Vascular calcification in diabetic foot

NewsBot · Apr 9, 2013

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Vascular calcification in diabetic foot and its association with calcium homeostasis.
Swain J, Tiwari S, Pratyush D, Dwivedi A, Gupta B, Shukla RC, Singh SK.
Indian J Endocrinol Metab. 2012 Dec;16(Suppl 2):S450-2.

INTRODUCTION:
Vascular calcification (VC), long thought to result from passive degeneration, involves a complex process of biomineralization resembling osteogenesis, frequently observed in diabetes and is an indicator of diabetic peripheral vascular disease with variable implications.

AIM AND OBJECTIVE:
To study the association between vascular calcification and calcium homeostasis in diabetic patients with foot ulcers without stage 4, 5 chronic kidney disease.

MATERIALS AND METHODS:
A total of 74 patients with diabetic foot ulcer were enrolled, and VC was detected by X-ray and Doppler methods. Serum calcium, phosphate, alkaline phosphatase (ALKP), fasting and post-prandial glucose levels, and glycosylated hemoglobin (HbA1C) were recorded. Serum iPTH and 25 (OH) vitamin D were estimated by immune radiometric assay and radioimmunoassay, respectively. Data was analyzed by SPSS 16.0.

RESULTS:
Vascular calcification was present in 42% of patients. Significant difference in the mean (±SD) of vitamin D, HbA1C, and eGFR was observed in VC +ve compared to VC -ve. There was no significant association of age, duration, BMI, PTH, Ca, PO4, ALKP with that of VC incidence. Severe vitamin D deficiency was more common in VC +ve (51.6%) compared to in VC -ve (18.6%). Sub-group analysis showed that the risk of VC was significantly higher (RR = 2.4, P < 0.05, 95% C.I. = 0.058-2.88) in patients with vitamin D < 10 ng/ml compared to others.

CONCLUSION:
Vitamin D deficiency could be a risk for vascular calcification, which possibly act through receptors on vascular smooth muscle cells or modulates osteoprotegerin/RANKL system like other factors responsible for VC in diabetic foot patients.
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Admin2 · Aug 20, 2013

Influence of peripheral vascular calcification on efficiency of screening tests for peripheral arterial occlusive disease in diabetes—a cross-sectional study
C. E. Aubert et al
Diabetic Medicine; in press

Aims
Pulse palpation and ankle brachial index are recommended to screen for peripheral arterial occlusive disease in people with diabetes. However, vascular calcification can be associated with false negative tests (arteriopathy present despite normal screening tests). We therefore studied the impact of peripheral vascular calcification on the performance of these tests.

Methods
This cross-sectional study included 200 people with diabetes at high risk of cardiovascular disease. The main exclusion factor was an estimated glomerular filtration rate < 30ml/min. Peripheral arterial occlusive disease was diagnosed by colour duplex ultrasonography and peripheral vascular calcification scored by computed tomography scan. We measured sensitivity, specificity, predictive values, accuracy and likelihood ratios of pulse palpation and ankle brachial index, and looked for the impact of calcification on false negative tests (arteriopathy present despite normal screening tests).

Results
Ankle brachial index alone had poor sensitivity and negative predictive value and high negative likelihood ratio. Pulse palpation had higher sensitivity and negative predictive value. An abnormal pulse palpation, defined by weak or missing pulses, combined with an abnormal ankle brachial index, had the highest sensitivity and negative predictive value (92.3 and 89.8%, respectively). Vascular calcification score was higher in patients with false negative tests, for both pulse palpation and ankle brachial index (P < 0.0001 for all). Ankle systolic blood pressure was higher in patients with false negative tests for pulse palpation (P = 0.004).

Conclusions
Below-knee vascular calcification gave a high rate of false negative results for ankle brachial index. Refined pulse palpation combined with ankle brachial index remained the best strategy to screen for peripheral arteriopathy.
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NewsBot · Oct 5, 2013

Neuropathy and the vascular-bone axis in diabetes: lessons from Charcot osteoarthropathy.
Petrova NL, Shanahan CM.
Osteoporos Int. 2013 Oct 3.

Emerging evidence from the last two decades has shown that vascular calcification (VC) is a regulated, cell-mediated process orchestrated by vascular smooth muscle cells (VSMCs) and that this process bears many similarities to bone mineralization. While many of the mechanisms driving VSMC calcification have been well established, it remains unclear what factors in specific disease states act to promote vascular calcification and in parallel, bone loss. Diabetes is a condition most commonly associated with VC and bone abnormalities. In this review, we describe how factors associated with the diabetic milieu impact on VSMCs, focusing on the role of oxidative stress, inflammation, impairment of the advanced glycation end product (AGE)/receptor for AGE system and, importantly, diabetic neuropathy. We also explore the link between bone and VC in diabetes with a specific emphasis on the receptor activator of nuclear factor κβ ligand/osteoprotegerin system. Finally, we describe what insights can be gleaned from studying Charcot osteoarthropathy, a rare complication of diabetic neuropathy, in which the occurrence of VC is frequent and where bone lysis is extreme.
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NewsBot · Nov 26, 2013

Factors Associated With Calcification in the Pedal Arteries in Patients With Diabetes and Neuropathy Admitted for Foot Disease and Its Clinical Significance
Javier Aragón-Sánchez, Jose L. Lázaro-Martínez
International Journal of Lower Extremity Wounds November 25,

The aim of this study was to determine the factors associated with calcification in the pedal arteries (CPAs) in a population of patients with diabetes admitted for acute foot disease and to find whether the presence of CPAs had any influence on the short-term outcomes. Electronic charts were retrospectively reviewed for patients admitted to our department for acute diabetic foot problems between January 1, 2008, and December 31, 2012. Digital images of the plain x-rays, which were performed on patients during this period, were reviewed. Patients were classified into 2 groups: those with absence (group 1) and presence of CPAs (group 2). One hundred and sixty-five patients were included in the present study. Ninety-eight (59.4%) patients had CPAs in the plain x-rays. The predictive variables related to the presence of CPAs were duration of diabetes >20 years (odds ratio [OR] = 2.1, 95% confidence interval [CI] = 1.0-4.3), retinopathy (OR = 2.2, 95% CI = 1.0-4.6), albuminuria (OR = 3.3, 95% CI = 1.5-7.4), and peripheral arterial disease (OR = 4.2, 95% CI = 2.0-8.7). Fifty-six patients underwent amputation (33.9%): 13 (19.4%) in group 1 and 43 (43.9%) in group 2 (P < .01). Thirty-four patients (20.6) required reoperation: 6 (9%) in group 1 and 28 (28.6%) in group 2 (P < .01). In conclusion, the predictive variables related to the presence of CPAs in a series of patients admitted for foot disease were duration of diabetes >20 years, retinopathy, albuminuria, and peripheral arterial disease. Differences in the outcomes were related to the association of CPAs with peripheral arterial disease.
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