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Bremer J, Meinhardt A, Katona I, Senderek J, Kämmerer‐Gassler EK, Roos A, Ferbert A, Schröder JM, Nikolin S, Nolte K, Sellhaus B, Popzhelyazkova K, Tacke F, Schara‐Schmidt U, Neuen‐Jacob E, de Groote CC, de Jonghe P, Timmerman V, Baets J, Weis J. Myelin protein zero mutation-related hereditary neuropathies: Neuropathological insight from a new nerve biopsy cohort. Brain Pathol 2024; 34:e13200. [PMID: 37581289 PMCID: PMC10711263 DOI: 10.1111/bpa.13200] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/19/2023] [Indexed: 08/16/2023] Open
Abstract
Myelin protein zero (MPZ/P0) is a major structural protein of peripheral nerve myelin. Disease-associated variants in the MPZ gene cause a wide phenotypic spectrum of inherited peripheral neuropathies. Previous nerve biopsy studies showed evidence for subtype-specific morphological features. Here, we aimed at enhancing the understanding of these subtype-specific features and pathophysiological aspects of MPZ neuropathies. We examined archival material from two Central European centers and systematically determined genetic, clinical, and neuropathological features of 21 patients with MPZ mutations compared to 16 controls. Cases were grouped based on nerve conduction data into congenital hypomyelinating neuropathy (CHN; n = 2), demyelinating Charcot-Marie-Tooth (CMT type 1; n = 11), intermediate (CMTi; n = 3), and axonal CMT (type 2; n = 5). Six cases had combined muscle and nerve biopsies and one underwent autopsy. We detected four MPZ gene variants not previously described in patients with neuropathy. Light and electron microscopy of nerve biopsies confirmed fewer myelinated fibers, more onion bulbs and reduced regeneration in demyelinating CMT1 compared to CMT2/CMTi. In addition, we observed significantly more denervated Schwann cells, more collagen pockets, fewer unmyelinated axons per Schwann cell unit and a higher density of Schwann cell nuclei in CMT1 compared to CMT2/CMTi. CHN was characterized by basal lamina onion bulb formation, a further increase in Schwann cell density and hypomyelination. Most late onset axonal neuropathy patients showed microangiopathy. In the autopsy case, we observed prominent neuromatous hyperinnervation of the spinal meninges. In four of the six muscle biopsies, we found marked structural mitochondrial abnormalities. These results show that MPZ alterations not only affect myelinated nerve fibers, leading to either primarily demyelinating or axonal changes, but also affect non-myelinated nerve fibers. The autopsy case offers insight into spinal nerve root pathology in MPZ neuropathy. Finally, our data suggest a peculiar association of MPZ mutations with mitochondrial alterations in muscle.
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Affiliation(s)
- Juliane Bremer
- Institute of NeuropathologyRWTH Aachen University HospitalAachenGermany
| | - Axel Meinhardt
- Institute of NeuropathologyRWTH Aachen University HospitalAachenGermany
| | - Istvan Katona
- Institute of NeuropathologyRWTH Aachen University HospitalAachenGermany
| | - Jan Senderek
- Friedrich Baur Institute at the Department of NeurologyUniversity Hospital, LMU MunichMunichGermany
| | | | - Andreas Roos
- Institute of NeuropathologyRWTH Aachen University HospitalAachenGermany
- Department of NeuropaediatricsUniversity of EssenEssenGermany
| | | | | | - Stefan Nikolin
- Institute of NeuropathologyRWTH Aachen University HospitalAachenGermany
| | - Kay Nolte
- Institute of NeuropathologyRWTH Aachen University HospitalAachenGermany
| | - Bernd Sellhaus
- Institute of NeuropathologyRWTH Aachen University HospitalAachenGermany
| | | | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité—Universitätsmedizin BerlinCampus Virchow‐Klinikum (CVK) and Campus Charité Mitte (CCM)BerlinGermany
| | | | - Eva Neuen‐Jacob
- Department of NeuropathologyUniversity Hospital, Heinrich‐Heine University DüsseldorfDüsseldorfGermany
| | - Chantal Ceuterick de Groote
- Laboratory of Neuromuscular Pathology, Institute Born‐Bunge, and Translational Neurosciences, Faculty of MedicineUniversity of AntwerpBelgium
| | - Peter de Jonghe
- Laboratory of Neuromuscular Pathology, Institute Born‐Bunge, and Translational Neurosciences, Faculty of MedicineUniversity of AntwerpBelgium
- Department of NeurologyUniversity Hospital AntwerpAntwerpBelgium
| | - Vincent Timmerman
- Laboratory of Neuromuscular Pathology, Institute Born‐Bunge, and Translational Neurosciences, Faculty of MedicineUniversity of AntwerpBelgium
- Peripheral Neuropathy Research Group, Department of Biomedical SciencesUniversity of AntwerpAntwerpBelgium
| | - Jonathan Baets
- Laboratory of Neuromuscular Pathology, Institute Born‐Bunge, and Translational Neurosciences, Faculty of MedicineUniversity of AntwerpBelgium
- Department of NeurologyUniversity Hospital AntwerpAntwerpBelgium
| | - Joachim Weis
- Institute of NeuropathologyRWTH Aachen University HospitalAachenGermany
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Wang P, Liu B, Rong T, Wu B. Is diabetes the risk factor for poor neurological recovery after cervical spine surgery? A review of the literature. Eur J Med Res 2022; 27:263. [PMID: 36419189 PMCID: PMC9686083 DOI: 10.1186/s40001-022-00879-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 11/01/2022] [Indexed: 11/25/2022] Open
Abstract
The poor prognosis of cervical spine surgery is mainly manifested as poor neurological recovery and the presence of new upper extremity dysfunction that promotes significant psychological and physiological burdens on patients. Many factors influence the prognosis of cervical spine surgery, including the age of patients, the time and mode of surgery, and the surgical technique used. However, in clinical studies, it has been observed that patients with diabetes have a higher probability of poor prognosis after surgery. Therefore, we review the pathophysiology of diabetic neuropathies and discuss its impact on cervical nerve system function, especially in cervical nerve roots and upper limb peripheral nerve conduction.
