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      The Influence of Glycemic Control on the Prognosis of Japanese Patients Undergoing Percutaneous Transluminal Angioplasty for Critical Limb Ischemia

      , MD 1 , , MD, PHD 1 , , MD 2 , , MD, PHD 2 , , MD, PHD 1 , , MD, PHD 1 , , MD, PHD 2 , , MD, PHD 1

      Diabetes Care

      American Diabetes Association

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          Abstract

          OBJECTIVE

          To reveal the influence of preoperative factors on the prognosis of patients undergoing percutaneous transluminal angioplasty (PTA) for critical limb ischemia (CLI).

          RESEACH DESIGN AND METHODS

          We recruited 278 Japanese patients who underwent PTA for CLI between 2003 and 2009. The outcome measures were mortality and major amputation. Cox proportional hazards regression analyses were performed.

          RESULTS

          The prevalence of diabetes was 71%, and A1C was 7.0 ± 1.4%. The follow-up period was 90 ± 72 weeks, and 48 patients underwent major amputations and 89 died. The presence of diabetes in the whole population and A1C level in the diabetic population had no influence on morality; rather, mortality was associated with age ( P = 0.007), impaired activities of daily living ( P < 0.001), hemodialysis ( P < 0.001), and albumin level ( P = 0.010). In contrast, the presence of diabetes and A1C level had significant association with major amputation ( P = 0.012 and P = 0.007, respectively). The quartile analysis showed that diabetic subjects with an A1C ≥6.8%, but not <6.8%, had a significantly higher risk of major amputation than nondiabetic subjects. The adjusted hazard ratio of diabetes with A1C ≥6.8% was 2.907 (95% CI 1.606–5.264) ( P < 0.001).

          CONCLUSIONS

          Diabetes with poor glycemic control is associated with major amputation, but not mortality, in CLI patients undergoing PTA. Prognostic indicators seem somewhat different between survival and limb salvage in the population.

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          Most cited references 18

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          Management of peripheral arterial disease (PAD). TASC Working Group. TransAtlantic Inter-Society Consensus (TASC).

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            Influence of diabetes and hyperglycaemia on infectious disease hospitalisation and outcome.

            Diabetes mellitus is believed to increase susceptibility to infectious diseases. The effects of hyperglycaemia per se on infectious disease risk are unknown and the influence of diabetes on infectious disease outcome is controversial. We studied 10,063 individuals from the Danish general population, who were participants in The Copenhagen City Heart Study, over a follow-up period of 7 years. Risk of hospitalisation caused by any infectious disease, and subsequent risk of disease progression to death were estimated by Cox proportional hazards regression analysis. At baseline, 353 individuals reported having diabetes. During 71,509 person-years of follow-up, a total of 1,194 individuals were hospitalised because of an infection. The risk of pneumonia (adjusted hazard ratio [aHR] 1.75, 95% CI 1.23-2.48), urinary tract infection (aHR 3.03, 95% CI 2.04-4.49) and skin infection (aHR 2.43, 95% CI 1.49-3.95) was increased in subjects with diabetes compared with subjects without. Each 1 mmol/l increase in plasma glucose at baseline was associated with a 6-10% increased relative risk of pneumonia, urinary tract infection and skin infection after adjustment for other possible confounders. Among patients hospitalised for urinary tract infection, diabetic patients were at an increased risk of death at 28 days after admission compared with non-diabetic subjects (HR 3.90, 95% CI 1.20-12.66). In the Danish general population, diabetes and hyperglycaemia are strong and independent risk factors for hospitalisation as a result of pneumonia, urinary tract infection and skin infection. Further, diabetes has a negative impact on the prognosis of urinary tract infection.
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              Acute hyperglycemia and the innate immune system: clinical, cellular, and molecular aspects.

              To extract from the biomedical literature the reported effects of acute hyperglycemia on the major components of the innate immune system and to describe the clinical benefits of strict blood glucose control in certain patients. A Medline/PubMed search (1966 to July 2004) with manual cross-referencing was conducted, including all relevant articles investigating the effects of acutely elevated glucose levels on innate immunity. All publication types, languages, or subsets were searched. Original and selected review articles, short communications, letters to the editor, and chapters of selected textbooks were extracted. Most recent and relevant clinical trials were reviewed for the introductory section to provide the clinical background to this topic. The selected bench laboratory articles were then divided into three main categories based on the timing of events: a) the early phase of the innate immune reaction; b) the cytokine network; and c) the phagocytic phase. The most obvious findings related to hyperglycemia included reduced neutrophil activity (e.g., chemotaxis, formation of reactive oxygen species, phagocytosis of bacteria), despite accelerated diapedesis of leukocytes into peripheral tissue, as well as specific alterations of cytokine patterns with increased concentrations of the early proinflammatory cytokines tumor necrosis factor-alpha and interleukin-6. Furthermore, a reduction of endothelial nitric oxide formation takes place, thus decreasing microvascular reactivity to dilating agents such as bradykinin, and complement function (e.g., opsonization, chemotaxis) is impaired, despite elevations of certain complement factors. Acute, short-term hyperglycemia affects all major components of innate immunity and impairs the ability of the host to combat infection, even though certain distinctive proinflammatory alterations of the immune response can be observed under these conditions.
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                Author and article information

                Journal
                Diabetes Care
                diacare
                dcare
                Diabetes Care
                Diabetes Care
                American Diabetes Association
                0149-5992
                1935-5548
                December 2010
                15 September 2010
                : 33
                : 12
                : 2538-2542
                Affiliations
                1Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan;
                2Department of Internal Medicine, Kansai Rosai Hospital, Hyogo, Japan.
                Author notes
                Corresponding author: Hideaki Kaneto, kaneto@ 123456endmet.med.osaka-u.ac.jp .
                Article
                0939
                10.2337/dc10-0939
                2992184
                20843974
                © 2010 by the American Diabetes Association.

                Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

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                Categories
                Original Research
                Clinical Care/Education/Nutrition/Psychosocial Research

                Endocrinology & Diabetes

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