[Risk factors for diabetic retinopathy]. / Rizikové faktory diabetické retinopatie.

Risk factors for diabetic retinopathy can be divided into modifiable and non modifiable. Non modifiable include the type of diabetes, age of the patient at the time of onset, duration, and genetic factors. Primarily it can be influenced by glycemic control, as well as systemic factors such as blood pressure, serum lipids. Concomitant diseases also affect diabetic retinopathy. The article also mentions the risk of rapid compensation and iatrogenic influences.

[Autofluorescence as a diagnostic method]. / Autofluorescence jako diagnostická metoda.

The authors demonstrate the diagnostic possibilities of autofluorescence. They discuss its uses in diagnosing of the optic disc drusen and astrocytic hamartomas of the retina and the optic disc. They also show the influence of autofluorescence in interpreting fluorescein angiography.

[Current views on the development of diabetic retinopathy]. / Soucasné názory na vznik diabetické retinopatie.

The basic pathogenic mechanism of the diabetic retinopathy is hyperglycaemia. Capillary damage could be explained by several mechanisms. Among many causes the sorbitol overload, the excessive storage of advanced glycosylation endproducts, oxidative stress and/or the cell apoptosis after the paradoxical glucose starvation can be emphasised. The article further analyses mechanism of capillary damage in the retina is on the basis of hemorheological, hemodynamical and histopathological changes. The specific role of the retinal pigment epithelium is described. Histopathological changes accompanying the elementary microcirculatory anomalies result from the apoptotic death of pericytes, damage of endothelial cells, and impairment of the basal membrane. Microcirculatory changes, which include the capillary dilation, vascular occlusion, and proliferation of new vessels, bring about further development of the diabetic retinopathy.

Beneficial effect of pancreas and kidney transplantation on advanced diabetic retinopathy.

In pancreas recipients with advanced diabetic eye disease, conflicting ophthalmologic results over different follow-up periods have been reported. In the present prospective study we performed ophthalmologic evaluation groups of type I diabetic patients: 1) normoglycemic recipients of pancreas and kidney grafts (group SPK, n = 43, follow-up 44.9 +/- 35.1 months), 2) pancreas and kidney graft recipients with nonfunctioning pancreatic graft, and recipients of isolated kidney graft (group K, n = 45, follow-up 60.3 +/- 34.2 months). The examinations were performed before transplantation, at the end of follow-up (at least 1 year), and in 63 recipients also at 3 years posttransplant. Visual acuity results at baseline and at the end of follow-up were 0.48 +/- 0.39 vs. 0.50 +/- 0.39 in the SPK group, and 0.46 +/- 0.38 vs. 0.40 +/- 0.39 in the K group. While intragroup changes were not significant, the changes were significantly different between the groups (p < 0.05). Fundoscopic findings at the end of follow-up were improved, stabilized, or deteriorated in the SPK group in 21.3%, 61.7%, and 17.0%, respectively. The respective figures for the K group were 6.1%, 48.8%, and 45.1% (p < 0.001). Similar results were obtained when evaluating findings at 3 years posttransplant. Before transplantation, 78% of the SPK group and 81% of the K group had been treated by laser. The need for additional posttransplant laser therapy was significantly lower in the SPK (31%) than in the K group (58%; p < 0.001). In conclusion, pancreas transplant exerts a beneficial effect on the course of diabetic retinopathy even in its late stage.

[Clinical development of unstable (brittle) diabetes mellitus, its therapy and prognosis]. / Klinický prubeh nestabilního (brittle) diabetes mellitus, jeho lécba a prognóza.