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Horton WB, Barrett EJ. Microvascular Dysfunction in Diabetes Mellitus and Cardiometabolic Disease. Endocr Rev 2021; 42:29-55. [PMID: 33125468 PMCID: PMC7846151 DOI: 10.1210/endrev/bnaa025] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Indexed: 02/07/2023]
Abstract
This review takes an inclusive approach to microvascular dysfunction in diabetes mellitus and cardiometabolic disease. In virtually every organ, dynamic interactions between the microvasculature and resident tissue elements normally modulate vascular and tissue function in a homeostatic fashion. This regulation is disordered by diabetes mellitus, by hypertension, by obesity, and by dyslipidemia individually (or combined in cardiometabolic disease), with dysfunction serving as an early marker of change. In particular, we suggest that the familiar retinal, renal, and neural complications of diabetes mellitus are late-stage manifestations of microvascular injury that begins years earlier and is often abetted by other cardiometabolic disease elements (eg, hypertension, obesity, dyslipidemia). We focus on evidence that microvascular dysfunction precedes anatomic microvascular disease in these organs as well as in heart, muscle, and brain. We suggest that early on, diabetes mellitus and/or cardiometabolic disease can each cause reversible microvascular injury with accompanying dysfunction, which in time may or may not become irreversible and anatomically identifiable disease (eg, vascular basement membrane thickening, capillary rarefaction, pericyte loss, etc.). Consequences can include the familiar vision loss, renal insufficiency, and neuropathy, but also heart failure, sarcopenia, cognitive impairment, and escalating metabolic dysfunction. Our understanding of normal microvascular function and early dysfunction is rapidly evolving, aided by innovative genetic and imaging tools. This is leading, in tissues like the retina, to testing novel preventive interventions at early, reversible stages of microvascular injury. Great hope lies in the possibility that some of these interventions may develop into effective therapies.
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Affiliation(s)
- William B Horton
- Division of Endocrinology and Metabolism, Department of Medicine
| | - Eugene J Barrett
- Division of Endocrinology and Metabolism, Department of Medicine.,Department of Pharmacology, University of Virginia School of Medicine, Charlottesville, Virginia
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Samuelsson K, Mariosa D, Fang F, Press R. Comorbidity of mitochondrial disease and dementia in patients with idiopathic polyneuropathy. Eur J Neurol 2018; 25:882-887. [DOI: 10.1111/ene.13612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 02/28/2018] [Indexed: 12/17/2022]
Affiliation(s)
- K. Samuelsson
- Department of Clinical Neuroscience; Karolinska Institutet; Stockholm
- Department of Neurology; Karolinska University Hospital; Stockholm
| | - D. Mariosa
- Department of Medical Epidemiology and Biostatistics; Karolinska Institutet; Stockholm Sweden
| | - F. Fang
- Department of Medical Epidemiology and Biostatistics; Karolinska Institutet; Stockholm Sweden
| | - R. Press
- Department of Clinical Neuroscience; Karolinska Institutet; Stockholm
- Department of Neurology; Karolinska University Hospital; Stockholm
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Samuelsson K, Press R. Microangiopathy-A Potential Contributing Factor to Idiopathic Polyneuropathy: A Mini Review. Front Neurol 2018; 9:43. [PMID: 29483890 PMCID: PMC5816333 DOI: 10.3389/fneur.2018.00043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 01/17/2018] [Indexed: 12/13/2022] Open
Abstract
Chronic idiopathic axonal polyneuropathy (CIAP) is a slowly progressive predominantly sensory axonal polyneuropathy. The prevalence of CIAP increases with age. The pathogenic cause of CIAP is unknown although there are several prevailing etiological hypotheses. In this mini review, we focus on the hypothesis of disturbed microcirculation in the vasa nervorum of peripheral nerves as a pathogenic cause of CIAP. There is an association between CIAP and metabolic risk factors. Furthermore, the phenotype of CIAP resembles diabetic neuropathy both clinically and electrophysiologically. In sural nerve biopsies from patients with diabetes mellitus, structural abnormalities indicating microangiopathy in the endoneurial microvessels are well documented. Similarly, sural microvessel abnormalities have been shown in patients with atherosclerotic non-diabetic peripheral vascular disease. However, the reported histopathological alterations of microvasculature in sural nerves of CIAP patients are inconsistent. Two studies report microangiopathic changes in CIAP sural nerves comparable with those found in patients with diabetic neuropathy. Conversely, another recent study showed no significant differences in the microangiopathic parameters in the endoneurial microvessels in the sural nerve biopsies from CIAP patients compared to controls without polyneuropathy. However, this CIAP patient group was younger compared to the patient groups in the other two studies. A general limitation with the published morphological studies are that different methods have been used in the assessment of microangiopathy, and there is also a risk of subjectivity in the results. Immunohistochemistry studies of sural nerves with verification of microangiopathy using specific biomarkers would be of great interest to develop.
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Affiliation(s)
- Kristin Samuelsson
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Rayomand Press
- Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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Samuelsson K, Osman AAM, Angeria M, Risling M, Mohseni S, Press R. Study of Autophagy and Microangiopathy in Sural Nerves of Patients with Chronic Idiopathic Axonal Polyneuropathy. PLoS One 2016; 11:e0163427. [PMID: 27662650 PMCID: PMC5035003 DOI: 10.1371/journal.pone.0163427] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 09/08/2016] [Indexed: 01/07/2023] Open
Abstract
Twenty-five percent of polyneuropathies are idiopathic. Microangiopathy has been suggested to be a possible pathogenic cause of chronic idiopathic axonal polyneuropathy (CIAP). Dysfunction of the autophagy pathway has been implicated as a marker of neurodegeneration in the central nervous system, but the autophagy process is not explored in the peripheral nervous system. In the current study, we examined the presence of microangiopathy and autophagy-related structures in sural nerve biopsies of 10 patients with CIAP, 11 controls with inflammatory neuropathy and 10 controls without sensory polyneuropathy. We did not find any significant difference in endoneurial microangiopathic markers in patients with CIAP compared to normal controls, though we did find a correlation between basal lamina area thickness and age. Unexpectedly, we found a significantly larger basal lamina area thickness in patients with vasculitic neuropathy. Furthermore, we found a significantly higher density of endoneurial autophagy-related structures, particularly in patients with CIAP but also in patients with inflammatory neuropathy, compared to normal controls. It is unclear if the alteration in the autophagy pathway is a consequence or a cause of the neuropathy. Our results do not support the hypothesis that CIAP is primarily caused by a microangiopathic process in endoneurial blood vessels in peripheral nerves. The significantly higher density of autophagy structures in sural nerves obtained from patients with CIAP and inflammatory neuropathy vs. controls indicates the involvement of this pathway in neuropathy, particularly in CIAP, since the increase in density of autophagy-related structures was more pronounced in patients with CIAP than those with inflammatory neuropathy. To our knowledge this is the first report investigating signs of autophagy process in peripheral nerves in patients with CIAP and inflammatory neuropathy.
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Affiliation(s)
- Kristin Samuelsson
- Department of Clinical Neuroscience, Department of Neurology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- * E-mail:
| | - Ayman A. M. Osman
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
| | - Maria Angeria
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mårten Risling
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Simin Mohseni
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
| | - Rayomand Press
- Department of Clinical Neuroscience, Department of Neurology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Abstract
ABSTRACT:Rational treatment of diabetic polyneuropathy depends upon establishing its cause, which is at present unknown. A number of animal models of diabetes have been examined and although abnormalities are detectable in the peripheral nervous system they do not duplicate the degenerative neuropathy encountered in the human. The relevance of these abnormalities is therefore uncertain, although they may reflect the earlier changes in man. For human neuropathy, it is likely that vascular lesions or an abnormal susceptibility to mechanical injury are responsible for focal neuropathies. The evidence that ischaemia and hypoxia are responsible for the diffuse sensory neuropathy and autonomic polyneuropathy is still equivocal and it is often difficult to establish whether the vascular changes are primary or secondary. Metabolic explanations, such as sorbitol accumulation in nerve, have not so far been adequately validated by responses to treatment. The manifestations of diabetic neuropathy are complex and a single explanation should not be sought.
