الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Diabetic peripheral neuropathy (DPN) is a major public health problem worldwide (Liu et al., 2017). It is one of the main causes of morbidity and increased mortality (Qu et al., 2017). Diagnosing DPN depends on clinical examination and nerve conduction study (Xu et al., 2017). Further development of DPN can lead to diabetic foot lesions as ulcers, infection, gangrene of the feet and amputation (Nakajima et al., 2018). These late complications are associated with a higher mortality and reduced quality of life and impose a great cost on healthcare systems (Santos et al., 2018). Therefore, searching for a reliable indicator for the early diagnosis of DPN is of most significance.
Epidemiological studies have indicated the main risk factors of DPN including the high level of blood glucose and glycated hemoglobin (Yagihashi, 2011). The study of Liu et al. (2017) showed that, neutrophil lymphocyte ratio (NLR) levels grow with the increase of nerve conduction velocity (NCV). The meta-analysis of Qu et al. (2017) demonstrated that, vitamin (D) is involved in the development of DPN, and vitamin (D) deficiency is very likely to be associated with increased risk of DPN.
The aim of our cross sectional study is to evaluate the association between NLR, vitamin (D) deficiency and development of peripheral neuropathy in type 2 diabetes mellitus (T2DM) patients.
Our study was done since November 2018 till November 2019 in Minia University Hospital. All participants were informed about this study before any procedure. We selected 60 patients with T2DM. During our selection, we excluded patients with cardiac problems, renal problems, active infection, acute massive hemorrhage, blood diseases that affect neutrophils and lymphocytes (e.g., myeloproliferative disease and leukemia), cancer, received blood transfusion during the last 2 weeks, received immunosuppressant or steroid drugs during the last 2 weeks or receiving vitamin supplementation.
First we took the medical data: the gender, age, smoking state, duration of DM, family history of DM, drug history (receiving oral anti-diabetic drugs or insulin) and other chronic illness. Then we examined our patients for weight, height, body mass index (BMI), systolic and diastolic blood pressures in the upper arm by using mercury sphygmomanometer.
Then nerve conduction study (NCS) was done to all patients. According to our results, the patients were divided into 45 patients with DPN and 15 patients without DPN as a control group. Patients with DPN were subdivided into 11 patients with mononeuropathy, 4 patients with mononeuropathy multiplex and 30 patients with polyneuropathy. In our study, DPN was defined as the presence of one or more abnormal nerve conduction results (distal latency, amplitude or conduction velocity) (Lin et al., 2018) in the form of mononeuropathy, mononeuropathy multiplex or polyneuropathy in T2DM patients. Normal NCS; is Normal findings of all results. Mononeuropathy; is a lesion restricted to one single peripheral nerve, producing the characteristic motor, sensory and reflex abnormalities distal to the site of the lesion. Mononeuropathy multiplex; is the term used to describe the coexistence of two or more separate mononeuropathies in one limb and this most usually occur in diabetes mellitus and vasculitis. Polyneuropathy; is a generalized neuropathy affecting all peripheral nerve fibers (Donaghy, 2001).
Participants’ laboratory tests were done as fasting plasma glucose (FPG), 2 hours post prandial blood sugar (2hpp), glycated hemoglobin (HbA1c), complete blood picture (CBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), lipid profile, urea, renal and liver function tests, hepatitis C virus antibodies (HCV Ab), [25(OH) D] levels and uric acid.
When we compared DPN group with non-DPN group as regards HbA1c, microalbuminuria and [25(OH) D] levels, we found that, there were very highly statistically significant differences between them, (P < 0.001*** for all). Spearman’s correlation analysis between [25(OH) D] levels and NCS results showed that, the values of [25(OH) D] were insignificantly positive correlated to the mean of motor nerve amplitude (r = 0.159, P = 0.226), significantly positive correlated to the mean of motor NCV (r = 0.304, P = 0.018), sensory nerve amplitude (r = 0.438, P < 0.001***) and sensory NCV (r = 0.516, P < 0.001***), while they were significantly negative correlated to the mean of motor nerve distal latency (r = - 0.271, P = 0.036) and sensory nerve distal latency (r = -0.430, P < 0.001***). Binary logistic regression analysis showed that HbA1c and [25(OH) D] levels were significantly independent risk factors for DPN, (P = 0.004**, OR = 2.02, 95% CI = 1.254 - 3.25), (P < 0.001***, OR = 0.86, 95% CI = 0.79 - 0.93) respectively. Multivariate logistic regression analysis showed that, [25(OH) D] levels were significantly independent risk factors for DPN, (P = 0.041*, OR = 0.88, 95% CI = 0.78 - 0.10). Combining the results of binary logistic regression analysis, multivariate logistic regression analysis, Spearman’s correlation analysis and independent sample T test suggest that, higher HbA1c levels and lower [25(OH) D] levels may predict a higher incidence of DPN in T2DM.
When we compared DPN group with non-DPN group as regards duration of DM, 2hpp and uric acid, we found that, there were a statistically significant differences between them, (P = 0.030*, 0.035* and 0.049* respectively). Binary logistic regression analysis showed that, duration of DM and 2hpp levels were significantly independent risk factors for DPN, (P = 0.039*, OR = 1.16, 95% CI = 1.01 - 1.34), (P = 0.042*, OR = 1.01, 95% CI = 1 - 1.02) respectively. Multivariate logistic regression analysis showed that, duration of DM was significantly independent risk factors for DPN, (P = 0.016*, OR = 1.54, 95% CI = 1.09 - 2.18). Combining the results of binary logistic regression analysis, multivariate logistic regression analysis and independent sample T test suggest that, higher duration of DM and 2hpp levels may predict a higher incidence of DPN in T2DM.
When we compared the DPN group with non-DPN group as regards smoking state, drug history of DM (oral hypoglycemic drugs or insulin), weight, height and BMI, SBP, DBP, FPG, neutrophils, lymphocytes, NLR, HCV Ab levels, LDL, HDL, triglycerides (TGs) and total cholesterol (TC), we found that, there were no statistically significant differences between them, (P = 0.627, 0.346, 0.081, 0.385, 0.162, 1.000, 0.972, 0.460, 0.743, 0.495, 0.501, 0.427, 0.895, 0.312, 0.922 and 0.801 respectively).
When we compared our subdivision groups as regards microalbuminuria and [25(OH) D] interpretation, we found that, there were very highly statistically significant differences between them, (P < 0.001*** for both). There were highly statistically significant differences between them as regards HbA1c, (P = 0.005**). When we compared them as regards height and BMI, we found that, there were statistically significant differences between them, (P = 0.029* and 0.016* respectively). The values of height and BMI in polyneuropathy group were significantly higher than those of mononeuropathy group, (163.7 ± 6.40 vs 157.91 ± 5.11), (37.97 ± 10.64 vs 30.50 ± 5.73) respectively. When we compared them as regards NLR and HCV Ab levels, we found that, there were no statistically significant differences between them, (P = 0.575, 1.000 respectively).