International Journal of Diabetes Mellitus 2 (2010) 6163

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International Journal of Diabetes Mellitus

journal homepage: ees.elsevier.com/locate/ijdm

Brief Communication

Chronic complications of diabetes mellitus in newly diagnosed patients

Iraj Heydari a,1, Vida Radi a,2, Sara Razmjou a,*,3, Afsaneh Amiri b,3
a
b

Institute of Endocrinology and metabolism, Iran University of Medical Sciences, Tehran, Iran
Gastrointestinal and Liver Disease Research Centre, Firouzgar hospital, Tehran, Iran

a r t i c l e

i n f o

Article history:
Received 12 July 2009
Accepted 31 August 2009

Keywords:
Diabetes mellitus
Retinopathy
Nephropathy
Neuropathy

a b s t r a c t
The prevalence of Diabetes Mellitus (DM) has increased in recent decades. This study was designed to
determine retinopathy, neuropathy, nephropathy, hypertension and hyperlipidemia and their interdependence in newly diagnosed diabetic patients. In this study, 200 consecutive newly diagnosed patients
were evaluated and screening tests for retinopathy, neuropathy, nephropathy, hypertension and hyperlipidemia were undertaken.
The frequency of positive screening tests for hyperlipidemia, hypertension, neuropathy, nephropathy
and retinopathy was found to be 73.5%, 58.5%, 52%, 10%, and 6% respectively.
A signicant proportion of newly diagnosed diabetic patients have signs of these chronic complications.
2009 International Journal of Diabetes Mellitus. Published by Elsevier Ltd.

1. Introduction
Diabetes mellitus (DM) is a metabolic disorder resulting from a
defect in insulin secretion and/or insulin action, which results in
hyperglycemia with disturbances of carbohydrate, fat and protein
metabolism [1]. The incidence of DM has increased dramatically
in recent decades, predominantly because of changes in life style,
an increase in the prevalence of obesity and longevity. Current projections estimate that the number of people with DM will increase
by 50.0% by 2010, and will nearly double by 2025 [2,3].
Type 2 diabetes is a very common disease, characterized by an
asymptomatic phase between the actual onset of diabetic hyperglycemia and clinical diagnosis. This phase has been estimated to
last at least 47 years, and 3050% cases of type 2 diabetic patients
remained undiagnosed. This leads to the development of chronic
complications of diabetes, which remain the chief problems in diabetic care, and which cause a lack of tness to work, disability, and
premature death [4,5].
The literature traditionally divides the diverse spectrum of vasculopathy associated with diabetes into two main subtypes: rstly,
the diabetes-specic microvascular complications of retinopathy,
nephropathy and neuropathy; and secondly, the atherothrombotic
macrovascular complications of myocardial infarction, hypertension and peripheral arterial disease [6].
* Corresponding author. Present Address: Institute of Endocrinology and metabolism, Iran University of Medical Sciences, Firouzgar, hospital, Valadi street, Valiasr
Square, Tehran, Iran. Tel.: +0098 91 26606701; fax: +0098 21 88942622.
E-mail address: sara_razmjou@yahoo.com (S. Razmjou).
1
Professor assistant of endocrinology and metabolism.
2
General practitioner, Iran University of Medical Sciences.
3
Research fellow, medical student at Iran University of Medical Sciences.

Open access under CC BY-NC-ND license.

Many studies [68] stress the strong link between the various
complications of diabetes. Andrew J et al. [6] have found a close
association between microvascular and macrovascular complications of diabetes.
The aim of this study is to determine the prevalence and relationship between different complications of diabetes in newly
diagnosed Iranian patients.

2. Materials and method

In this cross sectional study, 200 consecutive newly diagnosed
patients referred to the Institute of Endocrinology and Metabolism
afliated to Iran University of Medical Sciences (IUMS) from October to March 2006, were enrolled. The study was approved by the
ethics committee of IUMS. The patients were informed about the
study, and written consent was obtained from them.
The frequency of nephropathy, retinopathy, neuropathy, hyperlipidemia and hypertension were evaluated in these patients. The
diagnosis of diabetes is conrmed by fasting plasma glucose, measured from a venus sample after an overnight fast. Patients having
ketonuria upon presentation were excluded.
2.1. Nephropathy
In this study both urine albumin and creatinine were measured.
Albumiuria is dened as urinary albumincreatinine ratio >
or = 30 mg/g. (microalbuminuria with albumin of 30 to 300 mg/g
and macroalbuminuria with albumin > 300 mg/g) [9]. Renal failure
is dened according to the cut of value of laboratory; creatinine of
(?) more than 1 for women and more than 1.2 for men.