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Abstract
As ensheathing and secretory cells, Schwann cells are a ubiquitous and vital component of the endoneurial microenvironment of peripheral nerves. The interdependence of axons and their ensheathing Schwann cells predisposes each to the impact of injury in the other. Further, the dependence of the blood-nerve interface on trophic support from Schwann cells during development, adulthood, and after injury suggests these glial cells promote the structural and functional integrity of nerve trunks. Here, the developmental origin, injury-induced changes, and mature myelinating and nonmyelinating phenotypes of Schwann cells are reviewed prior to a description of nerve fiber pathology and consideration of pathogenic mechanisms in human and experimental diabetic neuropathy. A fundamental role for aldose-reductase-containing Schwann cells in the pathogenesis of diabetic neuropathy, as well as the interrelationship of pathogenic mechanisms, is indicated by the sensitivity of hyperglycemia-induced biochemical alterations, such as polyol pathway flux, formation of reactive oxygen species, generation of advanced glycosylation end products (AGEs) and deficient neurotrophic support, to blocking polyol pathway flux.
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Affiliation(s)
- Andrew P Mizisin
- Department of Pathology, School of Medicine, University of California San Diego, La Jolla, CA, USA.
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Kim H, Kim JJ, Yoon YS. Emerging therapy for diabetic neuropathy: cell therapy targeting vessels and nerves. Endocr Metab Immune Disord Drug Targets 2012; 12:168-78. [PMID: 22236028 DOI: 10.2174/187153012800493486] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 09/27/2011] [Indexed: 01/19/2023]
Abstract
Diabetic neuropathy (DN), the most common complication of diabetes, frequently leads to foot ulcers and may progress to limb amputations. Despite continuous increase in incidence, there is no clinical therapy to effectively treat DN. Pathogenetically, DN is characterized by reduced vascularity in peripheral nerves and deficiency in angiogenic and neurotrophic factors. We will briefly review the pathogenetic mechanism of DN and address the effects and the mechanisms of cell therapies for DN. To reverse the changes of DN, studies have attempted to deliver neurotrophic or angiogenic factors for treatment in the form of protein or gene therapy; however, the effects turned out to be very modest if not ineffective. Recent studies have demonstrated that bone marrow (BM)-derived cells such as mononuclear cells or endothelial progenitor cells (EPCs) can effectively treat various cardiovascular diseases through their paracrine effects. As BM-derived cells include multiple angiogenic and neurotrophic cytokines, these cells were used for treating experimental DN and found to reverse manifestations of DN. Particularly, EPCs were shown to exert favorable therapeutic effects through enhanced neural neovascularization and neuro-protective effects. These findings clearly indicate that DN is a complex disorder with pathogenetic involvement of both vascular and neural components. Studies have shown that cell therapies targeting both vascular and neural elements are shown to be advantageous in treating DN.
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Affiliation(s)
- Hyongbum Kim
- Graduate School of Biomedical Science and Engineering/College of Medicine, Hanyang University, Seoul, Korea
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10
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Professor P. K. Thomas: clinician, investigator, editor and leader—a retrospective appreciation. Brain 2011; 134:618-26. [DOI: 10.1093/brain/awq230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
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11
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O'Donnell ME, Badger SA, Anees Sharif M, Makar RR, Young IS, Lee B, Soong CV. The Effects of Cilostazol on Peripheral Neuropathy in Diabetic Patients With Peripheral Arterial Disease. Angiology 2008; 59:695-704. [DOI: 10.1177/0003319708321100] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Evidence from diabetic animal models suggests that cilostazol, a cyclic AMP phosphodiesterase inhibitor used in the treatment of claudication, is efficacious in the treatment of peripheral neuropathy, although this is unproven in humans. The main aim of this study was to assess the effects of cilostazol on neuropathic symptomatology in diabetic patients with peripheral arterial disease (PAD). Methods Diabetic patients with PAD were prospectively recruited to a randomized double-blinded placebo-controlled trial. Baseline clinical data were recorded prior to trial commencement following medical optimization. Neurological assessment included the Toronto Clinical Neuropathy Scoring system (TCNS) and vibration perception thresholds (VPT) with a neurothesiometer at baseline, 6 weeks, and 24 weeks. Results Twenty-six patients were recruited from December 2004 to January 2006, which included 20 males. Baseline patient allocation to treatment arms was matched for age, sex, and medical comorbidities. There was no significant difference in neurological assessment between the treatment groups using the TCNS and VPT at 6 and 24 weeks. Conclusions Despite extensive animal-based evidence that cilostazol attenuates neuropathic symptomatology, our results do not support this effect in human diabetic PAD patients.
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Affiliation(s)
- Mark E. O'Donnell
- Department of Vascular and Endovascular Surgery, Belfast City Hospital, Belfast, Faculty of Life and Health Sciences, University of Ulster, Ulster Northern Ireland, United Kingdom,
| | - Stephen A. Badger
- Department of Vascular and Endovascular Surgery, Belfast City Hospital, Belfast
| | | | - Ragai R. Makar
- Department of Vascular and Endovascular Surgery, Belfast City Hospital, Belfast
| | - Ian S. Young
- Department of Medicine, Queen's University, Belfast
| | - Bernard Lee
- Department of Vascular and Endovascular Surgery, Belfast City Hospital, Belfast
| | - Chee V. Soong
- Department of Vascular and Endovascular Surgery, Belfast City Hospital, Belfast
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Estrella JS, Nelson RN, Sturges BK, Vernau KM, Williams DC, LeCouteur RA, Shelton GD, Mizisin AP. Endoneurial microvascular pathology in feline diabetic neuropathy. Microvasc Res 2007; 75:403-10. [PMID: 18207200 DOI: 10.1016/j.mvr.2007.12.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2007] [Revised: 11/16/2007] [Accepted: 12/07/2007] [Indexed: 10/22/2022]
Abstract
Endoneurial capillaries in nerve biopsies from 12 adult diabetic cats with varying degrees of neurological dysfunction were examined for evidence of microvascular pathology and compared to nerves obtained at necropsy from 7 adult non-diabetic cats without clinical evidence of neurological dysfunction. As reported previously [Mizisin, A.P., Nelson, R.W., Sturges, B.K., Vernau, K.M., LeCouteur, R.A., Williams, D.C., Burgers, M.L., Shelton, G.D., 2007. Comparable myelinated nerve pathology in feline and human diabetes mellitus. Acta Neuropathol. 113, 431-442.], the diabetic cats had elevated glycosylated hemoglobin and serum fructosamine levels, decreased motor nerve conduction velocity and compound muscle action potential (CMAP) amplitude, and markedly decreased myelinated nerve fiber densities. Compared to non-diabetic cats, there was a non-significant 26% increase in capillary density and a significant (P<0.009) 45% increase in capillary size in diabetic cats. Capillary luminal size was also significantly (P<0.001) increased, while an index of vasoconstriction was significantly decreased (P<0.001) in diabetic cats compared to non-diabetic controls. No differences in endothelial cell size, endothelial cell number or pericyte size were detected between non-diabetic and diabetic cats. In diabetic cats, basement membrane thickening, seen as a reduplication of the basal lamina, was significantly (P<0.0002) increased by 73% compared to non-diabetic controls. Regression analysis of either myelinated nerve fiber density or CMAP amplitude against basement membrane size demonstrated a negative correlation with significant slopes (P<0.03 and P<0.04, respectively). These data demonstrate that myelinated nerve fiber injury in feline diabetic neuropathy is associated with microvascular pathology and that some of these changes parallel those documented in experimental rodent and human diabetic neuropathy.
