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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2010  |  Volume : 21  |  Issue : 2  |  Page : 295-299
Early evaluation of renal hemodynamic alterations in type I diabetes mellitus with duplex ultrasound


1 Department of Internal Medicine and Endocrinology, Center of Pediatric Nephrology and Transplantation, Cairo University, Egypt
2 Department of Pediatrics, Center of Pediatric Nephrology and Transplantation, Cairo University, Egypt
3 Vascular Laboratory, Cairo University, Egypt

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Date of Web Publication9-Mar-2010
 

   Abstract 

To evaluate the role of renal duplex ultrasonography in the detection of early alte­ration of renal blood flow in type I diabetic patients, we studied with duplex ultrasound 32 patients with type I diabetes mellitus (19 males, 13 females, age range 8-19 years) and 35 age and sex-matched controls. The resistivity indices (RIs) and pulsatility indices (PIs) of the main renal as well as intra­renal arteries were calculated. Compared with the healthy control subjects, diabetic patients had significantly higher resistivity indices (RIs) in the intrarenal (segmental, arcuate and interlobar) ar­teries (P= 0.001). The study, also revealed a significantly positive correlation between the RIs in the intrarenal arteries in diabetics and the albumin/creatinine ratio (r= 0.54, 0.52 and 0.51 respectively), glycated hemoglobin (r= 0.61, 0.59 and 0.63 respectively), as well as the estimated GFR (e-GFR) (r= 0.53, 0.51 and 0.57 respectively). We conclude that the current study documented early intra­renal hemodynamic alterations in the form of pathologically elevated intrarenal RIs. This denotes the potential usefulness of duplex evaluation of the intrarenal arteries, as a noninvasive procedure, for monitoring type 1 diabetic patients to predict those at risk of diabetic nephropathy.

How to cite this article:
Saif A, Soliman NA, Abdel-Hameed A. Early evaluation of renal hemodynamic alterations in type I diabetes mellitus with duplex ultrasound. Saudi J Kidney Dis Transpl 2010;21:295-9

How to cite this URL:
Saif A, Soliman NA, Abdel-Hameed A. Early evaluation of renal hemodynamic alterations in type I diabetes mellitus with duplex ultrasound. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2017 Sep 25];21:295-9. Available from: http://www.sjkdt.org/text.asp?2010/21/2/295/60198

   Introduction Top


Diabetic nephropathy affects about 40% of pa­tients with type I diabetes mellitus. Once fully developed, this complication carries a poor prog­nosis where reltive mortality is almost 40-100 times that of non-diabetics. [1] Therefore it is con­sidered one of the most common and most se­rious complications in type 1 diabetes. [2],[3]

Glomerular hyperfiltration is the first feature of renal involvement and can be observed soon after the inception of diabetes, accompanied by a loss of renal functional reserve. [4] Microalbu­minuria coincides with the morphological changes such as thickening of the glomerular basement membrane and mesangial expansion. [5]

Clinically evident diabetes-related microvas­cular complications are extremely rare in child­hood and adolescence. Nonetheless, early func­tional and structural abnormalities may be pre­sent a few years after the onset of the disease. [6],[7],[8]

Doppler ultrasonography is an easy and non­invasive tool for investigating renal hemody­namics. The resistivity index (RI) calculated from blood flow velocities in vessels reflects reno­vascular resistance and is known to increase in various disorders. [9],[10] Moreover, vasoactive agents, such as angiotensin II and its inhibitors are known to affect RI. [11]

This prospective study was carried out to de­tect possible changes in renal blood flow velo­city and vascular indices by duplex ultrasono­graphy and to correlate these changes with cli­nical and laboratory parameters results in chil­dren and adolescents with type I diabetes mel­litus.


   Patients and Methods Top


This study was approved by the Institutional Review Board at Cairo University Children's Hospital. Thirty two patients with type I diabetes mellitus (19 males and 13 females) with age range from 8-19 years, with a mean of 11.9 ± 3.7 years). Thirty five age and sex matched healthy children and adolescents (20 males and 15 females, age range 7-18 years, with a mean of 11.7 ± 4.8 years) were enrolled in the study. The parents and children were informed about the study and fully informed consent was ob­tained. The duration of diabetes in the study patients ranged from 2-17 years. All patients were normotensive, had normal renal function tests and showed no evidence of retinopathy or clinical nephropathy.

