% lower than Me in the control group and Me in
women (group I) is 16.1% lower than Me in the
control group, (p> 0.005)).
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Ac (passive factor)
–
Amax C - pulse wave:
significantly reduced Ac values in male patients of
group I together with reduced or normal PM values
may indicate a decrease in the inflow of arterial
blood into the microcirculatory bed of the lower
extremities (Me in men (group I) is 2.2% less than
Me KG and Me in women (group I) is 8.7% less than
Me KG, (p>0.05)).
Ae (active factor)
–
Amax E - endothelial
fluctuations: reliably elevated Ae values in male
patients (group I) (Me in males (group I) is 10.3%
higher than Me in CG and Me in females (group I)
is 3.4% higher than Me in CG, (p> 0.05)). indicate
the presence of endothelial dysfunction, and in
patients with high-amplitude pulse rhythm
–
indicate dilation of small arteries and large
arterioles.
An (active factor)
–
Amax H - neurogenic
fluctuations: reduced An values in patients in
group I (Me men (group I) by 2.4% less than Me CG
and Me women (group I) by 16.7% less than Me CG,
(p> 0.05)) indicate increased neurogenic tone, and
are also an indicator of increased arteriolar
resistance, which can be used in the diagnosis of
peripheral polyneuropathy in these patients.
Am (active factor)
–
Amax M- myogenic
fluctuations: the median values did not differ
significantly from the values in healthy volunteers
(Me in men (group I) was 17.9% higher than Me KG
and Me in women (group I) was 3.6% higher than
Me CG, (p>0.05)).
In Group II, we observed similar changes in the
microcirculation balance, which were more
pronounced in male patients, less pronounced
compared to Group I (Table 3).
The obtained results, presented in Tables 2 and 3,
allowed us to determine the specific features of
microcirculation for patients with type 2 diabetes
depending on the presence of metabolic syndrome
(MS).
Patients with type 2 diabetes in comorbidity with
MS in the anamnesis are characterized by reduced
perfusion indices, pulse and respiratory waves up
to 30%, high microcirculatory pressure, signs of
dilation of small arteries and large arterioles, more
pronounced changes were in male patients in this
group.
CONCLUSION
Based
on
the
identified
changes
in
microcirculation in patients with type 2 diabetes in
comorbidity with MS, negative dynamics of
pathological processes in the microcirculatory bed
of the lower extremities due to endothelial
dysfunction were established.
It should be noted that in patients with type 2
diabetes in comorbidity with MS, the severity of
microcirculation correlates with the level of
glycemia, the glycated hemoglobin index, male
gender, the pain syndrome score according to the
PainDetect scale, and with the scale indicators
(objective manifestations of diabetic distal
neuropathy in patients). In this regard, by
assessing the microcirculation of the upper and
lower extremities using the LDF method, it is
possible to assess the severity of distal
polyneuropathy.
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