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Affiliation(s)
- Jeannelyn S Estrella
- Department of Pathology 0612, School of Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0612, USA
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Malik RA, Tesfaye S, Newrick PG, Walker D, Rajbhandari SM, Siddique I, Sharma AK, Boulton AJM, King RHM, Thomas PK, Ward JD. Sural nerve pathology in diabetic patients with minimal but progressive neuropathy. Diabetologia 2005; 48:578-85. [PMID: 15729579 DOI: 10.1007/s00125-004-1663-5] [Citation(s) in RCA: 162] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2004] [Accepted: 11/17/2004] [Indexed: 10/25/2022]
Abstract
AIMS/HYPOTHESIS The early pathological features of human diabetic neuropathy are not clearly defined. Therefore we quantified nerve fibre and microvascular pathology in sural nerve biopsies from diabetic patients with minimal neuropathy. METHODS Twelve diabetic patients underwent detailed assessment of neuropathy and fascicular sural nerve biopsy at baseline, with repeat assessment of neuropathy 8.7+/-0.6 years later. RESULTS At baseline, neuropathic symptoms, neurological deficits, quantitative sensory testing, cardiac autonomic function and peripheral nerve electrophysiology showed minimal abnormality, which deteriorated at follow-up. Myelinated fibre density, fibre and axonal area, and g-ratio were normal but teased fibre studies showed paranodal abnormalities (p<0.001), segmental demyelination (p<0.01) and remyelination (p<0.01) without axonal degeneration. Unassociated Schwann cell profile density (p<0.04) and unmyelinated axon density (p<0.001) were increased and axon diameter was decreased (p<0.007). Endoneurial capillaries demonstrated basement membrane thickening (p<0.006), endothelial cell hyperplasia (p<0.004) and a reduction in luminal area (p<0.007). CONCLUSIONS/INTERPRETATION The early pathological features of human diabetic neuropathy include an abnormality of the myelinated fibre Schwann cell and unmyelinated fibre degeneration with regeneration. These changes are accompanied by a significant endoneurial microangiopathy.
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Affiliation(s)
- R A Malik
- Department of Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK.
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Hill RE, Williams PE. Perineurial cell basement membrane thickening and myelinated nerve fibre loss in diabetic and nondiabetic peripheral nerve. J Neurol Sci 2004; 217:157-63. [PMID: 14706218 DOI: 10.1016/j.jns.2003.09.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Diabetic neuropathy is associated with changes in the extracellular matrix of the perineurium, including thickening of the basement membrane of the perineurial cells. Peripheral vascular disease (PVD) is a common vascular condition that can occur in the absence or presence of diabetes. Thickening of the vascular basement membrane of the vasa nervorum is associated with both diabetes and nondiabetic peripheral vascular disease. However, perineurial cell basement membrane (PCBM) thickening in the nondiabetic PVD state has not, until now, been investigated. In this study, 36 nerve fascicles were examined from three patient groups: a diabetic group, a nondiabetic PVD group, and a group free of both PVD and diabetes (control group). PCBM thickness, fascicle size, and myelinated nerve fibre (MNF) density were measured in all three groups. Endoneurial blood vessels were also observed for evidence of morphological changes. The results showed that the thickness of the PCBM is significantly greater in the diabetic group in comparison with both the control and the nondiabetic PVD group, and this increase in thickness is linearly related to fascicle size. The thickness of the PCBM was not significantly different between the nondiabetic PVD and control groups. Although both the nondiabetic PVD and diabetic groups showed a loss of myelinated nerve fibres in comparison with the control group, this loss was statistically greater in the diabetic group. The endoneurial blood vessels of both the diabetic and nondiabetic PVD groups showed evidence of endothelial cell hyperplasia, hypertrophy, and basement membrane reduplication.
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Affiliation(s)
- Rebecca E Hill
- School of Nursing, Social Work and Applied Health Studies, The University of Hull, Cottingham Road, HU6 7RX, Hull, UK
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Thrainsdottir S, Malik RA, Dahlin LB, Wiksell P, Eriksson KF, Rosén I, Petersson J, Greene DA, Sundkvist G. Endoneurial capillary abnormalities presage deterioration of glucose tolerance and accompany peripheral neuropathy in man. Diabetes 2003; 52:2615-22. [PMID: 14514647 DOI: 10.2337/diabetes.52.10.2615] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To explore whether microangiopathy is associated with disturbed glucose tolerance and peripheral neuropathy, we assessed endoneurial capillary morphology in sural nerve biopsies from men with diabetes, impaired glucose tolerance (IGT), and normal glucose tolerance (NGT). Baseline morphology was related to glucose tolerance and neuropathy at baseline and at follow-up 6 years later. Capillary density (in number per millimeters squared) at baseline was higher in subjects with diabetes (n = 10) compared with those with NGT (n = 5) at follow-up (median [interquartile range]) (86.0 [24.3] vs. 54.9 [17.1]; P = 0.0200) and in those progressing from IGT to diabetes (n = 4) compared with those with persistent IGT (n = 4) (86.7 [25.2] vs. 54.1 [14.6]; P = 0.0433). The capillary luminal area (in micrometers squared) was lower in subjects with NGT progressing to IGT (n = 2) or subjects with IGT progressing to diabetes (n = 3) compared with subjects with constant NGT (n = 6) or constant IGT (n = 4) (11.9 [2.4] vs. 20.8 [7.8]; P = 0.0201). The capillary basement membrane area (in micrometers squared) was increased in patients with peripheral neuropathy (n = 10) compared with those without (n = 7) (114.6 [68.8] vs. 75.3 [28.7]; P = 0.0084). In conclusion, increased capillary density was associated with current or future diabetes, decreased capillary luminal area with future deterioration in glucose tolerance, and increased basement membrane area with peripheral neuropathy.
