Annals of Geriatric Medicine and Research

The Korean Geriatrics Society (대한노인병학회)
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Relationship between Glycemic Control and Diabetic Retinopathy

혈당관리 수준과 당뇨병성 망막증과의 관련성

  • Yun, Woo-Jun (Department of Preventive Medicine, Chonnam National University Medical School)
  • 윤우준 (전남대학교 의과대학 예방의학교실)
  • Published : 2010.12.31
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Abstract

Background: The prevalence of diabetes mellitus (DM) is higher in old age, and diabetic retinopathy is the leading cause of blindness. Appropriate glycemic control is known to reduce the incidence of diabetic retinopathy in diabetic patients. We evaluated the relationship between hemoglobin A1c levels and diabetic retinopathy. Methods: Our subjects included 654 diabetic patients registered with the public health center. Following an overnight fast, venous blood and urine samples were collected and analyzed. Non-mydriatic fundus photography was done to diagnosis diabetic retinopathy. We calculated the odds ratios of hemoglobin A1c and fasting plasma glucose for diabetic retinopathy using logistic regression. Results: Diabetic retinopathy was seen significantly more often at higher levels of hemoglobin A1c (odds ratio, 3.46; 95 % confidence interval, 1.90-6.30 for <50 percentile vs. >75 percentile). Fasting glucose, however, was not significantly associated with diabetic retinopathy after adjusting for hemoglobin A1c (Hb1cA). The odds ratio for diabetic retinopathy according to HbA1c was higher in those with DM for >10 years than <10 years. Conclusion: The HbA1c level was significantly associated with diabetic retinopathy in Koreans with type 2 diabetes.

연구배경: 당뇨병의 유병률이 전 세계적으로 증가하고 있으며, 당뇨병으로 인한 사회경제적 부담 역시 증가하고 있다. 우리 나라에서도 당뇨병이 증가하고 있는 추세이며, 특히 연령이 높을수록 유병률이 높다. 당뇨병성 망막증은 신증 및 신경병증과 더불어 당뇨병의 대표적인 미세혈관 합병증이며, 실명의 가장 흔한 원인이지만, 효과적인 혈당관리는 당뇨병성 망막증 발생을 줄일 수 있다고 알려졌다. 본 연구에서는 혈당수준을 반영하는 당화혈색소를 이용하여 보건소에 등록되어 관리되고 있는 당뇨병 환자들에서 혈당 조절 수준과 당뇨병성 망막증과의 관련성에 대해 알아보고자 하였다. 방법: 광주광역시 일개 보건소와 전라남도 일개 보건의료원에 등록되어 있는 1,275명의 당뇨병 환자들 중 654명을 최종 연구 대상자로 하였다. 혈액검사는 모든 대상자에서 최소한 12시간 이상 금식을 한 뒤 채취한 정맥혈을 이용하였다. 공복혈당은 자동 분석기(Hitachi-7600 Chemical Analyzer)를 이용하여 측정하였으며 효소법으로 검사하였다. 당화혈색소는 DCCT 분석에 표준화된 VARIANT II를 이용한 HPLC방법으로 측정하였다. 공복혈당과 당화혈색소의 검사 차례내(within-run) 변이계수는 각각 0.96%, 0.29%이었다. Topcon TRC-NW200 Non-Mydriatic Digital Retinal Camera (Topcon Co.)를 이용하여 무산동 안저촬영(non-mydriatic fundus photography)을 하였다. 촬영된 안저 사진은 안과 전문의에 의해 판독되었으며, Modified Airlie House 분류법을 사용하여 중증도(moderate), 중증(severe) 비증식성과 증식성 당뇨병성 망막증으로 분류하였다. 결과: 비망막군과 당뇨병성 망막군 사이에 당화혈색소, 공복혈당, 신체질량지수, 당뇨병 기간이 유의한 차이를 나타났으나, 수축기혈압, 이완기혈압, 총 콜레스테롤, 중성지방, 고밀도 지단백 콜레스테롤, 그리고 흡연율은 두 군 사이에 유의한 차이가 없었다. 당화혈색소가 증가할수록 당뇨병성 망막증의 위험도가 높았다(OR, 3.46; 95% CI, 1.90-6.30 for <50 percentile vs. >75 percentile). 체내 혈당 수준을 나타낼 수 있는 다른 지표인 공복혈당의 경우 당화혈색소를 보정한 분석에서는 당뇨병성 망막증과의 관련성을 보이지 않았다(OR, 1.23; 95% CI, 0.67-2.24 for <50 percentile vs. >75percentile). 당뇨병 이환기간이 10년 이상인 군이 10년 미만인 군에 비해 당화혈색소 증가에 따른 당뇨병성 망막증의 위험도가 더 높았다(0.61 vs. 6.72 for 51-75 percentile; 3.12 vs. 5.36 for >75 percentile). 결론: 혈당관리 수준이 낮을수록 당뇨병성 망막증의 위험이 높았으며, 당뇨병 이환 기간이 긴 경우 위험도가 더 높았다. 또한 혈당관리 수준을 나타내는 지표로서 당화혈색소가 공복혈당에 비해 당뇨병성 미세혈관 합병증의 위험도를 예측하는데 더 우수함을 보여주고 있다. 당뇨병 환자들에서 미세혈관 합병증을 예방하기 위해서는 당뇨병 초기에 당화 혈색소 측정을 통한 혈당 관리 수준 파악이 중요할 것으로 보이며, 당뇨병 환자를 관리하는데 있어 이러한 점들이 우선적으로 강조되어야 할 것이다.

