Skin microcirculation violations in hypertensive diabetic patients according to the stage of chronic kidney disease

THE AIM: to study skin microcirculation (MC) characteristics in hypertensive patients with diabetes mellitus (DM) type 2 depending on stage of chronic kidney disease (CKD). PATIENTS AND METHODS. Study included 120 patients with arterial hypertension stage II-III aged from 40 to 65 years. Patients were divided into groups depending on stage of CKD. We evaluated overall state, clinical heart rate measurement and blood pressure (BP) on both hands with the patient sitting in the standard method, anthropometry, analysis of combined risk of CKD progression and cardiovascular complications development. We also studied skin microcirculation (MC) by Laser Doppler flowmetry (LDF) and determined renal function, HbA1c level. RESULTS. Significant increase of patients with a reduction in tissue blood flow with the worsening of CKD from stage S1 to S3b was revealed. Number of patients with severe venous flow (stasis) was significantly greater among 3 groups compared with those 2 groups (31,9 vs 15,6%, p<0,05). Regardless of CKD stage hyperemic hemodynamic type of MC (GTMC) was prevailed among patients with hypertension and type 2 diabetes. During renal function analysis we noted that proteinuria (PU) level was lower in group 1 patients compared with patients 2, 3 and 4 groups (426,4 ± 49,4 vs 623,9 ± 61,4 vs 734,3 ± 60,1 vs 737,3 ± 85,2 mg / g, respectively, p <0.05). Albuminuria (AU) level significantly increased from 1 to 4 patients group with hypertension and type 2 diabetes. During correlation analysis we found statistically significant relationships between renal function and the skin MC parameters. There were significant correlations between AU level and MC indicator (r = -0,15, p<0,05), PU and MC indicator levels (r = -0,35, p<0,05), PU and tissue oxygen consumption (r = -0,34, p<0,05). It was shown that with CKD severity increase tissue blood flow decreased - direct correlation between GFR (CKD-EPI) and tissue oxygen consumption (I) (r = 0,20, p <0.05) was noted. CONCLUSION. Thus, skin MC indicators change reflects prognosis of combined risk of CKD progression and cardiovascular complications in hypertensive patients with type 2 diabetes.

microcirculation, arterial hypertension, diabetes mellitus type 2, chronic kidney disease

1. Стаценко МЕ, Деревянченко МВ, Титаренко МН, Пастухова ОР Кардиоренальные взаимоотношения у больных артериальной гипертензией в сочетании с сахарным диабетом 2 типа. Нефрология 2014; 18(5): 44-51 [Statsenko ME, Derevyanchenko MV, Titarenko MN, Pastukhova OR. Cardiorenal relationships in patients with arterial hypertension and type 2 diabetes. Nephrology 2014; 18 (5): 44-51].

2. Смирнов А.В., Добронравов В.А., Кисина А.А. и др. Клинические рекомендации по диагностике и лечению диабетической нефропатии. Нефрология 2015; 19(1): 67-77 [Smirnov A.V., Dobronravov V.A., Kisina A.A. i dr. Klinicheskie rekomendacii po diagnostike i lecheniju diabeticheskoj nefropatii. Nefrologija 2015; 19(1): 67-77]

3. Рабочая группа Российского кардиологического общества, Научного общества нефрологов России, Российской ассоциации эндокринологов, Российского медицинского общества по артериальной гипертонии, Национального общества по изучению атеросклероза, Российского научного медицинского общества терапевтов. Национальные рекомендации. Сердечно-сосудистый риск и хроническая болезнь почек: стратегии кардио-нефропротекции. Росс кардиол журн 2014; 8(112): 7-37 [Russian National Guidelines. Cardiovascular risk and chronic kidney disease: cardio nephroprotection strategy. Russian Journal of Cardiology 2014; 8 (112): 7-37].

4. Karalliedde J, Gnudi L. Future strategies to prevent renal microvascular disease complications in diabetes. Future Cardiol 2008; 4: 77-83.

5. Krentz AJ, Clough G, Byrne CD. Interactions between microvascular and macrovascular disease in diabetes: pathophysiology and therapeutic implications. Diabetes Obes Metab 2007; 9: 781-791.

6. Maric-Bilkan C, Flynn ER, Chade AR. Microvascular disease precedes the decline in renal function in the streptozotocin-induced diabetic rat. Am J Physiol Renal Physiol. 2012;302(3):F308-15.

7. Lindenmeyer MT, Kretzler M, Boucherot A et al. Interstitial vascular rarefaction and reduced VEGF-A expression in human diabetic nephropathy. J Am Soc Nephrol 2007; 18: 1765-1776.

8. Nawroth PP, Isermann B. Mechanisms of diabetic nephropathy-old buddies and newcomers part 2. Exp Clin Endocrinol Diabetes 2010; 118: 667-672.

9. Беленков ЮН, Привалова ЕВ, Данилогорская ЮА и др. Ремоделирование сосудистого русла у больных артериальной гипертонией: возможности диагностики и коррекции. Кардиология 2012; 52(6): 62-72 [Belenkov YN, Privalova EB Danilogorskaya SA, et al. Vascular remodeling in hypertensive patients: diagnostics and correction. Cardiology 2012; 52 (6): 62-72].