Treatment of labile (brittle) diabetes characterized by variations of the blood sugar level, liability to develop ketoacidosis and in susceptible subjects the development of organ complications, was always a serious problem. The objective of the present work is to evaluate the results of a long-term study concerned with the relationship of compensation, vascular and neurological complications of labile insulin-dependent diabetics. The authors investigated indicators of compensation, and in collaboration with an ophthalmologist, and neurologist also signals of possible damage of the eye, central and peripheral nerves, kidneys. The results achieved by treatment were evaluated systematically. Consistent with the actual situation, treatment with conventional insulin or less common regimes were selected, and the authors reacted also to findings pertaining to organ complications. The cause of lability was assessed and eliminated. During the average period of treatment of 10.6 +/- 2.7 years a significant (p < 0.001) drop of glycated haemoglobin occurred from the baseline value of 12.3 +/- 2.5% to 8.8 +/- 1.3%. The development of organ complications can be influenced favourably to certain extent in particular by satisfactory control of diabetes during the first 10 years of the disease. Treatment is ensured in collaboration with a neurologist, ophthalmologist and indicators of glomerular and tubular kidney function are monitored. The assumption was confirmed that at present it is possible to treat successfully labile (brittle) diabetes and eliminate deteriorating the life of diabetics.

Effect of successful combined renal and pancreatic transplantation on diabetic retinopathy.

UNLABELLED: The treatment of diabetic retinopathy (DR) is one of the most challenging problems in ophthalmology. The possibility of modulating DR by successful combined kidney and pancreas transplantation thus holds an attractive promise for the ophthalmologist. From June 1983 until April 1997, a total of 86 combined kidney and pancreas transplantation procedures were performed at the Prague-based Institute for Clinical and Experimental Medicine. All recipients are on close follow-up in terms of their ophthalmic status. However, evaluation of the effect of transplantation is problematic because of the advanced status of DR prior to the procedure. We divided the transplant recipients into two groups according to type of transplantation. In Group I (segmental transplantation), proliferative DR was present in 100% eyes, 70% had undergone vitrectomy, and there were 21% of blind eyes. All eyes had been treated by laser. In this group, long-term stabilization of the finding was observed in three patients. In Group II (whole pancreas transplantation), proliferative and non-proliferative DR was diagnosed in 86% and 14%, respectively. There were 12% of blind eyes, and 70% had been treated by laser prior to transplantation. After a successful transplantation, stabilization was found in 60%, improvement in 18%, and deterioration in 22% of eyes in this group. The stabilization and improvement can be explained by subsequent normoglycemia (HbAlc 5.6%). By contrast, we were unable to provide a satisfactory explanation for the deterioration and progression of these findings. While the effect of immunosuppression on DR remains unclear, it obviously accelerates the existing cataract. CONCLUSION: Successful combined transplantation has a beneficial effect on DR and is worthwhile even for patients at the end stage on account of its beneficial psychosocial effect and prevention of dolorous glaucoma. However, many effects of the procedure on the eye of diabetics remain to be identified in future studies.

[Long-term treatment of diabetes with transplantation of a pancreatic segment]. / Dlouhodobá lécba diabetu transplantací segmentu pankreatu.

BACKGROUND: Successful transplantation of the pancreas is at present the only way how to ensure on a long-term basis an almost physiological regulation of the carbohydrate metabolism in type 1 diabetics. So far it is, however, indicated mainly in patients with already advanced microangiopathy where at the same time also renal transplantation is planned and long-term experience is so far limited. The objective of the submitted paper is to report on the development of metabolic compensation and its impact on the development of microangiopathic changes in type 1 diabetics where the complete function of both grafts persisted more han five years. METHODS AND RESULTS: From a group of 34 combined transplantations of a pancreatic segment with an obliterated duct and a kidney, implemented in 1983-1988 in the Institute of Clinical and Experimental Medicine, a group of nine type 1 diabetics was followed up where the independence on exogenous insulin and haemodialyzation treatment persisted for or still persists for 5-8 years. After annual intervals the blood sugar level was examined, the intravenous glucose to tolerance test, free insulin levels, glycosylated haemoglobin, an ophthalmological and neurological examination was made, incl. the peripheral and autonomous system, and by means of a standard questionnaire the quality of life before and after transplantation was assessed. In all examined subjects normal blood sugar levels were recorded. The fasting insulin levels in transplant recipients were higher than in healthy subjects (22 vs. 10.2 microU/ml, p < 0.01) while in the course of the blood sugar curve corresponding levels were recorded. Glycosylated haemoglobin remained after 5 years quite or almost normal (4.2-7.2%). The coefficient of glucose assimilation after 5 years varied in the range from 0.7 to 1.9% min. Hypoglycaemic states were not recorded. In none of the recipients in the course of the investigation deterioration of the ophthalmological finding was observed and in three patients improvement was recorded. Symptoms of somatic polyneuropathy improved in all patients but signs of vegetative neuropathy remained unchanged. In all recipients psychic, physical and social rehabilitation as well as the general quality of life improved markedly. CONCLUSIONS: Although the group of investigated patients is so far small, the authors provided evidence that combined transplantation of the pancreas and kidney can influence in a very favourable way the quality of life and development of microangiopathic complications. As the success rate of transplantations of the pancreas in increasing and the risk of surgical complications is declining due to improving surgical techniques, the authors conclude that combined transplantation of the pancreas and kidney is at present the optimal therapeutic procedure in type 1 diabetics with chronic renal insufficiency and that indication for transplantation of the pancreas could be moved to earlier stages of diabetes when it would be possible to influence the development of diabetic microangiopathy more favourably.

