Correspondence
Vascular Risk Factors and Diabetic Neuropathy
N Engl J Med 2005; 352:1925-1927May 5, 2005
- Article
To the Editor:
In the article by Tesfaye et al. (Jan. 27 issue)1 on the European Diabetes (EURODIAB) Prospective Complications Study, which looked at modifiable risk factors for diabetic neuropathy, the first line of the abstract states, “Other than glycemic control, there are no treatments for diabetic neuropathy.” Although there have been no prospective, randomized trials to date, there is a growing literature regarding the role of nerve decompression in carefully selected patients with diabetic distal, large-fiber, symmetric polyneuropathy.
A recent analysis of 50 patients with diabetes who underwent decompression of the tibial and peroneal nerves in one leg and not the other showed that no ulcers or amputations occurred in the leg that had been operated on, whereas in 15 patients, there were 12 ulcers and three amputations in the unoperated leg, with an average follow-up of 4.5 years (P<0.001).2 A recent review that included our series of 25 patients showed that “in properly selected patients, surgical releases can decrease pain and improve sensation.”3
3 ReferencesGedge D. Rosson, M.D.
A. Lee Dellon, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21287
gedge@jhmi.edu 1
Tesfaye S ,Chaturvedi N ,Eaton SEM , et al. Vascular risk factors and diabetic neuropathy. N Engl J Med 2005;352:341-350
Full Text | Web of Science | Medline2
Aszmann O ,Tassler PL ,Dellon AL . Changing the natural history of diabetic neuropathy: incidence of ulcer/amputation in the contralateral limb of patients with a unilateral nerve decompression procedure. Ann Plast Surg 2004;53:517-522
CrossRef | Web of Science | Medline3
Biddinger KR ,Amend KJ . The role of surgical decompression for diabetic neuropathy. Foot Ankle Clin 2004;9:239-254
CrossRef | Medline
To the Editor:
Tesfaye et al. report that the incidence of diabetic neuropathy is associated with a history of cardiovascular disease at baseline and with cardiovascular risk factors. Additional information might further elucidate their important findings.
About 35 percent of the patients who qualified for follow-up either did not reach follow-up or were not assessed for neuropathy. Although the authors compared baseline data between patients who were assessed and those who were not, data on two of the major risk factors they identified (i.e., cardiovascular disease and smoking) were not included in that comparison. This raises the question of whether those data were collected only retrospectively, at the time of assessment for neuropathy, with a possibility of recall bias. If that is not the case, it is important to know whether there was differential loss to follow-up with regard to these factors, which could potentially compromise validity. Additional information on the role of variables known to be associated both with vascular risk factors and glycemic control and with the risk of diabetic complications — specifically, socioeconomic status,1,2 ethnic group,3 and the presence or absence of depression4 — would be instructive.
4 ReferencesRaz Gross, M.D., M.P.H.
Columbia University Medical Center, New York, NY 10032
rg547@columbia.edu 1
Chaturvedi N ,Stephenson JM ,Fuller JH . The relationship between socioeconomic status and diabetes control and complications in the EURODIAB IDDM Complications Study. Diabetes Care 1996;19:423-430
CrossRef | Web of Science | Medline2
Connolly VM ,Kesson CM . Socioeconomic status and clustering of cardiovascular disease risk factors in diabetic patients. Diabetes Care 1996;19:419-422
CrossRef | Web of Science | Medline3
Lavery LA ,Ashry HR ,van Houtum W ,Pugh JA ,Harkless LB ,Basu S . Variation in the incidence and proportion of diabetes-related amputations in minorities. Diabetes Care 1996;19:48-52
CrossRef | Web of Science | Medline4
de Groot M ,Anderson R ,Freedland KE ,Clouse RE ,Lustman PJ . Association of depression and diabetes complications: a meta-analysis. Psychosom Med 2001;63:619-630
Web of Science | Medline
To the Editor:
Tesfaye et al. report that, apart from glycemic control, the incidence of neuropathy in a European cohort of patients with type 1 diabetes was associated with potentially modifiable cardiovascular risk factors, including a raised triglyceride level, a high body-mass index, smoking, and hypertension. We analyzed the database of subjects with type 2 diabetes who had participated in our Japan Diabetes Complications Study1-3 for factors that were associated with neuropathy, defined as either the lack of an ankle tendon reflex or the development of abnormal sensation. During the seven-year study, neuropathy developed in 332 of 1618 patients. Odds ratios were calculated with the use of most of the variables included in the study by Tesfaye et al., and we similarly controlled for the glycosylated hemoglobin level and the duration of diabetes. Our data indicate that only obesity was a risk factor for neuropathy in our Japanese subjects (Table 1Table 1
Risk Factors for Neuropathy after Adjustment for Glycosylated Hemoglobin and Duration of Diabetes in 1618 Japanese Patients with Type 2 Diabetes.). These results support the notion that risk factors for diabetic neuropathy vary depending on the ethnic group of patients and on the type of diabetes.3 ReferencesHirohito Sone, M.D., Ph.D.
