Correlation between Retinopathy, Nephropathy and Peripheral Neuropathy among Adult Sudanese Diabetic Patients

: Diabetes Mellitus is a worldwide common metabolic disorder. Increasing prevalence of diabetes, lack of proper education about the nature and course of the disease and necessary control are the main factors for an early onset of micro vascular complications. Objective: To correlate between retinopathy, nephropathy and neuropathy, among adult Sudanese diabetic patients at Elshaab Teaching hospital, Ahmed Gasim Teaching hospital and Gabber Abu Eleaz centre, from December 2006 to September 2008. Methodology: This is a descriptive prospective cross sectional hospital based study, 71 patients were included. Result: Male to female ratio was1.4:1.Common age group affected was 60-69 (32.4%).Common duration of diabetes mellitus was 20-24 years (23.9%).All patients who had diabetes for 25 years or more had developed complications (19.7%).The commonest long term microvascular complication was found to be retinopathy (71.2%), followed by neuropathy (69 %) and nephropathy (50.7%).It was found that (47.6%) of our patients had the three complications. Conclusion: Long-term micro vascular complications affect male more than female, with average age of onset 60-69 years. All patients who had diabetes for 25 years or more had developed complications. Retinopathy is the most common micro vascular complication, followed by neuropathy. There is a significant correlation between retinopathy, nephropathy and neuropathy in association with the duration and control of blood glucose level.

iabetes mellitus (DM) comprises a group of common metabolic disorders that share the phenotype of hyperglycemia 1 .Several distinct types of DM exist and are caused by complex interactions of genetics, environmental factors and life style choices 2 .With an increasing incidence world-wide, DM will likely to continue to be a leading cause of morbidity and mortality 3 .Depending on the etiology of DM, factors contributing to hyperglycemia may include reduced insulin secretion, decreased glucose usage and increased glucose production 4 .The metabolic dys-regulation associated with DM causes secondary pathophysiologic changes in multiple organ systems that imposes tremendous burden on the individual and on the health care system 5 .*Corresponding author: Dr. Abbashar Hussein Mohmad, Asso.Prof of Neuro, U of K. Khartoum Sudan.E-mail:_ abbashar59@yahoo.com.
Diabetes is usually irreversible and although patients can have reasonable normal life style, its late complications result in reduced life expectancy and considerable uptake of health resources.Macro vascular disease leads to an increased prevalence of coronary artery disease, peripheral vascular disease and stroke 6 .In contrast to macro vascular disease, micro vascular disease is specific to DM.Small blood vessels throughout the body are affected but the disease process is of particular danger in three sites: the retina, the renal glomerulus and the nerve sheath 7 .DM can affect the eye in a number of ways, the most common and characteristic form is diabetic retinopathy which is subdivided into three stages: background retinopathy, preproliferative retinopathy, and proliferative retinopathy 8,9 .Diabetic nephropathy: Kidneys may be damaged by DM in three main ways: D glumerular damage, ischemia resulting from hypertrophy of afferent and efferent arterioles and ascending infection 10  Clinical examination was divided into general systemic examination and a detailed neurological examination emphasizing on the cranial nerves, upper and lower limbs examination in addition to autonomic nervous system examination.Dilated fundal examination using medriacyl, phenylepherine to evaluate the posterior segment and the retina was done by the authors and reevaluated by ophthalmologist.Then retinopathy was staged into: mild nonproliferative, moderate non-proliferative, severe non-proliferative and proliferative diabetic retinopathy.Neuropathy was diagnosed when the patient complained of burning or loss of sensation, pain or tingling in addition to impaired or absent tendon reflexes, decreased sensitivity to light touch and pinprick, impaired vibration and position senses in addition to abnormalities detected by nerve conduction studies of the median ,ulnar, lateral peroneal and sural nerves.Nephropathy was diagnosed by finding of enlarged kidneys in U/S of the abdomen, micro and macro albuminuria in the urine and raised serum creatinine and blood urea.The following investigations were done for each patient: total blood count, FBG, P P B S, RFT, urine for micro and macro-albuminuria and lipid profile, in addition to ECG, U/S abdomen, nerve conduction study and EMG.Hemoglobin A1 C (HbA1 c ) was measured to assess the degree of metabolic control.Data were introduced into the computer from a master sheet recording using software programme.Data entered and analyzed, then the results expressed in the form of tables, figures and graphs using SPSS programme (Statistical Package for Social Science).
Regarding fundal examination, 28.2% had normal fundus, 39.4% had dot and blot hemorrhages, 19.7% had hard exudates and cotton wool, 12.7% had newvascularization, while 5.6% had retinal detachments.Concerning examination of the upper and lower limbs, 53.1% had wasting and 34.7% had power grade 4, 24.4% had power grade 3, 18.4% had power grade 5, and 4.1% had power grade 2. The study showed varieties of sensory disturbance, 81.6% presented with decrease vibration sense, 71.45% presented with decreased pinprick sensation, and 69.3% presented with loss of position sense and 2% had ataxic gait (Figure1).The