10. Подзолков ВИ, Булатов ВА, Сон ЕА, Маколкин ВИ. Антигипертензивная эффективность валсартана, влияние на состояние центральной гемодинамики и микроциркуляции: взгляд с позиций органопротекции. Системные гипертензии 2004; 1: 40-43 [Podzolkov VI, Bulatov VA, Son EA, Makolkin VI. Antihypertensive efficacy of valsartan, impact on the state of the central hemodynamics and microcirculation: from the point of view of organoprotection. Systemic Hypertension 2004; 1: 40-43].

11. Levy BI. Microcirculation in hypertension. A new target for treatment? Circulation 2001; 104: 735-740.

12. Struijker Boudier HAJ. Hypertension and the microcirculation. In: Kaplan N., ed. Hypertension, microcirculation and end organ damage. London.; Lippincott Williams & Wilkins. 2002: 49-55.

13. Маколкин ВИ, Подзолков ВИ, Павлов ВИ, Самойленко ВВ. Состояние микроциркуляции при гипертонической болезни. Кардиология 2003; 5: 60-7 [Makolkin VI, Podzolkov VI, Pavlov VI, Samoilenko VV. Microcirculation in hypertension. Cardiology 2003; 5: 60-67].

14. Yudkin JS, Forrest RD, Jackson CA. Microalbumiuria as predictor of vascular disease in non-diabetic subjects. Islington. Diabetes Surv. Lancet 1988; 2: 530-533.

15. Baumann M, Burkhardt K, Heemann U. Microcirculatory marker for the prediction of renal end points: a prospective cohort study in patients with chronic kidney disease stage 2 to 4. Hypertension 2014; 64(2): 338-346.

16. Wong TY Improving the prediction of hypertensive target organ damage using novel markers: lessons from retinal vascular imaging research. Hypertension 2014; 64(2): 233-234.

17. Смирнов АВ, Петрищев НН, Мнускина ММ и др. Дисфункция эндотелия и апоптоз на ранних стадиях хронической болезни почек. Тер арх 2012; 84(6): 9-15 [Smirnov AV, Petrishhev NN, Mnuskina MM i dr. Disfunkcija jendotelija i apoptoz na rannih stadijah hronicheskoj bolezni pochek. Terarh 2012; 84(6): 9-15].

18. Стаценко МЕ, Деревянченко МВ. Особенности ведения пациентов с артериальной гипертензией и сахарным диабетом 2 типа: взгляд кардиолога. Фарматека 2013; 16: 52-57 [Statsenko ME, Derevyanchenko MV. Features of hypertensive patients with type 2 diabetes: a view of the cardiologist. Pharmateka 2013; 16: 52-57].

19. Стаценко МЕ, Деревянченко МВ. Коррекция дис функции эндотелия у больных артериальной гипертензией и сахарным диабетом 2 типа на фоне комбинированной антигипертензивной терапии. Тер арх 2014; 86(8): 90-93 [Statsenko ME, Derevyanchenko MV. Correction of endothelial dysfunction in patients with hypertension and type 2 diabetes by combined antihypertensive therapy. Therapeutic Archives 2014; 86 (8): 90-93].

20. Крупаткин АИ, Сидоров ВВ. Лазерная допплеровская флоуметрия микроциркуляции крови. М., 2005, 256 с [Krupatkin AI, Sidorov VV. Laser Doppler flowmetry of microcirculation. M., 2005, 256 p.].

21. Levey AS, Stevens LA, Schmid CH et al. A new equation to estimate glomerular filtration rate. Ann Intern Med 2009; 150: 604-612.

22. Васильев АП, Стрельцова НН. Возрастные особенности микрогемоциркуляции. Регионарное кровообращение и микроциркуляция. 2012; 11 (4(44)): 23-27 [Vasilyev AP, Streltsova NN. Age features of circulation. Regional circulation and microcirculation. 2012; 11 (4 (44)): 23-27].

23. Козлов ВИ. Система микроциркуляции крови: клинико-морфологические аспекты изучения. Регионарное кровообращение и микроциркуляция. 2006; 5(2): 84-101 [Kozlov VI. The system of blood microcirculation: clinical and morphological aspects of the study. Regional circulation and microcirculation. 2006; 5 (2): 84-101].

24. Крупаткин АИ. Колебания кровотока - новый диагностический язык в исследовании микроциркуляции. Регионарное кровообращение и микроциркуляция 2014; 13(1(49)): 83-99 [Krupatkin AI. Fluctuations in blood flow - a new diagnostic language in the study of microcirculation. Regional circulation and microcirculation 2014; 13 (1 (49)): 83-99].

25. Васильев АП, Стрельцова НН, Секисова МА. Функциональные особенности микроциркуляторной картины у больных артериальной гипертонией и их прогностическое значение Кардиоваскулярная терапия и профилактика 2011; 10(5): 14-19 [Vasilyev AP, Streltsova NN, Sekisova MA. Functional features microcirculatory pattern in patients with arterial hypertension and their prognostic value Cardiovascular therapy and prevention. 2011; 10 (5): 14-19].