Haemorheology in diabetic foot.
SS Karandikar, RD Bapat, RR Puniyani
Dept of Surgery, KEM Hospital, Parel, Bombay.
S S Karandikar
Dept of Surgery, KEM Hospital, Parel, Bombay.
A prospective study was undertaken to study the haemorheology in patients with diabetic foot lesions. Haemorheology of 30 patients with foot lesions and 30 age and sex matched controls was studied. The haemorheological parameters evaluated were whole blood and plasma viscosity and RBC filter ability. Plasma viscosity was significantly increased (p < 0.05). It substantiates the need for using rheomodulators in management of diabetic foot lesions.
|How to cite this article:|
Karandikar S S, Bapat R D, Puniyani R R. Haemorheology in diabetic foot. J Postgrad Med 1994;40:21-2
|How to cite this URL:|
Karandikar S S, Bapat R D, Puniyani R R. Haemorheology in diabetic foot. J Postgrad Med [serial online] 1994 [cited 2021 Mar 3 ];40:21-2
Available from: https://www.jpgmonline.com/text.asp?1994/40/1/21/578
Diabetes mellitus is a multi-systemic disease involving eyes, kidneys, nerves and blood vessels. The vascular lesion is predominantly a microangiopathy. The altered intravascular flow properties (i.e. haemorheology) further compromise peripheral circulation and enhance complications of diabetes mellitus. The prospective study was carried in Indian subjects to evaluate the haemorheological parameters in patients with diabetic foot lesions.
Thirty diabetic patients with age range between 32 and 74 years (average 57 years) and male to female ratio 6:1 attending surgical OF'D for foot lesions were investigated for changes in the haemorrheological parameters. Sixteen of these patients were 'fresh' diabetics (i.e. suspected on examination and confirmed by biochemical investigations after admission) and the rest (14) were taking therapy with insulin for average period of 5 years. All these patients had either ulcers, cellulitis or gangrene of lower limb. No other associated diseases were found except complications of diabetes [e.g. 10% patients were obese, 15% had higher serum creatinine (> 2 mg%), 50% had sensory or motor loss as detected by neurological examination (2 of them had Hansen's disorder)]. To confirm the diagnosis of diabetes and to rule out the presence of other associated disease along with clinical examination, following biochemical investigations were carried out: - hematocrit, hemogram, fasting and postprandial blood sugar, total proteins, fibrinogen and renal chemistry. History of intake of vasodilators, drugs affecting hemorheology was asked however none of the patient was found to take any such drugs.
To compare the data of haemorheological parameters in this group, investigations were carried out in another set of 30 age and sex matched healthy adult volunteers who served as controls.
Five ml blood was collected from each patient and volunteers in EDTA bulb and transported to Indian Institute of Technology within 4 hrs of collection. This time period is important because any further delay alters significantly the values of the parameters to be assessed. Three parameters were studied viz. whole blood viscosity, plasma viscosity and RBC filterability. Whole blood viscosity was measured using cone plate viscometer, plasma viscosity by a simple capillary viscometer and RBC filterability by passing red blood cells through carbonate membrane of cylindrical pore filter having a pore diameter of 5/?.
The management of these patients included control of diabetes, control of infection, improvement of nutritional status, improvement of blood flow and surgical treatment depending on type of lesions. The mortality was 5%, the causes being uncontrollable diabetes with ketosis, septicaemia and gas gangrene.
The results of the study are depicted in the form of diagrams in [Figure:1], [Figure:2] and [Figure:3].
As shown in [Figure:1], average whole blood viscosity was 4.66, cp for normal and 4.18 cp for diabetic patients.
Though the values in diabetic patients appeared to be low, the difference was not significant. On the other hand, plasma viscosity was found to be significantly higher than normal (p < 0.05). The passage of RBCs through 5 ? pore size at a given filtration pressure was found to be retarded and filterability of RBCs in diabetic patient was found to be significantly decreased. The 30 diabetic patients had mean haemoglobin 9.9 gm%, mean PCV 34.1 % and mean fibrinogen 500 mg%. These mean values for normal volunteers being 11 gm%, 36% and 300 mg% respectively.
Our data of 30 patients with diabetes (both fresh cases and those taking treatment for 5 years) show that the haemorheological changes are significantly altered as compared to normal.
We found low values of blood viscosity in diabetics as compared to normal individuals. In western population on the other hand, whole blood viscosity in diabetics appeared to be on higher side 2. We attribute variation in our population to lower values of hematocrit (average 34.1 % in diabetics and 36% in normal). The patients who attend our OPD are from poor socio-economic class and therefore poor nutritional status accounts for their low hematocrit level.
Plasma viscosity was found to be significantly higher in diabetic patients. This may be a result of increased plasma fibrinogen (average; 500 mg %) and immunoglobulins (?1, ?2, ? globulins),. A raised plasma viscosity causes sluggish flow in microcirculation and results in insufficient tissue perfusion, as well as endothelial injury.
The reduced RBIG filterability is a result of decreased red cell membrane elasticity, an increased intracellular viscosity and alteration in cytoskeleton of cells in diabetes. Increased viscosity coupled with reduced RBC filterability jeopardize perfusion of microcirculation further.
Thus the altered haemorheological parameters in patients with diabetic foot lesion highlight the need for use of a rheomodulator like pentoxiphylline in the management.
Punyani RR. Evaluation of hemorheological parameters. J Gen Med 1989; 1:5-11.|
|2||Grigoleit HG Lehrach F, Miller R. Diabetic angiopathy and blood viscosity. Acta Diabetol 1973; 10:1311-1323.|
|3||Mc' Millan DE. The effect of diabetes on blood flow properties. Diabetes 1983; 32:56-63.|
|4||Marvin C, Levin L O'Neil. The Diabetic Foot, 2nd ed. Philadelphia: WB Saunders; 1974, pp 73-75.|
|5||Schmid - Schoubein H, Velger E. Red cell aggregation and red cell deformability in diabetes. Diabetes 1976; 25:897-902.|
|6||Mc’Millan DE, Utterback NG. Reduced erythrocyte deformability in diabetes. Diabetes 1978; 27:895-901.