[Blood pressure and insulin resistance in type 2 diabetics]. / Krevní tlak a inzulinová rezistence u diabetiku 2. typu.

The authors analyzed in 145 patients with Type 2, diabetes, persisting on average for 10 years, influences affecting the blood pressure reading. 1. In patients treated on account of hypertension (40%) the increase of systolic and diastolic pressure persisted and the fasting concentrations of C peptide were elevated. 2. In patients with elevated levels of diastolic blood pressure and C peptide the rate of cerebrovascular attacks in direct relatives was higher. 3. Higher blood pressure readings were associated with a higher C peptide concentration, signs of ischaemia on the ECG tracing and left ventricular hypertrophy respectively. 4. The higher blood pressure levels were associated also with other manifestations of insulin resistance, i.e. elevated triacylglycerols, low HDL cholesterol levels, raised uric acid levels. 5. Also in stepwise regression analysis the fasting concentration of C peptide held one of the important places among variables which contribute towards variations of systolic blood pressure. 6. These findings support the idea on common pathogenic influences of raised insulin concentrations on metabolism, blood pressure and the development of complications of atherosclerosis.

[Relation of diabetic polyneuropathy to vascular and organ complications in type I diabetes mellitus]. / Vztah diabetické polyneuropatie k cévním a orgánovým komplikacím u diabetu mellitu I. typu.

The authors investigated in 194 type I diabetics the incidence and severity of diabetic polyneuropathy in relation to other organ and vascular complications, incl. autonomous neuropathy. It was revealed that the increasing severity of polyneuropathy was significantly v séru (Cr equal to or less than 130-200 mumol/l); 4--Cr greater than 200 mumol/l; associated with severe stages of nephropathy and proliferative retinopathy with amaurosis. The concurrent presence of hypertension and polyneuropathy was surprising and striking--even in patients with the mildest grade 1 polyneuropathy hypertension was present in 10% and the incidence increased significantly with the increasing severity of polyneuropathy. Ischaemic heart disease and ischaemia of the lower extremities was significantly more frequent only in patients with grade 5 polyneuropathy. In patients with grade 4 and 5 neuropathy there was a 100% incidence of autonomous neuropathy in the cardiovascular sphere. The authors did not reveal significant differences between men and women as regards the relationship between the incidence of polyneuropathy and organ and vascular complications.

[The clinical profile of cataracts now and 30 years ago]. / Klinický profil katarakty dnes a pred triceti lety.

Comparison of two periods of cataract operations and evaluations of some characteristic changes. Authors analyzed frequency of cataract occurrence in various age groups of patients, some differences between their clinical appearance and changing pattern of the general diseases being present in the cataract patients. At present time the number of complications is decreased and the postoperative results are more favourable. On the other hand, during this rather short time period the clinical forms of cataracts and the age distribution changed, and there are present general diseases in more patients in comparison with the patients thirty years ago.