1877-5934 2009 International Journal of Diabetes Mellitus. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
doi:10.1016/j.ijdm.2009.08.001

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I. Heydari et al. / International Journal of Diabetes Mellitus 2 (2010) 6163

2.2. Retinopathy
To assess the presence of diabetic retinopathy, fundus
examination was performed by an ophthalmologist following
mydriasis of both eyes with tropicamide and phenylephrine eye
drops. Retinopathy was grouped into proliferative and nonproliferative.
2.3. Neuropathy
Patients fullled a questionnaire about their symptoms such as
a feeling of pins and needles, abnormal cold or warm sensations in
their feet, sharp pain, aching pain, or irritation to feet or legs by
bedclothes at night. A modied neuropathy disability score (NDS)
was used to diagnose and quantify the severity of diabetic neuropathy on clinical examination [10].
2.4. Lipids
Blood sampling after a 12-hour fasting in patients was performed. Total cholesterol and triglyceride were measured and dislipidemia was dened as cholesterol > 200 or TG > 150.
2.5. Hypertension
Blood pressure was measured in the right arm supported on a
table at heart level with an appropriate cuff to the patients arm
girth. We measured BP three times within a one week interval
and the average of these recordings was considered as their blood
pressure. Those with systolic BP of more than 139 or diastolic BP of
more than 89, or those who were taking antihypertensive medication, were considered to have hypertension.
2.6. Statistical analyses
Data are presented as a mean, using SPSS software version 15. p
Values of less than 0.05 were considered to be statistically
signicant.

3. Result
Of 200 newly diagnosed diabetic patients, 52% were men and
48% women. The Mean SD age at presentation was 52.39
10.03 years. The prevalence of nephropathy was 10%, including
13 patients (65%) with microalbuminuria, 4 patients (20%) with
macroalbuminuria, and 3 patients (15%) with renal failure. Retinopathy was recorded in 12 patients (6%); 7 patients (58.3%) had
proliferative, 5 patients (41.6%) had non-proliferative. Symptomatic neuropathy was found in 104 patients (52%). Among the patients with cardiovascular problems, 147 patients (73.5%) had
hyperlipidemia, 37 (25.2%) showed hypercholesterolaemia, 49
(33.3%) revealed hypertriglyceridaemia and 61 patients (41/5%)
had both hypercholesterolaemia and hypertriglyceridaemia. The
prevalence of hypertension was 58.50%.
There was a statistically signicant relationship between the
following variables:
(1) Age and hypertension (p < 0.001): The average age of hypertensive patients was 6.2 years higher than non-hypertensive
patients.
(2) Age and the form of nephropathy (p < 0.01): There was no
statistically signicant difference between age and the prevalence of nephropathy, but renal failure was more common
in older patients, so that the mean age of patients with renal
failure was 71.33 14.43 years, whereas the mean age of

patients with macro and microalbuminuria was 55.5 10.5

and 42 11.1 years respectively.
(3) Retinopathy and hypertension (p < 0.003): The prevalence of
retinopathy increased statistically with the presence of
hypertension, so that 33.3% of patients with retinopathy
were also hypertensive.
(4) Retinopathy and neuropathy (p < 0.01): 77.7% of patients
with proliferative retinopathy had neuropathy.
(5) Retinopathy and nephropathy (p < 0.01): The prevalence of
nephropathy was 86% among patients with retinopathy and
its probability increased with the severity of retinopathy.

