Increased carotid intima-media thickness in Brazilian adolescents with type 1 diabetes mellitus

Correlation between transforming growth factor-β1 (TGF- β1) with premature atherosclerosis in type 1 diabetes

BACKGROUND

Type 1 diabetes (T1D) carries a significant risk of atherosclerosis as the main driver for cardiovascular events. Atherosclerosis is initiated by the activation of the endothelium by various risk factors through the inflammation process. The anti-inflammatory cytokine TGF-β1 may inhibit the development of atherosclerosis.

METHODS

In a cross-sectional study, a total of 40 patients aged 14.5±3.16 years old with T1D and 40 healthy controls aged 14.7±0.99 years old were involved. Common carotid artery IMT (cIMT) was measured by real-time M-echocardiography mode (Affinity 50G Philips) and Flow Mediated Dilatation (FMD), using high-resolution ultrasonography and Doppler flow characteristics. The TGF-β1 level was measured by indirect ELISA at Saiful Anwar Hospital Laboratory.

RESULTS

There were no differences in age, gender, Body Mass Index (BMI), duration of diabetes, renal function, or nutritional status between the T1D and healthy groups (p>0.05). A significant difference in cIMT was observed between the T1D group and the healthy group (0.567 ± 0.87 mm vs. 0.387 ± 0.57 mm, p = 0.000), FMD (7.17 ± 3.98 mm vs. 11.22 ± 5.48 mm, p = 0.000), and the level of TGF-β1 cytokine (39.83±13.51 vs. 73.67±15.34 pg/ml, p = 0.000). A significantly negative correlation between TGF-β1 and cIMT (p = 0.000; r = -0.685) and a significantly positive correlation between TGF-β1 and FMD (p = 0.000; r = +0.55) were found.

CONCLUSION

Atherosclerosis is an inflammatory disease accelerated by diabetes. The inflammation process is more prominent in T1D patients. T1D patients show a decreased level of TGF-β1, increased measurement of cIMT (>0.5 mm), and a decreased measurement of FMD.

Current applications for measuring pediatric intima-media thickness

Intima-media thickness is a known subclinical radiologic marker of the early manifestations of atherosclerotic disease. It is the thickness of the vessel wall, most often the carotid artery. Intima-media thickness is measured on conventional US manually or automatically. Other measurement techniques include radiofrequency US. Because there is variation in its measurement, especially in children, several recommendations have been set to increase the measurement's validity and comparability among studies. Despite these recommendations, several pitfalls should be avoided, and quality control should be performed to avoid erroneous interpretation. This article summarizes current literature in relation to the clinical applications for intima-media thickness measurement in children with known risk factors such as obesity, liver steatosis, hypercholesterolemia, diabetes, hypertension, systemic inflammatory diseases, cancer survival, kidney and liver transplant, and sickle cell disease or beta thalassemia major. Most potential indications for intima-media thickness measurement remain in the research domain and should be interpreted combined with other markers. The objective of diagnosing an increased intima-media thickness is to start a multidisciplinary treatment approach to prevent disease progression and its sequelae in adulthood.

Estimation of Vascular Cell Adhesion Molecule 1 (VCAM-1) Levels In Type 1 Diabetic Mellitus Patients

High glucose levels in patients with diabetes are associated with increased plasma levels of soluble adhesion molecules. They could explain that the patients with diabetes mellitus will require the development of premature atherosclerosis related to hyperglycemia or hyperinsulinemia and that it not only affects vascular endothelium but also contributes to the development of microvascular complications. This study aimed to evaluate the serum concentration of VCAM-1 in type 1 diabetes mellitus patients with and without cardiovascular disease. Also, investigation the association of insulin levels, duration of diabetes, and HbA1C with VCAM-1. Include in this study a total of 60 types 1 diabetic patient. According to characteristic laboratory investigations and electrocardiogram (ECG), they were subdivided into two groups (G1) 30 T1DM patients without cardiovascular disease and (G2) 30 T1DM patients with cardiovascular disease in addition to 30 healthy subjects as a control group (G3). All subjects measured the levels of fasting blood glucose FBG, glycated hemoglobin HbA1c, and insulin levels, and VCAM-1 were also determined by ELISA technique. This study shows a highly significant difference in the average diabetic profile between G1 and G2 compared to the control group and found that VCAM-1 level was significantly higher among diabetic patients than the control group. Also, there was a significant negative correlation of VCAM-1 with the levels of FBG, HbA1c in diabetic patients G1 and G2. While insulin had a positive correlation in G1 but correlated negatively in G2

Endothelin-1 levels are decreased in pediatric Type 1 diabetes and negatively correlate with the carotid intima media thickness

AIMS

Better understanding of the timeline and risk factors for the appearance of complications in pediatric Type-1-diabetes is key for developing prevention strategies. We studied endothelial markers and their determinants in adolescents with Type-1-diabetes at different time points from diagnosis.