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Affiliation(s)
- Soley Thrainsdottir
- Department of Neurology, University of Lund, Malmö University Hospital, Malmö, Sweden
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Zochodne DW. Nerve and ganglion blood flow in diabetes: an appraisal. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2003; 50:161-202. [PMID: 12198810 DOI: 10.1016/s0074-7742(02)50077-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Vasa nervorum, the vascular supply to peripheral nerve trunks, and their associated cell bodies in ganglia have unique anatomical and physiological characteristics. Several different experimental approaches toward understanding the changes in vase nervorum following injury and disease have been used. Quantative techniques most widely employed have been microelectrode hydrogen clearance palarography and [14C]iodoantipyrine autoradiographic distribution, whereas estimates of red blood cell flux using a fiber-optic laser Doppler probe offer real time data at different sites along the nerve trunk. There are important caveats about the use of these techniques, their advantages, and their limitations. Reports of nerve blood flow require careful documentation of physiological variables, including mean arterial pressure and nerve temperature during the recordings. Several ischemic models of the peripheral nerve trunk have addressed the ischemic threshold below which axonal degeneration ensues (< 5ml/100 g/min). Following injury, rises in local blood flow reflect acitons of vasoactive peptides, nitric oxide, and the development of angiogenesis. In experimental diabetes, a large number of studies have documented reductions in nerve blood flow and tandem corrections of nerve blood flow and conduction slowing. A significant proportions, however, of the work can be criticized on the basis of methodology and interpretation. Similarly, not all work has confirmed that reductions of nerve blood flow are an invariable feature of experimental or human diabetic polyneuropathy. Therefore, while there is disagreement as to whether early declines in nerve blood flow "account" for diabetic polyneuropathy, there is unquestioned eveidence of early microangiopathy. Abnormalities of vase nervorum and micorvessels supplying ganglia at the very least develop parallel to and together with changes in neurons, Schwann cells, and axons.
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Affiliation(s)
- Douglas W Zochodne
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada T2N 4N1
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17
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Abstract
In this article we will review the clinical signs and symptoms of diabetic somatic polyneuropathy (DPN), its prevalence and clinical management. Staging and classification of DPN will be exemplified by various staging paradigms of varied sophistication. The results of therapeutic clinical trials will be summarized. The pathogenesis of diabetic neuropathy reviews an extremely complex issue that is still not fully understood. Various recent advances in the understanding of the disease will be discussed, particularly with respect to the differences between neuropathy in the two major types of diabetes. The neuropathology and natural history of diabetic neuropathy will be discussed pointing out the heterogeneities of the disease. Finally, the various prospective therapeutic avenues will be dealt with and discussed.
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Affiliation(s)
- K Sugimoto
- Department of Pathology, Wayne State University, School of Medicine and Detroit Medical Center, Detroit, MI 48201, USA
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18
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Thomas PK, King RH, Feng SF, Muddle JR, Workman JM, Gamboa J, Tapia R, Vargas M, Appenzeller O. Neurological manifestations in chronic mountain sickness: the burning feet-burning hands syndrome. J Neurol Neurosurg Psychiatry 2000; 69:447-52. [PMID: 10990502 PMCID: PMC1737143 DOI: 10.1136/jnnp.69.4.447] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To characterise the clinical features and nerve biopsy findings in patients with chronic mountain sickness (CMS) living in the Peruvian Andes, with particular attention to the occurrence of the "burning feet-burning hands" syndrome. METHODS Symptoms and signs were documented clinically in 10 patients with CMS and compared with those in five healthy subjects all living at 4338 metres altitude. Sural nerve biopsies were obtained from three patients with CMS. The nerve fibre population and endoneurial microvessels were analyzed morphometrically. RESULTS All patients with CMS experienced burning and tingling paraesthesiae in the distal parts of their limbs. Similar but milder symptoms confined to the feet occurred in four of five controls. Three patients with CMS had a mild sensory neuropathy on examination, controls were clinically normal. Nerve biopsies showed a mild demyelinating neuropathy in all three with a reduction in the unmyelinated axon population in one. The endoneurial blood vessels showed a reduced thickness in the basal laminal zone compared with control values but were otherwise normal. CONCLUSIONS Apart from well recognised symptoms and signs of CMS, the study has shown that such patients may also exhibit a mild sensory neuropathy. Its relation to the burning feet-burning hands syndrome, which was not confined to the patients but was also found in controls at altitude, is uncertain. The time course and pattern of the centrifugal resolution of the burning paraesthesiae complex on low altitude sojourn of high altitude natives raises the possibility that a mechanism involving altered axonal transport may be involved. The reduced thickness of the basal laminal zone of microvessels implies that adaptive structural changes to hypobaric hypoxia may also occur in peripheral nerve and are similar to those reported in other tissues of high altitude natives.
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Affiliation(s)
- P K Thomas
- University Department of Clinical Neurology, Institute of Neurology, London WC1N 3BG, UK.
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19
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Rehman HU. The role of growth hormone in the pathogenesis of vascular complications of diabetes mellitus. Am J Med Sci 2000; 320:128-34. [PMID: 10981489 DOI: 10.1097/00000441-200008000-00012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- H U Rehman
- Department of Medicine, Hull Royal Infirmary, Ireland
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20
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Khawaja KI, Walker D, Hayat SA, Boulton AJ, Malik RA. Clinico-pathological features of postural hypotension in diabetic autonomic neuropathy. Diabet Med 2000; 17:163-6. [PMID: 10746489 DOI: 10.1046/j.1464-5491.2000.00238.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report the clinico-pathological features and management of a 49-year-old male with a 30-year history of Type 1 diabetes mellitus who had nephropathy (proteinuria 1.81 g/24 h, creatinine 136 micromol/l), proliferative retinopathy and severe somatic and autonomic neuropathy. A sural nerve biopsy demonstrated marked myelinated fibre loss with unmyelinated fibre degeneration and regeneration combined with extensive endoneurial microangiopathy. The management of the patient's blood pressure problems (supine hypertension) and symptomatic postural hypotension is discussed.