The following was done for both patients and control subjects:

  1. Blood pressure (BP) measurement with cal­culation of the mean blood pressure (MBP).
  2. Laboratory investigations including: urinary Albumin/Creatinine ratio (Alb/Cr), glycated hemoglobin, and serum creatinine (Cr). Glo­merular filtration rate was estimated (e-GFR) using the adapted Schwartz formula. [12],[13]
  3. Color-coded duplex ultrasound scan using 3.5 or 5 MHz transducer (HP Sonos 1500 ma­chine, Hewlett Packard, Santa Clara, CA, USA). Patients were scanned in the supine position. The transducer was placed in the midline with slight inclination to the left to get a coronal section of the aorta. Each re­nal artery was identified as lying between the superior mesenteric artery and the corres­ponding renal vein. Flow velocities were measured by real time pulsed Doppler ultra­sonography.
Recordings were obtained from the main renal artery as well as its main intrarenal branches (segmental, interlobar, and arcuate). For each artery, the resistivity index (RI), the pulsatility index (PI), and diastolic systolic ratio (D/S) were measured according to the following for­mulas:




   Statistical Analysis Top


The mean renal RIs, PIs, and D/S ratios were used for statistical analysis of differences bet­ween patients and controls using student t-test (P value); P< 0.05 was considered significant. The correlation between the duplex indices in patients and the clinical or imaging parameters were studied using the Pearson's correlation co­efficient (r value); r > 0.38 was accepted as sta­tistically significant.


   Results Top


Comparative analysis of the duplex results in both patients and controls revealed that the re­sistivity indices (RIs) in the intrarenal (segmen­tal, arcuate and interlobar) arteries were signi­ficantly elevated in the study group compared to controls (P= 0.001). Nevertheless, there was no significant difference between the two groups regarding the RI in the main renal artery (P=0.44), pulsatility index (PI) in the main renal ar­tery (P= 0.10) or the pulsatility indices (PIs) in the intrarenal arteries (P= 0.26, 0.09, 0.43) [Table 1].

Moreover, the study revealed a significantly­positive correlation between the RIs in the in­trarenal (segmental, arcuate and interlobar) ar­teries in diabetics and the albumin/creatinine ratio (r= 0.54, 0.52 and 0.51 respectively) as well as glycated hemoglobin (r= 0.61, 0.59 and 0.63 respectively). Also, there was a significantly­positive correlation between the RIs in the in­trarenal arteries and the e-GFR in the diabetic patients (r= 0.53, 0.51 and 0.57 respectively). No other significant correlations could be found between any of the duplex indices and the diffe­rent clinical and laboratory parameters studied [Table 2].


   Discussion Top


Our results showed that many of patients with type 1 diabetes of variable duration and without the usual signs of clinical diabetic nephropathy had evidence of increased intrarenal arterial re­sistance compared to control subjects. It is note­worthy that these hemodynamic changes even preceded the development of microalbuminuria in some of our patients denoting that renal dup­lex assessment might be used as an early and sensitive tool to detect early diabetic nephro­pathy.

Studies of the glomerular physiologic abnor­malities in diabetic nephropathy demonstrated glomerular hypertension and hypertrophy [14] si­milar to that seen in rodent models of ablative nephrectomy. [15] Furthermore, the elevation in capillary pressure may be damaging to glome­rular endothelial, epithelial and mesangial cells; thereby intiating and contributing to the prog­ression of diabetic nephropathy. [16]

Boeri et al used renal duplex to prove that the RI of the interlobar arteries as a marker of the intra-renal circulation is higher in type II diabe­tics compared to normal controls. [17] Also, Spe­randeo et al found that the RI of the interlobar arteries is higher in type I diabetics (aged bet­ween 28 and 46 years) compared to controls. [18]

