Albuminuria Reduction after High Dose of Vitamin D in Patients with Type 1 Diabetes Mellitus: A Pilot Study

BackgroundSome studies suggest an association between diabetic kidney disease (DKD) and vitamin D (VD), but there is no data about the effect of high dose of VD on DKD in type 1 diabetes mellitus (T1DM). Our pilot study aims to evaluate albuminuria reduction in patients with T1DM supplemented with high dose of VD.Methods22 patients received doses of 4,000 and 10,000 IU/day of cholecalciferol for 12 weeks according to patient’s previous VD levels. They were submitted to continuous glucose monitoring system, 24 hours ambulatory blood pressure monitoring and urine albumin-to-creatinine ratio before and after VD supplementation.ResultsThere was a reduction of DKD prevalence at the end of the study (68 vs 32%; p = 0.05), with no changes on insulin doses, glycated hemoglobin, glycemic variability and blood pressure values. A correlation between percentage variation of VD levels (ΔVD) and albuminuria at the end of the study was presented (r = −0.5; p < 0.05). Among T1DM patients with DKD at the beginning of the study, 8/13 (62%) had their DKD stage improved, while the other five ones (38%) showed no changes (p < 0.05).ConclusionOur pilot study suggests an association between VD high dose supplementation, lower prevalence and improvement in stages of DKD in T1DM

Influência da suplementação de altas doses de vitamina D no controle glicêmico em pacientes com diabetes mellitus tipo 1

Although the intensive glycemic control of Diabetes Mellitus (DM) with insulin has reduced the incidence of microvascular and macrovascular complications, most patients still develop these injuries with high morbidity and mortality. It has been suggested that low levels of vitamin D (VD) may be associated with the development of Type 1 diabetes mellitus (DM1) and poor glycemic control. As a therapeutic potential, the use of VD in patients with DM1 has presented controversial results regarding the reduction of glucose levels. The objective of this study is to analyze the effects of high-dose vitamin D supplementation on glycemic control of patients with DM1, assessed through glycated hemoglobin levels (HbA1c). A prospective, 12week clinical trial including 52 patients with DM1, which were supplemented with high doses of cholecalciferol, was performed. The dose used for this vitamin was according to the participant's VD value. Patients with VD levels below 30 ng / mL received 10,000 IU / day, and when 30-60 ng / mL, they used 4,000 IU / day. The levels of VD and HbA1c were evaluated before and after 3 months of vitamin supplementation. When we analyzed the total number of patients (N = 52), there was no improvement in the glycemic control evaluated by HbA1c ((9.3 ± 2.3 vs 9.5 ± 2.4, p=NS). To better study the effects of VD on HbA1c, patients were divided into 3 groups according to HbA1c variation: those whose HbA1c reduced ≥ 0.5% (group 1, N = 14); those with no variation in HbA1c (group 2, N = 19) and those with ≥ 0.5% increase in HbA1c (group 3, N = 24). There was a decrease in HbA1c in only one specific group (N = 14). In addition, there was no reduction in prandial basal insulin needs or full dose after three months of VD supplementation. Thus, our data suggest that there is no additional benefit of VD supplementation in the optimization of glycemic control evaluated by HbA1C in patients with DM1.Embora o controle glicêmico intensivo do Diabetes Mellitus (DM) com insulina tenha reduzido a incidência de complicações microvasculares e macrovasculares, a maioria dos pacientes ainda desenvolve essas injúrias com elevada morbimortalidade. Tem sido sugerido que baixos níveis de vitamina D (VD) podem estar associados com desenvolvimento de Diabetes Mellitus tipo 1 (DM1) e controle glicêmico precário. Como potencial terapêutico, a utilização de VD em pacientes com DM1 tem apresentado resultados controversos no que diz respeito à redução dos níveis de glicose. O objetivo deste estudo é analisar os efeitos da suplementação de altas doses de vitamina D no controle glicêmico de pacientes com DM1, avaliado através dos níveis da hemoglobina glicada (HbA1c). Foi realizado um ensaio clínico prospectivo, com duração de 12 semanas, incluindo 52 pacientes portadores de DM1, os quais foram suplementados com altas doses de colecalciferol. A dose utilizada dessa vitamina foi de acordo com o valor sérico da VD do participante. Pacientes com níveis de VD inferiores a 30 ng/mL, receberam 10.000 UI/ dia, e quando de 30 a 60 ng/mL, utilizaram 4.000 UI/dia. Os níveis de VD e HbA1c foram avaliados antes e após 3 meses de suplementação dessa vitamina. Quando analisamos o total de pacientes (N= 52), não houve melhora do controle glicêmico avaliado pela HbA1c. Para melhor estudar os efeitos da VD sobre a HbA1c, os pacientes foram divididos em 3 grupos de acordo com a variação da HbA1c: aqueles cuja HbA1c reduziu ≥ 0,5% (grupo 1, N= 13); aqueles sem variação na HbA1c (grupo 2, N= 19) e aqueles com aumento ≥ 0,5% na HbA1c (grupo 3, N= 20). Houve diminuição da HbA1c apenas em um grupo específico (N= 13). Adicionalmente, não ocorreu redução nas necessidades das insulinas basais, prandiais e nem na dose total, após os três meses da suplementação com VD. Assim, nossos dados sugerem que não haja benefício adicional da suplementação de VD na otimização do controle glicêmico avaliado pela HbA1c em pacientes com DM1.HUJBB - Hospital Universitário João de Barros Barret