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Affiliation(s)
- K I Khawaja
- Department of Medicine, Manchester Royal Infirmary, UK
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21
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King RH, Tournev I, Colomer J, Merlini L, Kalaydjieva L, Thomas PK. Ultrastructural changes in peripheral nerve in hereditary motor and sensory neuropathy-Lom. Neuropathol Appl Neurobiol 1999; 25:306-12. [PMID: 10476047 DOI: 10.1046/j.1365-2990.1999.00174.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Ultrastructural observations have been made on nerve biopsy specimens from five cases of hereditary motor and sensory neuropathy-Lom (HMSNL). A number of features that distinguish it from other hereditary demyelinating neuropathies were identified. Teased fibre studies were not feasible but examination of longitudinal sections by electron microscopy demonstrated demyelination/remyelination. Severe progressive axonal loss was a conspicuous feature. There was no indication of axonal atrophy. Hypertrophic onion bulb changes were present in the younger patients which later regressed, probably secondary to axonal loss. Myelin thickness was generally reduced in relation to axon diameter, indicating hypomyelination, and partial ensheathment of axons by Schwann cells was observed. The Schmidt-Lanterman incisures were atypical in extending for long lengths along the internode. Uncompacted myelin with a periodicity greater than that observed in other neuropathies in which it occurs was a feature, as was the accumulation of pleomorphic material in the adaxonal Schwann cell cytoplasm. An unusual finding was the presence of intra-axonal accumulations of irregularly arranged curvilinear profiles. These resemble those that have been described in experimental vitamin E deficiency. The amount of endoneurial collagen was markedly increased and some endoneurial blood vessels showed a non-specific basal laminal reduplication.
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Affiliation(s)
- R H King
- Royal Free and University College Medical School, London, UK
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22
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McKenzie D, Nukada H, van Rij AM, McMorran PD. Endoneurial microvascular abnormalities of sural nerve in non-diabetic chronic atherosclerotic occlusive disease. J Neurol Sci 1999; 162:84-8. [PMID: 10064174 DOI: 10.1016/s0022-510x(98)00303-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neuropathic abnormalities are found in chronically ischaemic limbs associated with non-diabetic atherosclerotic peripheral vascular disease (PVD). In chronic ischaemic neuropathy, microvascular alterations play a key role in its development. We undertook morphometric assessment of endoneurial microvessels in the sural nerves, taken from severely ischaemic amputated legs in nine chronic non-diabetic PVD. These subjects had threatened ischaemic limbs and revealed clinical, physiological and pathological evidence of neuropathy. For comparison, sural nerves taken from amputated legs due to non-ischaemic disorders (n=4) and chronic PVD associated with diabetes (n=3) were also assessed. We evaluated the areas of vascular lumen, endothelial cells and whole vessel, as well as the percentage of closed capillaries. Endothelial area of sural nerve microvessels in non-diabetic PVD nerves was significantly greater than in non-ischaemic control nerves. Periendothelial cell area containing pericytes and basement membranes was also significantly increased in non-diabetic PVD nerves when compared with control nerves. Vascular lumen area was significantly less in non-diabetic PVD nerves than in non-ischaemic control nerves. Endoneurial microvessels in diabetic PVD nerves showed similar results: thickened vessel wall and smaller lumen. Periendothelial area in diabetic nerves was significantly greater than in non-diabetic PVD nerves. We demonstrated swollen endothelial cells and increased periendothelial area associated with narrowed lumen in sural nerve endoneurial microvessels of severe chronic PVD. Basement membrane reduplication of endoneurial capillaries was seen in non-diabetic PVD nerves. These microvascular abnormalities could play an important role in the development of chronic ischaemic neuropathy in PVD limbs.
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Affiliation(s)
- D McKenzie
- Department of Medicine, University of Otago Medical School, Dunedin, New Zealand
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23
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Abstract
Better clinical characteristics and a standardized approach to the definition of neuropathy has enabled us to define more precisely the natural history of diabetic neuropathy. Detailed studies on the pathology and pathogenesis have allowed dissection of important pathogenetic pathways. Effective treatment is currently limited, although a number of new and potentially important therapeutic interventions, including modification of the vascular supply and antioxidant status and growth factors, may prove to be of benefit in preventing damage and also promoting repair of peripheral nerves in human diabetic neuropathy.
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Affiliation(s)
- A J Boulton
- Department of Medicine, University of Manchester, United Kingdom
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24
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Yagihashi S. Pathology and pathogenetic mechanisms of diabetic neuropathy. DIABETES/METABOLISM REVIEWS 1995; 11:193-225. [PMID: 8536541 DOI: 10.1002/dmr.5610110304] [Citation(s) in RCA: 113] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- S Yagihashi
- Department of Pathology, Hirosaki University School of Medicine, Japan
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25
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Bradley JL, Thomas PK, King RH, Muddle JR, Ward JD, Tesfaye S, Boulton AJ, Tsigos C, Young RJ. Myelinated nerve fibre regeneration in diabetic sensory polyneuropathy: correlation with type of diabetes. Acta Neuropathol 1995; 90:403-10. [PMID: 8546031 DOI: 10.1007/bf00315014] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Observations were made on myelinated fibre regeneration in diabetic sensory polyneuropathy assessed in sural nerve biopsy specimens. These confirmed that regenerative clusters initially develop within abnormally persistent Schwann cell basal laminal tubes. The number of regenerating fibres, identified by light microscopy, was found to decline in proportion to the reduction in total myelinated fibre density. The relative number of regenerating fibres was significantly greater in patients with insulin-dependent as compared with those with non-insulin-dependent diabetes after correction for age. There was a slight negative correlation between the relative proportion of regenerating fibres and age, but this was not statistically significant. The progressive reduction in the number of regenerating fibres with declining total fibre density indicates that axonal regeneration fails with advancing neuropathy. The production of nerve growth factor (NGF) and NGF receptors by denervated Schwann cells is likely to be important for axonal regeneration. To investigate whether the failure of axonal regeneration could be related to a lack of NGF receptor production by Schwann cells, we examined the expression of p75 NGF receptors by Büngner bands immunocytochemically. In comparison with other types of peripheral neuropathy, p75 NGF receptor expression appeared to take place normally. It is concluded that failure of axonal regeneration constitutes an important component in diabetic neuropathy. Its explanation requires further investigation.
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Affiliation(s)
- J L Bradley
- Department of Clinical Neurosciences, Royal Free Hospital School of Medicine, London, UK
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26
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Benstead TJ, Sangalang VE. Nerve microvessel changes in diabetes are prevented by aldose reductase inhibition. Neurol Sci 1995; 22:192-7. [PMID: 8529170 DOI: 10.1017/s0317167100039834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite the potential importance of endoneurial microvessel abnormalities in diabetic neuropathy, the pathogenesis of these abnormalities is incompletely understood. We wished to evaluate the effect of experimental diabetes on endoneurial microvessels and determine if an aldose reductase inhibitor alters any of the changes induced by diabetes. METHODS We compared streptozocin diabetic rats with and without aldose reductase inhibitor treatment to non-diabetic rats after 10 months of diabetes. Transverse microvessels from the mid-sciatic level were studied by electron microscopic morphometric evaluation. RESULTS Microvessel endothelial, pericyte, basement membrane and total mural area were greater in untreated diabetic animals than non-diabetic animals. Aldose reductase inhibitor treated diabetic animals had greater endothelial area and possibly pericyte area but not basement membrane or total mural area. CONCLUSIONS This study demonstrates that endoneurial microvessel abnormalities can be detected in experimental diabetic neuropathy. Microvessel basement membrane thickening will be prevented by an aldose reductase inhibitor. One mechanism by which abnormal polyol pathway activity may contribute to diabetic neuropathy could be through damage to microvessels.