Keywords

References

  1. Pan WH, Cedres LB, Liu K, Dyer A, Schoenberger JA, Shekelle RB, et al. Relationship of clinical diabetes and asymptomatic hyperglycemia to risk of coronary heart disease mortality in men and women. Am J Epidemiol 1986;123:504-16. https://doi.org/10.1093/oxfordjournals.aje.a114266
  2. Stamler J, Vaccaro O, Neaton JD, Wentworth D. Diabetes, other risk factors, and 12-yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 1993;16:434-44. https://doi.org/10.2337/diacare.16.2.434
  3. Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabet Med 1997;14 Suppl 5:S1-85.
  4. Park Y, Lee H, Koh CS, Min H, Yoo K, Kim Y, et al. Prevalence of diabetes and IGT in Yonchon County, South Korea. Diabetes Care 1995;18:545-8. https://doi.org/10.2337/diacare.18.4.545
  5. Kim SM, Lee JS, Lee J, Na JK, Han JH, Yoon DK, et al. Prevalence of diabetes and impaired fasting glucose in Korea: Korean National Health and Nutrition Survey 2001. Diabetes Care 2006;29:226-31. https://doi.org/10.2337/diacare.29.02.06.dc05-0481
  6. Korea Center for Disease Control and Prevention; Yonsei University. In-deep analyses of the third national health and nutrition examination survery: the health examination part. Seoul: Korea Center for Disease Control and Prevention; 2007. p. 135.
  7. Korea National Statistical Office. 2003 Annual report on the cause of death statistics. Daejeon: Korea National Statistical Office; 2005.
  8. Fong DS, Aiello LP, Ferris FL 3rd, Klein R. Diabetic retinopathy. Diabetes Care 2004;27:2540-53. https://doi.org/10.2337/diacare.27.10.2540
  9. Congdon NG, Friedman DS, Lietman T. Important causes of visual impairment in the world today. JAMA 2003;290:2057-60. https://doi.org/10.1001/jama.290.15.2057
  10. IDF DIABETES ATLAS. Diabetes atlas - 2007 (3rd edition) [Internet]. Brussels: International Diabetes Federation - atlas; c2010. [cited 2010 Aug 15]. Available from: http://www.diabetesatlas.org/sites/default/files/IDF%20 Diabetes %20Atlas-2007%20(3rd%20edition).pdf.
  11. Saaddine JB, Honeycutt AA, Narayan KM, Zhang X, Klein R, Boyle JP. Projection of diabetic retinopathy and other major eye diseases among people with diabetes mellitus: United States, 2005-2050. Arch Ophthalmol 2008;126:1740-7. https://doi.org/10.1001/archopht.126.12.1740
  12. Cheung N, Wong TY. Diabetic retinopathy and systemic vascular complications. Prog Retin Eye Res 2008;27:161-76. https://doi.org/10.1016/j.preteyeres.2007.12.001
  13. Zhang X, Saaddine JB, Chou CF, Cotch MF, Cheng YJ, Geiss LS, et al. Prevalence of diabetic retinopathy in the United States, 2005-2008. JAMA 2010;304:649-56. https://doi.org/10.1001/jama.2010.1111
  14. Nathan DM, Singer DE, Hurxthal K, Goodson JD. The clinical information value of the glycosylated hemoglobin assay. N Engl J Med 1984;310:341-6. https://doi.org/10.1056/NEJM198402093100602
  15. Goldstein DE. Is glycosylated hemoglobin clinically useful? N Engl J Med 1984;310:384-5. https://doi.org/10.1056/NEJM198402093100609
  16. Klein R. Hyperglycemia and microvascular and macrovascular disease in diabetes. Diabetes Care 1995;18:258-68. https://doi.org/10.2337/diacare.18.2.258
  17. Klein R, Klein BE, Moss SE. Relation of glycemic control to diabetic microvascular complications in diabetes mellitus. Ann Intern Med 1996;124(1 Pt 2):90-6. https://doi.org/10.7326/0003-4819-124-1_Part_2-199601011-00003
  18. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86. https://doi.org/10.1056/NEJM199309303291401
  19. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53. https://doi.org/10.1016/S0140-6736(98)07019-6