Discussion
The study showed that male to female ratio was found to be 1.4 to 1; this is similar to what was mentioned in the literature 12 .
According to age distribution 70% of our patients their age above 50 years and more than 65% of the patients had diabetes for more than 15 years.70.4% of our patients have type 2 DM.The micro vascular complications are highly distributed in Khartoum (45.1%).This is due to the fact that it is the area where the study was conducted.
Like what was reported by other researchers blurring of vision, numbness, parasthesia, were the most common symptoms among our diabetic patients 13,14 .Significant number of our patients was asymptomatic; this is similar to what was reported by Boulton AJM in Manchester UK 15 .1t was found that non-proliferative changes in ocular fundal examination were the commonest abnormalities (ranging from mild, moderate and severe).This goes with the findings in Peshawar 16 .Symmetrical sensory polyneuropathy is the commonest type of peripheral neuropathy.Multiple cranial nerves involvement is one of the neurological complications associated with diabetes.The most common cranial nerves involved were the third, the fourth, and the six respectively.This is similar to what was mentioned in the literature 17,18 .Duration of diabetes and poor glycemic control were shown significantly (p=001) associated with the complications.This is similar to reports from Japan 19,20 .Hypertension is a highly co-morbid condition in diabetic patients.In our study it was observed in 50.7%, this similar to study conducted in Punjab 21 .Hypertensive and non-hypertensive patients were compared for retinopathy, nephropathy and neuropathy, patients with hypertension had more complications with statistical significance as compared to those without hypertension (P < 0.01 for retinopathy and < 0.05 in case of nephropathy and neuropathy).This is similar to Gadhavi R study in India 22 .Significant numbers of patients with complications were smoker, and this definitely increases the risk of developing complications in the presence of hyperglycemia.There was high percentage of micro vascular complications patients, this goes with the findings from Peshawar, but differs from those from UAE 16,[23][24][25][26][27] .This can be due to the fact that our study included more patients with older age, longer diabetes duration, and poor glycemic control.The percentage of diabetic patients who have peripheral neuropathy is higher than what was mentioned in the literature 14,25,26 .The commonest long term micro vascular complication in our study was retinopathy.It differed from reports from Pakistan and India.Environmental, nutritional and genetic variations may stand behind that 16,28,29 .All patients with nephropathy, had retinopathy, while two third of our patients with retinopathy developed peripheral neuropathy, this is similar to literature.Most of our patients were not on regular treatment (60%) or follow up.Conclusion: Long term micro vascular complications of diabetes mellitus are more common in males.The most affected age group was found to be 60-69 years.Going with international reports we found significant correlation between the duration of the disease and the development of

Table 1 :
Various combination of micro vascular complications among 71 adult Sudanese diabetic patients seen in Khartoum Dec2006-Sep 2007.