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Affiliation(s)
- T J Benstead
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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27
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Abstract
We have measured non-enzymatic glycation of proteins in the cytoskeletal and myelin fractions of nerve fascicles from human sural nerves obtained from diabetic and non-diabetic amputation specimens. Levels of the early reversible glycation adduct, measured as furosine did not differ significantly between diabetics and controls in either protein fraction. Pentosidine levels per unit protein were significantly elevated in diabetics relative to controls in both cytoskeletal (5.96 vs 4.47; p = 0.037) and myelin protein (1.35 vs 0.69; p = 0.023) fractions. Protein cross-linkage in the cytoskeletal fraction, probably due to AGEs, was also higher in diabetics than controls (504 vs 349; p = 0.057). These results show that increased AGE accumulation occurs in cytoskeletal, as well as myelin, peripheral nerve proteins in diabetics. This suggests a possible new mechanism contributing to the axonal degeneration polyneuropathy of diabetes which is based upon irreversible glycation of axonal cytoskeletal proteins causing their cross-linkage and altered function.
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Affiliation(s)
- C Ryle
- Institute of Molecular Medicine, University of Oxford, UK
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28
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Abstract
Neuropathy is the most common symptomatic chronic complication in diabetic patients and accounts for substantial morbidity in the diabetic population. It is predominently a disease of the older diabetic population, and shows a progressive course with limb amputation as the final end-point of the disease. Pathologically the disorder is characterised by progressive degeneration as well as impaired regenerative ability of peripheral nerve fibers, resulting in a progressive loss and dying-back of the longest nerve fibres innervating the distal limbs. These changes are associated with progressive impairment of nerve function leading to impaired sensitivity in the limbs, which sometimes is associated with troublesome pain. Qualitatively similar but much milder functional and structural changes occur during normal aging processes, which potentially could make elderly diabetic patients more susceptible to an additional hyperglycaemic insult. The mechanisms underlying the development of diabetic neuropathy involve hyperglycaemia-induced metabolic abnormalities of peripheral nerve fibres and the supporting nutritive vascular supply. One of the major abnormalities involves activation of the polyol pathway with subsequent impairments in nerve function and vascular supply. Since hyperglycaemia appears to be the major culprit in the development of diabetic neuropathy, good glycaemic control is paramount in the long term treatment of diabetic patients to attenuate the development and/or progression of the disorder. Furthermore, elimination of risk factors such as obesity, smoking and excessive alcohol (ethanol) consumption, as well as patient education, are all important factors in the care of diabetic patients. In symptomatic neuropathic patients, including those with painful neuropathy, symptomatic and palliative measures are often effective. Stepwise addition of antidepressants to simple analgesics has proven to be effective in patients with troublesome pain. During recent years a class of drugs have been developed that inhibits the activation of the polyol pathway in diabetic nerves. These so-called aldose reductase inhibitors hold promise for a targeted treatment regimen in the near future. The aldose reductase inhibitors are already available in several European countries and in Japan.
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Affiliation(s)
- A A Sima
- Department of Pathology, University of Michigan Medical Center, Ann Arbor, USA
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29
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Abstract
A variety of soluble growth factors influence the peripheral nervous system. Although of considerable importance during development and growth, they appear also to be implicated in tissue maintenance in adult life and, particularly, during nerve regeneration. In addition, cell-surface and extracellular connective tissue matrix molecules are intimately involved in regeneration. So far, the possible participation of such growth factors in the causation of diabetic neuropathy is only speculative, but there are indications that their use could be of value in treatment.
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Affiliation(s)
- P K Thomas
- Department of Neurosciences, Royal Free Hospital School of Medicine, London, UK
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30
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Giannini C, Dyck PJ. Ultrastructural morphometric abnormalities of sural nerve endoneurial microvessels in diabetes mellitus. Ann Neurol 1994; 36:408-15. [PMID: 8080248 DOI: 10.1002/ana.410360312] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We evaluated 433 transversely sectioned microvessels from 54 sural nerves of diabetic patients with (43) and without (11) polyneuropathy and compared the findings with those of 366 microvessels from 50 sural nerves from controls, spanning the same ages. Whereas the number of microvessels per square millimeter and lumen areas and their size distribution were not significantly different between diabetic patients and controls, striking changes of the vessel wall were found in the nerves of diabetic patients. Mural area containing reduplicated basement membranes and pericyte degeneration were significantly increased in diabetic when compared with control nerves. A very low frequency of microvessel degeneration and endothelial cell separation was also encountered but only in diabetics with polyneuropathy. The microvessel changes we have found in nerve largely confirm and strengthen our previous findings. This study provides additional strong support for the idea that the mural changes of endoneurial microvessels do not relate to aging but do relate to diabetes mellitus. The structural alterations of endoneurial microvessel mirror changes seen in diabetic retinopathy and are sufficiently severe that they may accompany and account for functional alterations of the blood-nerve barrier and endoneurial microenvironment. It remains to be shown whether and how these changes relate to the development of polyneuropathy.
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Affiliation(s)
- C Giannini
- Department of Neurology, Mayo Clinic, Rochester, MN 55905
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31
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Abstract
Diabetes mellitus is associated with multiple connective tissue changes, such as generalized thickening of basement membranes. These alterations are suspected of contributing to the development of diabetic long-term complications encountered in many organs, including kidney, eye and peripheral nerves. The latter tissue, however, has gained relatively little attention with respect to connective tissue changes associated with diabetes. The morphological alterations of connective tissue in the diabetic peripheral nerve include thickening of basement membranes, increased diameter of endoneurial collagen fibrils, and accumulation of microfibrillar material. Recent studies have further elucidated the changes in the extracellular matrix of diabetic nerves and the molecular mechanisms underlying these alterations. For instance, elevated glucose concentrations modulate the expression of several proteins of the extracellular matrix in cultured nerve-derived connective tissue cells. In this article, we review the recent progress in the field of connective tissue alterations in diabetes and particularly in the diabetic peripheral nerve.