Moreover, it was clearly shown that these ele­vated intrarenal RIs correlated strongly with glycated hemoglobin, being higher in the poorly controlled patients, therefore implying the ne­cessity for tighter control of diabetes to prevent, or at least delay, the incidence of nephropathic complications. [19]

Our results are comparable with those of ano­ther study in diabetic children, which demons­trated that RI values were significantly greater in children with diabetes and no evidence of renal dysfunction than in age-matched healthy controls; therefore, suggesting a preclinical sta­ge of diabetic nephropathy. Moreover, the au­thors found that RI correlated positively with HbA1c and diabetes duration. [20]

Our study further demonstrates the positive correlation between intrarenal RIs and e-GFR as none of our patients showed any evidence of clinical diabetic nephropathy. It has been pre­viously demonstrated that the intrarenal arterial resistance correlates with creatinine clearance (Ccr) differently depending upon the stage of diabetic nephropathy. Soldo et al showed a po­sitive correlation in IDDM patients with no evi­dence of clinical diabetic nephropathy. [21] Another study clearly demonstrated that intrarenal arte­rial resistance is significantly increased in chro­nic kidney disease patients with type 2 diabetes compared to non-diabetics. [22] However, Ishimura et al found a negative correlation in patients with evident clinical nephropathy. [16]

Two final points deserve to mention. Firstly, none of the duplex indices in our study showed a significant correlation with age, sex, mean blood pressure or serum creatinine. Intrarenal RIs were, however, higher in patients with lon­ger duration of diabetes though it failed to reach statistical significance. Secondly, our study de­monstrates a strongly positive correlation bet­ween intrarenal RIs (at the segmental, arcuate and interlobar levels) and albumin/creatinine ratio.

We conclude that the current study documen­ted early intrarenal hemodynamic alterations in the form of pathologically elevated intrarenal RIs. This denotes the potential usefulness of du­plex evaluation of the intrarenal arteries, as a noninvasive procedure, for monitoring type 1 diabetic patients to predict those at risk of dia­betic nephropathy.


   Acknowledgement Top


The authors thank the patients, the control sub­jects and their families for participation in this study.