  20. Polak BC, Crijns H, Casparie AF, Niessen LW. Cost-effectiveness of glycemic control and ophthalmological care in diabetic retinopathy. Health Policy 2003;64:89-97. https://doi.org/10.1016/S0168-8510(02)00143-4
  21. Choi SW, Yun WJ, Kim HY, Lee YH, Kweon SS, Rhee JA, et al. Association between albuminuria, carotid atherosclerosis, arterial stiffness, and peripheral arterial disease in Korean type 2 diabetic patients. Kidney Blood Press Res 2010;33:111-8. https://doi.org/10.1159/000313594
  22. Yun WJ, Shin MH, Kweon SS, Park KS, Lee YH, Nam HS, et al. A comparison of fasting glucose and HbA1c for the diagnosis of diabetes mellitus among Korean adults. J Prev Med Public Health 2010;43:451-4. https://doi.org/10.3961/jpmph.2010.43.5.451
  23. Diabetic retinopathy study. Report Number 6. Design, methods, and baseline results. Report Number 7. A modification of the Airlie House classification of diabetic retinopathy. Prepared by the Diabetic Retinopathy. Invest Ophthalmol Vis Sci 1981;21(1 Pt 2):1-226.
  24. Krolewski AS, Canessa M, Warram JH, Laffel LM, Christlieb AR, Knowler WC, et al. Predisposition to hypertension and susceptibility to renal disease in insulin-dependent diabetes mellitus. N Engl J Med 1988;318:140-5. https://doi.org/10.1056/NEJM198801213180303
  25. Molitch ME, Steffes MW, Cleary PA, Nathan DM. Baseline analysis of renal function in the Diabetes Control and Complications Trial. The Diabetes Control and Complications Trial Research Group [corrected]. Kidney Int 1993;43:668-74. https://doi.org/10.1038/ki.1993.96
  26. Dahl-Jorgensen K, Bjoro T, Kierulf P, Sandvik L, Bangstad HJ, Hanssen KF. Long-term glycemic control and kidney function in insulin-dependent diabetes mellitus. Kidney Int 1992;41:920-3. https://doi.org/10.1038/ki.1992.140
  27. Barzilay J, Warram JH, Bak M, Laffel LM, Canessa M, Krolewski AS. Predisposition to hypertension: risk factor for nephropathy and hypertension in IDDM. Kidney Int 1992;41:723-30. https://doi.org/10.1038/ki.1992.113
  28. The Diabetes Control and Complications Trial (DCCT). Design and methodologic considerations for the feasibility phase. The DCCT Research Group. Diabetes 1986;35:530-45. https://doi.org/10.2337/diabetes.35.5.530
  29. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53. https://doi.org/10.1016/S0140-6736(98)07019-6
  30. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86. https://doi.org/10.1056/NEJM199309303291401
  31. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the diabetes control and complications trial. Diabetes 1995;44:968-83. https://doi.org/10.2337/diabetes.44.8.968
  32. Reichard P, Nilsson BY, Rosenqvist U. The effect of longterm intensified insulin treatment on the development of microvascular complications of diabetes mellitus. N Engl J Med 1993;329:304-9. https://doi.org/10.1056/NEJM199307293290502
  33. Selvin E, Steffes MW, Zhu H, Matsushita K, Wagenknecht L, Pankow J, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010;362:800-11. https://doi.org/10.1056/NEJMoa0908359
  34. Kim HY, Yun WJ, Shin MH, Kweon SS, Ahn HR, Choi SW, et al. Management of diabetic mellitus in low-income rural patients. J Prev Med Public Health 2009;42:315-22. https://doi.org/10.3961/jpmph.2009.42.5.315
  35. Larsen ML, Horder M, Mogensen EF. Effect of long-term monitoring of glycosylated hemoglobin levels in insulindependent diabetes mellitus. N Engl J Med 1990;323:1021-5. https://doi.org/10.1056/NEJM199010113231503

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