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Affiliation(s)
- P Muona
- Department of Medical Biochemistry, University of Turku, Finland
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32
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Bradley JL, Thomas PK, King RH, Watkins PJ. A comparison of perineurial and vascular basal laminal changes in diabetic neuropathy. Acta Neuropathol 1994; 88:426-32. [PMID: 7847071 DOI: 10.1007/bf00389494] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Measurements were made of the thickness of the basal lamina of perineurial cells in the sural nerve in a series of patients with diabetic neuropathy and compared with a group of patients with type I hereditary motor and sensory neuropathy (HMSN) and with organ donor control cases. The thickness was significantly greater in the diabetic patients as compared both with the HMSN cases and the organ donor controls. This was most obvious for the intermediate layers of the perineurium. Perineurial basal laminal thickness was only slightly greater in the HMSN cases than in the organ donor controls and the difference was not statistically significant. The thickening of the perineurial cell basal laminae was compared with the thickening of the basal laminal zone around the endoneurial microvessels. No significant correlation was found either for the diabetic neuropathy or HMSN cases or for the organ donor controls. As had been observed previously, the basal laminal zone around the endoneurial capillaries was of increased thickness both in the diabetic neuropathy and the HMSN cases and, although it was greater for the diabetic neuropathy patients, the difference was not statistically significant. Taken together, these findings indicate that the thickening of the basal lamina of the perineurial cells is a more characteristic feature of diabetic neuropathy than is thickening of the basal laminal zone around the endoneurial capillaries. The results suggest that the causative mechanisms are likely to differ, a conclusion supported by the morphological appearances: the basal laminal thickening around the perineurial cells is uniform, whereas that around the capillaries consists of basal laminal reduplication.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- J L Bradley
- Department of Neurosciences, Royal Free Hospital School of Medicine, London, UK
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33
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Greene DA, Sima AA, Stevens MJ, Feldman EL, Killen PD, Henry DN, Thomas T, Dananberg J, Lattimer SA. Aldose reductase inhibitors: an approach to the treatment of diabetic nerve damage. DIABETES/METABOLISM REVIEWS 1993; 9:189-217. [PMID: 8187607 DOI: 10.1002/dmr.5610090304] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- D A Greene
- Department of Internal Medicine, University of Michigan, Ann Arbor
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34
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Malik RA, Tesfaye S, Thompson SD, Veves A, Sharma AK, Boulton AJ, Ward JD. Endoneurial localisation of microvascular damage in human diabetic neuropathy. Diabetologia 1993; 36:454-9. [PMID: 8314451 DOI: 10.1007/bf00402283] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Twenty diabetic patients with neuropathy underwent clinical and neurophysiological evaluation together with a detailed morphometric assessment of capillary pathology in endoneurial and epineurial microvascular beds of the sural nerve. Morphological data were compared with ten non-diabetic control subjects. There were no significant differences in control subjects between basement membrane area, endothelial cell area, endothelial cell profile number or luminal area of endoneurial when compared with epineurial capillaries. In contrast, when compared with epineurial capillaries, endoneurial capillaries from diabetic patients demonstrated a significant increase in basement membrane (p < 0.001) and endothelial cell (p < 0.001) area and a significant reduction in luminal area (p < 0.001). There was no significant difference in endothelial cell profile number between endoneurial and epineurial capillaries amongst diabetic patients. Previous studies have demonstrated a good correlation between the degree of microangiopathy and measures of neuropathic severity. In the present study increased endoneurial capillary basement membrane area was significantly related to reduced peroneal nerve conduction velocity (p < 0.001), myelinated fibre density (p < 0.001) and elevated vibration (p < 0.05) and thermal (p < 0.001) perception. Increased endothelial cell area and reduced luminal size were related to a reduced peroneal nerve conduction (p < 0.05, p < 0.01, respectively), reduced myelinated fibre density (p < 0.05, p < 0.01) and elevated thermal perception (p < 0.05, p < 0.001). Epineurial capillary basement membrane, endothelial cell and luminal area failed to relate to measures of neuropathic severity.(ABSTRACT TRUNCATED AT 250 WORDS)
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MESH Headings
- Adult
- Aged
- Basement Membrane/pathology
- Basement Membrane/ultrastructure
- Capillaries/pathology
- Capillaries/ultrastructure
- Diabetes Mellitus, Type 1/pathology
- Diabetes Mellitus, Type 1/physiopathology
- Diabetes Mellitus, Type 2/pathology
- Diabetes Mellitus, Type 2/physiopathology
- Diabetic Angiopathies/pathology
- Diabetic Angiopathies/physiopathology
- Diabetic Neuropathies/pathology
- Diabetic Neuropathies/physiopathology
- Endothelium, Vascular/pathology
- Endothelium, Vascular/ultrastructure
- Humans
- Microscopy, Electron
- Middle Aged
- Muscle, Smooth, Vascular/pathology
- Muscle, Smooth, Vascular/ultrastructure
- Neural Conduction
- Neurologic Examination
- Peroneal Nerve/physiology
- Peroneal Nerve/physiopathology
- Reference Values
- Sural Nerve/blood supply
- Sural Nerve/pathology
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Affiliation(s)
- R A Malik
- Department of Medicine, Manchester Royal Infirmary, UK
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35
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Abstract
Microvascular abnormalities are prominent in the retina and kidney in diabetic subjects with the specific complications of the disease. It would not therefore be surprising to find similar changes in nerve, the other tissue prominently damaged in diabetes. A variety of biochemical abnormalities have been postulated as a cause of nerve damage but so far none has been reversed with any benefit to patients. It is now very clear that major structural and functional changes in the microvasculature occur in diabetic neuropathy and are probably involved in resulting nerve damage. Endothelial thickening of the endothelial basement membrane occurs, as does luminal occlusion caused by endothelial cell proliferation; human sural nerve is hypoxic; sural nerve epineurial arterioles are attenuated and involved in arteriovenous shunting associated with gross distension and tortuosity of veins; flow of fluorescein is impaired in neuropathic nerves and nerve conduction increment on exercise is impaired in neuropathy. Therapeutic intervention should now be directed at these gross abnormalities.
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Affiliation(s)
- J D Ward
- Royal Hallamshire Hospital, Sheffield, UK
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36
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Affiliation(s)
- S Yagihashi
- Department of Pathology, Hirosaki University School of Medicine, Japan
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37
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Malik RA, Veves A, Masson EA, Sharma AK, Ah-See AK, Schady W, Lye RH, Boulton AJ. Endoneurial capillary abnormalities in mild human diabetic neuropathy. J Neurol Neurosurg Psychiatry 1992; 55:557-61. [PMID: 1640230 PMCID: PMC489165 DOI: 10.1136/jnnp.55.7.557] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Microvascular factors have been implicated in the pathogenesis of human diabetic neuropathy. The extent of microangiopathy was assessed in 15 diabetic patients with clinically mild neuropathy and compared with eight age matched control subjects. Endoneurial capillary density was reduced (p less than 0.04) and correlated significantly with reduced myelinated fibre density (p less than 0.01). Both basement membrane area (p less than 0.0001) and endothelial cell profile number per capillary (p less than 0.002) were significantly increased in diabetic patients and correlated significantly with both neurophysiological and neuropathological measures of neuropathic severity. There was no evidence of endothelial cell hypertrophy as assessed by either cross sectional endothelial cell area or a reduction in luminal size. Furthermore, the percentage of closed vessels did not differ between diabetic patients and control subjects and failed to relate to measures of neuropathic severity. It was concluded that microvascular abnormalities are prominent in patients with clinically mild human diabetic neuropathy, and that these data provide further support for the role of endoneurial capillary disease in the development of this condition.
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Affiliation(s)
- R A Malik
- Department of Anatomy, Aberdeen Royal Infirmary
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