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BuAbbud, John; Al-latayfeh, Motasem; Sun, Jennifer
doi: 10.1007/s11892-010-0129-zpmid: 20556548
Optical coherence tomography (OCT) is a noninvasive imaging modality that uses low-coherent interferometry to visualize an optical cross-section of biological tissues. Over the past two decades, the ability to perform OCT imaging of the neural retina has afforded clinicians and researchers a highly reproducible method of diagnosing and following diabetic macular edema (DME) that compares favorably to other methods of DME assessment such as clinical examination and fundus photography. Although central subfield mean thickness has been the OCT parameter most commonly used to evaluate DME in clinical research trials, OCT also allows evaluation of morphologic changes that occur in DME, including compact retinal thickening, intraretinal cystic changes, subretinal fluid, and vitreomacular traction. OCT parameters have been shown to be only moderately correlated with visual acuity. However, improvements in technology leading to higher resolution, faster acquisition speed, image registration, and three-dimensional imaging that are available with newer spectral domain OCT models may allow future identification of valid OCT-derived surrogate markers for visual function in patients with diabetes.
doi: 10.1007/s11892-010-0127-1pmid: 20535647
Recent proteomic studies have identified components of the kallikrein kinin system, including plasma kallikrein, factor XII, and kininogen, in vitreous obtained from individuals with advanced diabetic retinopathy. In rodent models, activation of plasma kallikrein in vitreous increases retinal vascular permeability; whereas inhibition of the kallikrein kinin system reduces retinal leakage induced by diabetes and hypertension. These findings suggest that intraocular activation of the plasma kallikrein pathway may contribute to excessive retinal vascular permeability that can lead to diabetic macular edema. The kallikrein kinin system contains two separate and independently regulated serine proteases that generate bradykinin peptides: plasma kallikrein and tissue kallikrein. Tissue kallikrein is expressed in the retina and ciliary body, where it has been implicated in exerting autocrine or paracrine effects via bradykinin receptors that are colocalized in these tissues. Emerging evidence suggests that plasma kallikrein inhibitors may provide a new therapeutic opportunity to reduce retinal vascular permeability.
Pop-Busui, Rodica; Herman, William; Feldman, Eva; Low, Phillip; Martin, Catherine; Cleary, Patricia; Waberski, Barbara; Lachin, John; Albers, James
doi: 10.1007/s11892-010-0120-8pmid: 20464532
The DCCT/EDIC (Diabetes Control and Complications Trial/ Epidemiology of Diabetes Interventions and Complications) provides a comprehensive characterization of the natural history of diabetic neuropathy in patients with type 1 diabetes and provides insight into the impact of intensive insulin therapy in disease progression. The lessons learned about the natural history of distal symmetrical polyneuropathy and cardiovascular autonomic neuropathy and the impact of glycemic control on neuropathy are discussed in this review.
Ndip, Agbor; Lavery, Lawrence; Boulton, Andrew
doi: 10.1007/s11892-010-0128-0pmid: 20532700
Among the spectrum of risk for diabetic foot disease conferred by chronic kidney disease (CKD), end-stage renal disease (ESRD) has emerged as a novel independent risk factor. Apart from the classical triad of neuropathy, infection, and peripheral arterial disease that operate in these individuals, the risk is further compounded by inadequate foot self-care by patients and by dialysis centers not providing onsite foot care, as medical priorities are diverted to the dialysis itself. Consequently, the burden of diabetic foot disease has increased in the CKD and ESRD population as exemplified by high ulceration, amputation, and foot-related mortality rates. Current guidelines on foot care in diabetes should recognize advanced CKD and ESRD/dialysis as a separate risk factor for foot disease to alert professionals and highlight the opportunity for prevention. Recent studies have demonstrated improved foot outcomes when chiropody programs are instituted within dialysis units.
doi: 10.1007/s11892-010-0123-5pmid: 20544312
The triad of diabetes mellitus, anemia, and chronic kidney disease (CKD) define a group of patients at high risk for death and cardiovascular complications. The approval of epoetin alfa in 1989 transformed the treatment of anemia in patients with CKD. However, evidence has emerged from randomized controlled trials that correcting anemia with erythropoiesis-stimulating agents in CKD patients is associated with increased risk. Most recently, the TREAT (Trial to Reduce Cardiovascular Events With Aranesp Therapy) study of anemic type 2 diabetic patients with CKD reported that treatment with darbepoetin conferred no benefit in mortality or in attenuating cardiovascular or renal events. Instead, there was a twofold higher rate of stroke and thromboembolic complications and a higher rate of cancer deaths in patients randomized to treatment with darbepoetin. Furthermore, there was an inconsistent and modest improvement in health-related quality of life. TREAT raises questions about whether anemia in type 2 diabetic patients should be treated and under what circumstances.
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