diaendoСахарный диабетDiabetes mellitus2072-03512072-0378Endocrinology research centre10.14341/DM12372diaendo-12372Research ArticleОригинальные исследованияOriginal StudiesНарушение микроциркуляторного кровотока у больных сахарным диабетом 2 типа и кардиоваскулярной автономной нейропатиейImpairment of microvascular blood flow in patients with type 2 diabetes and cardiovascular autonomic neuropathyhttps://orcid.org/0000-0001-6208-0972ЗеленинаТ. А.ZeleninaT. A.

Зеленина Татьяна Александровна, к.м.н.; eLibrary SPIN: 2382-8579194044, Санкт-Петербург, ул. Боткинская, д. 21

Tatiana A. Zelenina, MD, PhD; eLibrary SPIN: 2382-857921 Botkinskaya street, 194044 Saint-Petersburg

tzelenina@mail.ruhttps://orcid.org/0000-0003-1851-0941СалуховВ. В.SalukhovV. V.

Салухов Владимир Владимирович, д.м.н., профессор; eLibrary SPIN: 4531-6011Санкт-Петербург

Vladimir V. Salukhov, MD, PhD, Professor; eLibrary SPIN: 4531-6011Saint-Petersburg

vlasaluk@yandex.ruhttps://orcid.org/0000-0002-5438-0075ЗемлянойА. Б.ZemlianoiA. B.

Земляной Александр Борисович, д.м.н., профессор; eLibrary SPIN: 8820-0367Москва

Aleksandr B. Zemlianoi, MD, PhD, Professor; eLibrary SPIN: 8820-0367Moscow

aleks9@bk.ruЖелезнякС. Г.ZheleznjakS. G.

Железняк Сергей Григорьевич, к.м.н.Санкт-Петербург

Sergei G. Zheleznjak, MD, PhDSaint-Petersburg

zheleznjak-sg@gmail.comhttps://orcid.org/0000-0002-2686-8786КлиценкоО. А.KlitsenkoO. A.

Ольга Анатольевна Клиценко, к.б.н.; eLibrary SPIN: 7354-3080Санкт-Петербург

Olga A. Klitsenko, PhD in Biology; eLibrary SPIN: 7354-3080Saint-Petersburg

olkl@yandex.ruВоенно-медицинская академия им. С.М. КироваРоссияMilitary medical academy of S. M. KirovRussian FederationНациональный медико-хирургический центр им. Н.И. ПироговаРоссияNational Medical-Surgical Center N.I. PirogovRussian FederationСеверо-Западный государственный медицинский университет им. И.И. МечниковаРоссияNorth-Western State Medical University named after I. I. MechnikovRussian Federation2021260120212413244Copyright © Зеленина Т.А., Салухов В.В., Земляной А.Б., Железняк С.Г., Клиценко О.А., 20212021Зеленина Т.А., Салухов В.В., Земляной А.Б., Железняк С.Г., Клиценко О.А.Zelenina T.A., Salukhov V.V., Zemlianoi A.B., Zheleznjak S.G., Klitsenko O.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.dia-endojournals.ru/jour/article/view/12372ОБОСНОВАНИЕ

ОБОСНОВАНИЕ. Диабетическая кардиоваскулярная автономная нейропатия (КАН) ассоциирована с ранней смертностью и инвалидизацией пациентов. Нарушается иннервация как сердца, так и периферических сосудов.

ЦЕЛЬ

ЦЕЛЬ. Оценить параметры микроциркуляторного кровотока кожи у больных сахарным диабетом (СД) и КАН. Выделить предикторы наличия КАН и оценить их значимость у больных СД.

МЕТОДЫ

МЕТОДЫ. В исследование включены 76 больных СД 2 типа (СД2) (24 больных с впервые выявленным СД и/или СД без микрососудистых осложнений, 26 с диабетической сенсомоторной нейропатией (ДСМН), 26 с хирургическими операциями по поводу синдрома диабетической стопы (СДС) в анамнезе). ДСМН диагностирована на основании жалоб, анамнеза и клинико-неврологического обследования. Для установления КАН выполнены кардиоваскулярные тесты (КВТ) как золотой стандарт диагностики: титл-тест, тест с глубоким дыханием, маневр Вальсальвы, тест с динамометром, холодовая вазоконстрикция. Согласно рекомендациям международной группы по исследованию нейропатии, все пациенты были разделены на группы: КАН 0 (все тесты нормальные), КАН 1 (возможная/ранняя стадия — один измененный тест), КАН 2 (подтвержденная стадия — как минимум два КВТ изменены), КАН 3 (тяжелая стадия — все случаи симптоматической и/или бессимптомной ортостатической гипотензии). Микроциркуляторный кровоток кожи околоногтевого валика кистей оценивался в покое, а также в ходе холодового теста методом высокочастотной ультразвуковой допплерографии на приборе «Минимакс Допплер К» (ООО «Минимакс», Санкт-Петербург, Россия).