 
   References Top

1.Liew Liew BS, Perry C, Boulton-Jones JM, Simpson K, Paterson K. Diabetic nephropathy: An observational study on patients attending a joint diabetes renal clinic. QJM 1997;90(5):353-­8.  Back to cited text no. 1      
2.Krolewski AS, Laffel LM, Krolewski M, Quinn M, Warran JH. Glycosylated hemoglobin and the risk of microalbuminuria in patients with insulin-dependent diabetes mellitus. N Engl J Med 1995;332:1251-5.  Back to cited text no. 2      
3.Garcia MJ, McNamara PM, Gordon J, Kannel WB. Morbidity and mortality in diabetics in the Framingham population sixteen year follow-up study. Diabetes 1974;23:105-11.  Back to cited text no. 3      
4.Tolins JP, Shultz PJ, Raij L, Brown DM, Mauer SM. Abnormal renal hemodynamic response to reduced renal perfusion pressure in diabetic rats: role of NO. Am J Physiol 1993;265:F886-95.  Back to cited text no. 4  [PUBMED]    
5.Mauer SM, Bilous RW, Ellis E, Harris R, Steffes MW. Some lessons from the studies of renal biopsies in patients with insulin-dependent diabetes mellitus. J Diabet Complications 1988; 2:197-202.  Back to cited text no. 5  [PUBMED]    
6.Chiarelli F, Cipollone F, Romano F, et al. In­creased circulating nitric oxide in young patients with type 1 diabetes and persistent microalbu­minuria: Relation to glomerular hyperfiltration. Diabetes 2000;49:1258-63.  Back to cited text no. 6  [PUBMED]    
7.Savino A, Pelliccia P, Schiavone C, et al. Serum and urinary nitrites and nitrates and Doppler sonography in children with diabetes. Diabetes Care 2006;29(12):2676-81.  Back to cited text no. 7      
8.Komers R, Anderson S. Paradoxes of nitric oxide in the diabetic kidney. Am J Physiol Renal Physiol 2003;284:F1121-37.  Back to cited text no. 8  [PUBMED]    
9.Platt JF, Rubin JM, Ellis JH, DiPetro MA. Duplex Doppler US of the kidney: Differentiation of obstructive from non obstructive dilatation. Radiology 1989;171:515-7.  Back to cited text no. 9      
10.Platt JF, Ellis JH, Rubin JM, DiPetro MA. Intra­renal arterial Doppler sonography in the detec­tion of renal vein thrombosis of the native kid­ney. AJR Am J Roentgenol 1994;162:1367-70.  Back to cited text no. 10      
11.Leoncini G, Martinoli C, Viazzi F. Changes in renal resistive index and urinary albumin excre­tion in hypertensive patients under longterm treatment with lisinopril or nifedipne GITS. Nephron 2002;90:169-73.  Back to cited text no. 11      
12.Schwartz GJ, Haycock GB, Edelmann CM, Spitzer A. A simple method estimate of glome­rular filtration rate in children derived from body lengh and plasma creatinine. Pediatrics 1976; 58:259-63.  Back to cited text no. 12      
13.Van Rossum LK, Mathot RA, Cransberg K, Zietse R, Vulto AG. Estimation of the glomerular fil­tration rate in children: Which algorithm should be used? Pediatr Nephrol 2005;20:1769-75.  Back to cited text no. 13  [PUBMED]    
14.O'Bryan GT, Hostetter TH. The renal hemo­dynamic basis of diabetic nephropathy. Semin Nephrol 1997;17(2):93-100.  Back to cited text no. 14      
15.Hostetter TH, Oslen JL, Rennke HG, Venkata­chalam MA, Brenner BM. Hyperfiltration in remnant nephrons: a potentially adverse response to renal ablation. Am J Physiol 1981;241(1): F85-93.  Back to cited text no. 15      
16.Ishimura E, Nishizawa Y, Kawagish Okuno Y, et al. Intrarenal hemodynamic abnormalities in diabetic nephropathy measured by duplex Doppler sonography. Kidney Int 1997;51(6): 1920-7.  Back to cited text no. 16      
17.Boeri D, Derchi LE, Martinoli C, et al. Intrarenal arteriosclerosis and impairment of kidney func­tion in NIDDM. Diabetologia 1998;41:121-4.  Back to cited text no. 17  [PUBMED]    
18.Sperandeo M, D'Amico G, Varriale A, Sperandeo G, Annese MA, Correra M. Pulsed-wave color Doppler echography of the intrarenal vessels in patients with insulin-dependant diabetes melli­tus and incipient nephropathy. Arch Ital Urol Androl 1996;68:183-7.  Back to cited text no. 18  [PUBMED]    
19.Steffes MW. Glycemic control and the initiation and progression of the complications of diabetes mellitus. Kidney Int Suppl 1997;63:S36-9.  Back to cited text no. 19  [PUBMED]    
20.Pelliccia P, Savino A, Cecamore C, Primavera A, Schiavone C, Chiarelli F. Early changes in renal hemodynamics in children with diabetes: Doppler sonographic findings. J Clin Ultrasound 2008;36(6):335-40.  Back to cited text no. 20      
21.Soldo D, Brkljacic B, Bozikov V, Drinkovic I, Hauser M. Diabetic nephropathy. Comparison of conventional and duplex Doppler ultrasono­graphic findings. Acta Radiol 1997;38(2):296-­302.  Back to cited text no. 21      
22.Matsumoto N, Ishimura E, Taniwaki H, et al. Diabetes mellitus Worsens Intrarenal Hemody­namic abnormalities in non-dialyzed patients with chronic renal failure. Nephron 2000;86:44-51.  Back to cited text no. 22  [PUBMED]    

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Correspondence Address:
Neveen A Soliman
Professor of Pediatrics, Center of Pediatric Nephrology and Transplantation, Cairo University, Egyptian Group for Orphan Renal Diseases Cairo, 11451
Egypt
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PMID: 20228516

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    Tables

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    Abstract
    Introduction
    Patients and Methods
    Statistical Analysis
    Results
    Discussion
    Acknowledgement
    References
    Article Tables
 

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