1. Journal Club 亀田メディカルセンター 糖尿病内分泌内科 Diabetes and Endocrine Department, Kameda Medical Center 松田 昌文 Matsuda, Masafumi 2008 年７月 31 日 8:20-8:50 B 棟８階 カンファレンス室 Cheung N, Wang JJ, Rogers SL, Brancati F, Klein R, Sharrett AR, Wong TY; ARIC (Atherosclerosis Risk In Communities) Study Investigators. Diabetic retinopathy and risk of heart failure. J Am Coll Cardiol. 2008 Apr 22;51(16):1573-8. Dixon JB, O'Brien PE, Playfair J, Chapman L, Schachter LM, Skinner S, Proietto J, Bailey M, Anderson M. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA. 2008 Jan 23;299(3):316-23.

3. Aim Microvascular disease might play a more prominent role in the pathogenesis of diabetic cardiomyopathy, a major cause of HF in diabetes. Whether diabetic retinopathy, a microvascular complication of diabetes, predicts HF is unclear. The purpose of this study was to examine the association of diabetic retinopathy with incident heart failure (HF).

4. Methods A population-based study included 1,021 middle-aged type 2 diabetic persons with normal renal function and free of clinical coronary heart disease or HF at baseline. Diabetic retinopathy signs were graded from retinal photographs. Incident HF events were prospectively identified from hospital stay and death records.

6. Heart Failure Free Survival in Participants With and Without Diabetic Retinopathy Participants with diabetic retinopathy were more likely to develop incident heart failure than those without retinopathy in the Atherosclerosis Risk In Communities Study.

8. Results There were 125 (12.8%) participants with diabetic retinopathy. After 9-year follow-up, 106 (10.1%) participants developed incident HF events. Persons with retinopathy were more likely to develop HF (cumulative incidence of 21.6%) than those without retinopathy (cumulative incidence of 8.5%). After controlling for age, gender, race, smoking, diabetes duration, insulin use, blood pressure, lipid profile, and other risk factors, participants with retinopathy had more than 2.5-fold higher risk of developing HF than those without retinopathy (hazard ratio [HR] 2.71; 95% confidence interval [CI] 1.46 to 5.05). This association remained significant after further adjustments for glycemic control, carotid atherosclerosis, and serum markers of endothelial dysfunction (HR 2.20, 95% CI 1.08 to 4.47).

9. Conclusion The presence of diabetic retinopathy signifies an excess risk of HF, independent of known risk factors. This further supports a contribution of microvascular disease to the development of HF in people with diabetes.

11. JAMA. 2008;299(3):316-323

12. Aim Observational studies suggest that surgically induced loss of weight may be effective therapy for type 2 diabetes. Objective ： To determine if surgically induced weight loss results in better glycemic control and less need for diabetes medications than conventional approaches to weight loss and diabetes control. Trial Registration actr.org Identifier: ACTRN012605000159651

13. Methods Design, Setting, and Participants: Unblinded randomized controlled trial conducted from December 2002 through December 2006 at the University Obesity Research Center in Australia, with general community recruitment to established treatment programs. Participants were 60 obese patients (BMI 40) with recently diagnosed (<2 years) type 2 diabetes. Interventions: Conventional diabetes therapy with a focus on weight loss by lifestyle change vs laparoscopic adjustable gastric banding with conventional diabetes care. Main Outcome Measures: Remission of type 2 diabetes (fasting glucose level<126 mg/dL [7.0 mmol/L] and glycated hemoglobin [HbA1c] value <6.2% while taking no glycemic therapy). Secondary measures included weight and components of the metabolic syndrome. Analysis was by intention-to-treat.

14. Figure 1. Participant Recruitment, Assessment, and Participation Throughout the Study

15. Table 1. Baseline Characteristics of Participants a

17. Table 2. Primary and Secondary Outcomes at 2 Years a Abbreviations: CI, confidence interval; HbA1c, glycated hemoglobin; HDL-C, high-density lipoprotein cholesterol; HOMA IR, insulin resistance by homeostatic model assessment; LDL- C, low-density lipoprotein cholesterol; RR, relative risk. SI conversion factors: see Table 1 footnote. a Mean (SD) percentage change for participants with baseline values carried forward for those who dropped out of the study. A comparison of the actual change from baseline is also presented. Data include all 60 participants with baseline data carried forward for missing data. b An indirect measure of insulin resistance calculated from levels of fasting plasma glucose and fasting C- peptide.26 c P <.05 calculated using independent t test.

18. Results Of the 60 patients enrolled, 55 (92%) completed the 2- year follow-up. Remission of type 2 diabetes was achieved by 22 (73%) in the surgical group and 4 (13%) in the conventional-therapy group. Relative risk of remission for the surgical group was 5.5 (95% confidence interval, 2.2-14.0). Surgical and conventional-therapy groups lost a mean (SD) of 20.7% (8.6%) and 1.7% (5.2%) of weight, respectively, at 2 years (P<.001). Remission of type 2 diabetes was related to weight loss (R 2 =0.46, P<.001) and lower baseline HbA1c levels (combined R 2 =0.52, P<.001). There were no serious complications in either group.

19. Conclusion Participants randomized to surgical therapy were more likely to achieve remission of type 2 diabetes through greater weight loss. These results need to be confirmed in a larger, more diverse population and have long-term efficacy assessed.