METHODS

A cross-sectional study of 58 adolescents, mean age 15.0 ± 2.4 years; 20 with recent-onset Type-1-diabetes, 20 with over 7 years of Type-1-diabetes and 18 controls. Clinical and biochemical data were collected. Fingertip arterial reactive hyperemia (EndoPAT) and carotid intima-media-thickness (cIMT) were measured to assess endothelial function and structure.

RESULTS

Compared to controls, individuals with prolonged Type-1-diabetes had higher mean cIMT (0.49 ± 0.07 mm vs. 0.43 ± 0.05 mm p = 0.021) and maximal cIMT (0.61 ± 0.08 mm 0.52 ± 0.08 mm, p = 0.025). Endothelin-1 levels were significantly lower in subjects with prolonged Type-1-diabetes (1.2 ± 1.0 pg/ml) compared to controls (3.0 ± 1.7, p = 0.008 pg/ml); they negatively correlated with the mean cIMT (c = - 0.291, p = 0.031) and mean 6 months hemoglobin A1c (c = - 0.301, p = 0.022) and positively correlated with mean c-peptide levels (c = 0.356, p = 0.006) and the weekly exercise time (c = 0.485, p < 0.001). Endothelin-1 levels did not correlate with EndoPAT results.

CONCLUSIONS

Our results suggest that the early years after the diagnosis of Type-1-diabetes are an important window for prevention of arterial damage in the pediatric population. The trajectories of relationships of Endothelin-1 with metabolic and vascular measures were opposite from the anticipated, yet consistent. Endothelin-1 related indirectly to adverse measures and directly to favorable measures. Decreased Endothelin-1 levels might reflect early stages in endothelial impairment in Type-1-diabetes, yet its' exact role in the development of complications is yet to be unraveled.

INTIMA-MEDIA THICKNESS OF THE CAROTID ARTERIES IS AFFECTED BY PUBERTAL MATURATION IN HEALTHY ADOLESCENTS

OBJECTIVE

To contribute to the assessment of normal parameters of carotid intima-media thickness (CIMT) in healthy adolescents.

METHODS

A cross-sectional study was conducted through clinical, laboratory and ultrasound evaluation in 61 healthy adolescents. The inclusion criteria consisted of being in good health. The exclusion criteria were: presence or history of any chronic disease; being obese or overweight according to the World Health Organization (WHO) established criterion; continuous use of medication; or presenting a febrile condition or requiring medication within 48-hours prior to assessment. The pubertal stages were evaluated using the Tanner criteria. The high-resolution B-mode ultrasound examinations were performed according to the recommendations of the Consensus Statement from the American Society of Echocardiography Carotid Intima-Media Thickness Task Force.

RESULTS

Adolescents were 14±2.6 years old, 62.3% female, 19 (31%) at early puberty (Tanner II and III), and 38 (62%) at late puberty (Tanner IV and V). They presented normal clinical and laboratorial parameters. CIMT values were 0.46±0.04 to 0.55±0.04 mm on the right and 0.48±0.02 to 0.53±0.04 mm on the left, according to pubertal maturation. CIMT values increased significantly on the right and left sides, according to pubertal stage (p<0.001 and p=0.016), and maximum internal diameters of the common carotid artery (p<0.025 and p<0.003). It was higher in males compared to females.

CONCLUSIONS

An increase in CIMT in the healthy adolescents group, according to both age, and the degree of pubertal maturation should be considered when evaluating adolescents in diagnostic procedures.

Epicardial Fat Thickness in Children with Classic Congenital Adrenal Hyperplasia

OBJECTIVE

Epicardial fat thickness (EFT) is an emerging cardio-metabolic risk factor and has been shown to be related to atherosclerosis. EFT has not been studied in the context of CAH. This study aimed to evaluate EFT in children with CAH and its relation to carotid artery intima-media thickness (CA-IMT) and left ventricular (LV) functions.

METHODS

Thirty-six children with classical CAH were compared with 36 healthy controls. All patients had confirmed CAH and were receiving steroid substitution therapy. Patients and controls underwent anthropometric evaluation, measurement of fasting lipids, glucose, insulin, homeostasis model assessment for insulin resistance (HOMA-IR). LV functions and EFT were assessed using conventional echocardiography. Duplex ultrasonography was used to measure CA-IMT.