University of Tsukuba, Tsukuba 305-8575, JapanSachiko Mizuno, Ph.D.
University of Tokyo, Tokyo 113-0033, JapanNobuhiro Yamada, M.D., Ph.D.
University of Tsukuba, Tsukuba 305-8575, Japan
jdcstudy@mc.tsukuba. ac. jp 1
Sone H ,Katagiri A ,Ishibashi S , et al. Effects of lifestyle modifications on patients with type 2 diabetes: the Japan Diabetes Complications Study (JDCS) study design, baseline analysis and three year-interim report. Horm Metab Res 2002;34:509-515
CrossRef | Web of Science | Medline2
Sone H ,Ito I ,Ohashi Y ,Akanuma Y ,Yamada N . Obesity and type 2 diabetes in Japanese patients. Lancet 2003;361:85-85
CrossRef | Web of Science | Medline3
Sone H ,Yoshimura Y ,Ito H ,Ohashi Y ,Yamada N . Energy intake and obesity in Japanese patients with type 2 diabetes. Lancet 2004;363:248-249
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Gross comments on the completeness of information and follow-up. None of the data in the EURODIAB Prospective Complications Study were collected retrospectively. Recall bias is therefore not an issue. When we compare the presence of cardiovascular disease and smoking at baseline between patients with and those without a full neuropathy assessment at follow-up, we find no significant difference in the prevalence of cardiovascular disease at baseline. There were 6 percent more smokers among those who did not have a neuropathy assessment at follow-up. A possible consequence of the association between patients who were lost to follow-up and a slightly higher cardiovascular risk profile might be that our results underestimate the true incidence of neuropathy. However, loss of patients to follow-up is unlikely to bias observed associations between risk factors and disease, because a situation in which a poor cardiovascular risk profile reduces the risk of neuropathy in those lost to follow-up and increases the risk in those returning for follow-up is unlikely. All study centers were instructed not to include subjects from ethnic minority groups, since this would have generated small but extremely heterogeneous subgroups. The population of the EURODIAB Prospective Complications Study can thus be regarded as white European. Because of the varying situations in the 15 countries from which participants were recruited, it was difficult to assess socioeconomic status. Information was gathered concerning higher education; however, adjustment for this variable did not affect our findings. Information on depression was not collected, although we think that depression may be more a consequence of rather than a cause of diabetic complications.
We are aware of surgical decompression of peripheral nerves as a possible treatment for diabetic distal symmetric polyneuropathy. However, the review cited in the letter by Drs. Rosson and Dellon concludes that “the role that this surgery can play remains controversial.”1 Thus, this promising form of treatment will need to be confirmed in a randomized controlled trial involving several centers.
1 ReferencesSolomon Tesfaye, M.D.
Royal Hallamshire Hospital, Sheffield S10 2JF, United Kingdom
solomon.tesfaye@sth. nhs. uk Daniel R. Witte, Ph.D.
John H. Fuller, M.A.
Royal Free and University College Medical School, London WC1E 6BT, United Kingdom- Citing Articles (4)
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