The Ankle-Arm Index As a Predictive Risk Factor For Peripheral Arterial Disease In Patients With In Patients With Type 2 Diabetes Mellitus

Background: Peripheral arterial disease in patients with type 2 diabetes mellitus is an important risk factor for vascular events. Recommendations about whether ankle-brachial index should be performed differ depending on the source; therefore, it is necessary to re-evaluate the most important risk factors associated with peripheral arterial disease and whether it is useful to perform ankle-brachial index in newly diagnosed and drug-naïve patients with diabetes, independent of age or peripheral arterial disease symptoms. Methods: A total of 711 subjects were divided into groups: group 1, 600 type 2 diabetes mellitus patients, symptomatic or not for peripheral arterial disease; group 2, 61 type 2 diabetes mellitus patients newly diagnosed and drug naïve; and group 3, 50 subjects without diabetes. Ankle-brachial index, medical records and physical examination were performed in all patients, accessing cardiovascular risk factors. Results: Analysing group 1 asymptomatic patient to peripheral arterial disease, we found abnormal ankle-brachial index in 49% (77/156) ⩾50years and 42% (16/38) <50years (p=not significant). Considering drug-naïve patients, a peripheral arterial disease prevalence of 39% (24/61) was found; among these, 48% (13/27) were <50years and 32% (11/34) were ⩾50years (p=not significant). A forward stepwise regression model was developed, with type 2 diabetes mellitus duration (r2=0.12) and sedentary lifestyle (r2=0.14) found as independent variable predictors of severity of peripheral arterial disease, related to ankle-brachial index. Conclusion: We suggest that, in type 2 diabetes mellitus, ankle-brachial index should be measured at diagnosis. In addition, sedentary lifestyle was strongly associated with presence and severity of peripheral arterial disease

Cochlear dysfunction and microvascular complications in patients with type 1 diabetes mellitus

Abstract Sensorineural hearing impairment has been associated with DM, and it is probably linked to the same pathophysiological mechanisms as well-established in microvascular diabetes complications. The study of otoacoustic emissions (OAEs) is useful to identify subclinical cochlear dysfunction. Therefore, the aim of this study was to evaluate the association between abnormal OAEs responses, diabetic kidney disease (DKD) and diabetic cardiac autonomic neuropathy (CAN). We performed a cross-sectional study with 37 type 1 DM patients without auditory symptoms, submitted to the study of Distortion Product Otoacoustic Emissions (DPOAEs) and screened for DKD and CAN. The otoacoustic emissions responses were considered abnormal in 27/37 (73%) patients. A correlation was found between abnormal OAEs responses and presence of DKD (r = 0.36, p < 0.05), and 14/16 (88%) patients with a lower amplitude of OAEs in 8 kHz frequency band presented DKD. Abnormal OAEs responses in the 6 kHz frequency band were correlated with the presence (r = 0.41, p = 0.01) and severity of CAN (r = 0.44, p < 0.001). Additionally, 7/9 (78%) patients with abnormal OAE responses in this frequency also presented abnormal CAN scores. Our results suggest that abnormal otoacoustic emissions responses in high frequency bands are associated with diabetes microvascular complications and could be a risk marker for DKD and CAN, presenting low sensitivity and high specificity. Therefore, assuming that hearing impairment is a pre-clinical stage of hearing loss, performing distortion product otoacoustic emissions in T1DM patients with microvascular complications could be useful to identify those who would be benefit with regular audiologic follow up and tighter diabetes control