RESULTS

Compared to controls, patients had greater EFT (p=0.001), CA-IMT (p=0.01), LV mass index (LVMI) (p=0.001) and prolonged mitral deceleration time (DcT) (p=0.01). CAH patients also had significantly worse HOMA-IR (p=0.001) than controls. Abnormalities were worse in uncontrolled CAH on treatment. Multivariate analysis in CAH subjects showed EFT correlated positively with waist circumference odds ratio (OR) [OR=1.9; 95% confidence interval (CI): 1.07-1.14; p=0.01], 17-hydroxyprogesterone [OR=1.6; 95% CI: 1.33-2.89; p=0.05], testosterone concentration (OR=1.7; 95% CI: 1.55-2.13; p=0.01), LVMI (OR=1.14; 95% Cl: 1.08-1.13; p=0.01), mitral DcT (OR=2.25; 95% CI: 1.15-2.05; p=0.01) and CA-IMT (OR=1.6; 95% CI: 1.15-2.05; p=0.01).

CONCLUSION

EFT is elevated in children with classical CAH, particularly in those with poor control, and is correlated with CA-IMT, LV mass and mitral DcT. Measurement of EFT in CAH children may help to identify those at high risk of developing LV dysfunction and subclinical atherosclerosis.

Methods to evaluate arterial structure and function in children - State-of-the art knowledge

BACKGROUND

With increasing rates of hypertension, obesity, and diabetes in the pediatric population, wide available, and reproducible methods are necessary to evaluate arterial structure and function in children and adolescents.

METHODS

MEDLINE/Pubmed was searched for articles published in years 2012-2017 on methodology of, current knowledge on, and limitations of the most commonly used methods to evaluate central, proximal and coronary arteries, as well as endothelial function in pediatric patients.

RESULTS

Among 1528 records screened (including 1475 records from years 2012 to 2017) 139 papers were found suitable for the review. Following methods were discussed in this review article: ultrasound measurements of the intima-media thickness, coronary calcium scoring using computed tomography, arterial stiffness measurements (pulse wave velocity and pulse wave analysis, carotid artery distensibility, pulse pressure, and ambulatory arterial stiffness index), ankle-brachial index, and methods to evaluate vascular endothelial function (flow-mediated vasodilation, peripheral arterial tonometry, Doppler laser flowmetry, and cellular and soluble markers of endothelial dysfunction).

CONCLUSIONS

Ultrasonographic measurement of carotid intima-media thickness and measurement of pulse wave velocity (by oscillometry or applanation tonometry) are highly reproducible methods applicable for both research and clinical practice with proved applicability for children aged ≥6 years or with height ≥120cm. Evaluation of ambulatory arterial stiffness index by ambulatory blood pressure monitoring is another promising option in pediatric high-risk patients. Clearly, further studies are necessary to evaluate usefulness of these and other methods for the detection of subclinical arterial damage in children.

Association between Vascular Endothelial Markers and Carotid Intima-Media Thickness in Children and Adolescents with Type 1 Diabetes Mellitus

Introduction

Type 1 Diabetes Mellitus (T1DM) is one of the important risk factor for cardiovascular disease. Endothelial dysfunction and increased Carotid Intima-Media Thickness (CIMT) result in cardiovascular complications. Vascular Cell Adhesion Molecule-1 (VCAM-1) and Intercellular Adhesion Molecule-1 (ICAM-1) are two adhesion molecules that are markers of early atherosclerosis and play a significant role in developing atherosclerosis.

Aim

To evaluate CIMT and its association with the levels of ICAM-1 and VCAM-1 in children and adolescents with T1DM.

Materials and Methods

In this descriptive, cross-sectional study conducted between April 2013 and September 2014, 29 children aged 7-20 years with T1DM for at least two years and 29 age and sex-matched, healthy individuals were evaluated. Plasma level of ICAM-1 and VCAM-1 was measured by ELISA, and CIMT via Doppler ultrasound was also assessed. The data were analysed by t-test and Pearson's correlation coefficient in SPSS 16.0 (p≤0.05).

Results

Independent t-test indicated that there is a significant difference in ICAM-1 level between the patients and controls (p<0.001). Further, CIMT was significantly higher in diabetic subject (p<0.001). CIMT was not significantly associated with the level of VCAM-1 and ICAM-1 in the patients (p>0.5).

Conclusion

ICAM-1 and VCAM-1 were not associated with CIMT but, CIMT and level of ICAM-1 were significantly, higher in diabetic patients, and therefore could be used as useful tools for identification of early atherosclerosis in children and adolescents with T1DM.