РЕЗУЛЬТАТЫ

РЕЗУЛЬТАТЫ. КАН 1 диагностирована у 8% больных с СД без микрососудистых осложнений и у 42% и 21% пациентов с ДСМН и операциями по поводу СДС в анамнезе соответственно. КАН 2 выявлена у 27% больных с ДСМН и у 58% с операциями на стопах в анамнезе. КАН 3 определена в 8% и 19% случаев у больных с ДСМН и СДС соответственно. Параметры базального микроциркуляторного кровотока были снижены значительно у пациентов с подтвержденной/тяжелой стадией КАН по сравнению с ранней стадией и больными без КАН (Vm=2,5±0,66 см/с и 4,4±0,54 см/с, 5,1±1,01 см/с соответственно; p=0,0033). Положительный результат холодового теста зарегистрирован у 94% пациентов с подтвержденной/выраженной КАН и у 26% больных с КАН 1.

ЗАКЛЮЧЕНИЕ

ЗАКЛЮЧЕНИЕ. В исследовании на когорте больных СД2 с/без ДСМН, с/без ампутаций на стопах в анамнезе продемонстрировано увеличение риска подтвержденной/тяжелой стадии КАН в 6,4 раза в случаях снижения Vm (средней скорости микроциркуляторного кровотока по данным высокочастотной ультразвуковой допплерографии) менее 2,4 см/с. Положительный результат холодового теста ассоциирован с увеличением риска подтвержденной/тяжелой КАН в 28,6 раза.

BACKGROUND

BACKGROUND: Diabetic autonomic neuropathy is the reason for early morbidity and mortality on diabetic patients. The pathology not only cardiac innervation but microvascular is presented.

AIMS

AIMS: We estimated the parameters of skin microvascular blood flow in accordance with cardiovascular autonomic neuropathy (CAN) staging in diabetic patients. We also assessed other risk factors of CAN in patients with diabetes.

MATERIALS AND METHODS

MATERIALS AND METHODS: We included 76 patients with type 2 diabetes in the study (24 patients with resent-onset diabetes and/or diabetes without microvascular complications, 26 with diabetic sensorimotor neuropathy (SMN) and 26 with SMN and previous history of diabetic foot amputation). The SMN was diagnosed on the basis of patients complaints, anamnesis and data of clinical neurological examinations. CAN was detected using several cardiovascular autonomic reflex tests (CART) as a gold standard of diagnosis: the tilt-table test, a deepbreathing and Valsalva Maneuver, handgrip test, cold-stress vasoconstriction. According to the Toronto Diabetic Neuropathy Expert Group Recommendation all patients was separated on the groups: CAN 0 (all CARTs were normal), CAN 1 (possible/early CAN — one abnormal CART was presented), CAN 2 (definite/confirmed CAN –at least two abnormal CARTs were found), CAN 3 (severe/advanced CAN — in the cases of orthostatic hypotension in addition to CARTs abnormalities). Microvascular blood flow of skin at the nail roller of fingers skin was valuated at rest as well as in functional cold test by the method of High-frequency Ultrasonic Dopplerography using the “Minimax Doppler K” device (LLC JV “Minimax”, St. Petersburg, Russia).

RESULTS

RESULTS: CAN 1 was found in 8% diabetic patients without microvascular complications, 42 and 21% patients with SMN and diabetic foot amputations respectively. CAN 2 was diagnosed in 27% patients with SMN and 58% patients history of diabetic foot amputations. CAN 3 in 8% and 19% cases in patients with SMN and history of diabetic foot amputations respectively. The parameters of microvascular blood flow at rest were significantly decreased in patients with confirmed/severe CAN in comparison with early staging of CAN and patients without CAN (Vm=2.5±0.66 sm/sec vs. 4.4±0.54 sm/sec and 5.1±1.01 sm/sec respectively; p=0.0033). The abnormal result of cold test was detected in 94% patients with confirmed/ severe CAN and 26% patients with CAN 1.

CONCLUSIONS

CONCLUSIONS: This investigation has demonstrated in a cohort with type 2 diabetes patients with/without SMN and with/ without history of previously foot amputations that decrease the Vm (the variable of microvascular blood flow assessed by High-frequency Ultrasonic Dopplerography) lower than 2.4 sm/sec is associated with 6.4 times increased likelihood of confirmed/severe CAN as well as positive cold test result. That the patients with positive cold test results were 28.6 times more likely have confirmed/severe CAN.

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The authors declare that there are no conflicts of interest present.