4. Discussion
Diabetes Mellitus is a multifactorial disease, associated with a
number of microvascular (retinopathy, neuropathy and nephropathy) and macrovascular (ischemic heart disease, cerebrovascular
disease and peripheral vascular diseases) complications [11]. This
metabolic disease is one of the most common endocrine disorders
affecting almost 6% of the worlds population [12]. The prevalence
of DM in Iran was estimated at 5.5% in a population-based study
conducted by Azimi-nezhad et al. [13].
Type 2 DM is likely to remain undiagnosed for (many?)years.
The gap between the onset of the disease and clinical diagnosis
of diabetes leads to the development of these chronic complications, which are the leading causes of premature mortality among
diabetic patients [14].
In this study, which is one of the rst studies in this regards in
Iran, we assessed the prevalence of micro and macro vascular complications of DM in 200 newly diagnosed diabetic patients.
Nephropathy was reported in 10%, neuropathy in 52%, retinopathy
in 6%, hypertension in 58.5% and hyperlipidemia in 73.5% of the patients. There are further studies that assess the prevalence of these
chronic complications; Harrzallah F et al. [15] found neuropathy in
24%, nephropathy in 13%, retinopathy 8% and hypertension in 22%
of diabetic patients. In another study conducted by Weerasuriya
[16] in Sri Lanakan diabetic patients, neuropathy was present in
25.1 %, nephropathy in 29%, retinopathy in 15% and hypertension
in 23%. Considering the prevalence of these chronic complications
at the time of diagnosis in different studies, appropriate screening
procedures for diabetic patients is strongly recommended.
Microvascular and macrovascular complications frequently
coexist. It is well recognized that vascular complications in a given
tissue are often accompanied by evidence of pathology in other
vascular territories [6]. There are several studies [7,8,17] that demonstrate a concordance between chronic complications of DM. This
study found nephropathy in 86% of diabetic patients with retinopathy. Osterby et al. [17], also found a strong concordance between
retinopathy and the structural parameters of diabetic nephropathy.
Our study also showed that the prevalence of retinopathy increased with hypertension, since hypertension coexisted in 33.5%
of patients with retinopathy. This data is in agreement with the
ndings of Matthews et al. [18], which showed high blood pressure
to be detrimental to each aspect of diabetic retinopathy, and that a
rigid blood pressure control policy reduces the risk of clinical complications from diabetic eye disease.
Hideharu and Hidetoshi [19], similarly, concluded that hypertension is a risk factor for the progression of diabetic retinopathy,
mostly because hyperglycaemia in diabetic patients impairs the
regulation of retinal perfusion, leading to increased susceptibility
to injury by systemic hypertension.
In this study, 77.7% of diabetic patients with proliferative retinopathy had neuropathy. Similarly, in Zander et al. study [20], proliferative retinopathy was found to be correlated with somatic and
autonomic neuropathy in diabetic patients.

I. Heydari et al. / International Journal of Diabetes Mellitus 2 (2010) 6163

[6]

[7]

[8]

[9]

[10]
Fig. 1. The prevalence of chronic complication of type 2 Diabetes Mellitus in 200
newly diagnosed patients.

[11]

[12]

Furthermore, the prevalence of hypertension in diabetic individuals demonstrated a highly signicant trend with age [21], as
in this study, the average age of hypertensive patients was
6.2 years higher than for non-hypertensive ones.
In conclusion, there seems to be a strong concordance between
chronic complications of diabetes mellitus. Thus, thorough screening of these complications in newly diagnosed diabetic patients is
strongly recommended (see Fig. 1).

[13]

[14]

[15]

[16]

References
[1] Hovens MMC, Van de Laar FA, Cannegieter SC, Vandenbroucke JP.
Acetylsalicylic acid (Aspirin) for primary prevention of cardiovascular
disease in type 2 Diabetes Mellitus. (protocol) Cochrane Database of
Systematic Reviews 2005, Issue 3. Art. No.: CD005446.
[2] Arinzon Z, Shabat S, Shuval I, Peisakh A, Berner Y. Prevalence of Diabetes
Mellitus in elderly patients received enteral nutrition long-term care service.
Arch Gerontol Geriatr. 2007.
[3] Bethel MA, Sloan FA, Belsky D, Feinglos MN. Longitudinal incidence and
prevalence of adverse outcomes of Diabetes Mellitus in elderly patients. Arch
Intern Med. 2007;167(9):9217.
[4] Piechowski-Jozwiak B, Maulaz A, Bogousslavsky J. Secondary prevention of
stroke with antiplatelet agents in patients with Diabetes Mellitus. Cerebrovasc
Dis. 2005;20(Suppl 1):1523.
[5] Spijkerman AM, Dekker JM, Nijpels G, Adriaanse MC, Kostense PJ, Ruwaard D,
et al. Microvascular complications at time of diagnosis of type 2 diabetes are
similar among diabetic patients detected by targeted screening and patients

[17]

[18]

[19]
[20]

[21]

63

newly diagnosed in general practice: the hoorn screening study. Diabetes Care.
2003;26(9):26048.
Krentz AJ, Clough G, Byrne CD. Interactions between microvascular and
macrovascular disease in diabetes: pathophysiology and therapeutic
implications. Diabetes Obes Metab. 2007;9(6):78191.
Rosolova H, Petrlova B, Simon J, Sifalda P, Sipova I, Sefrna F. Macrovascular and
microvascular complications in type 2 diabetes patients. Vnitr Lek.
2008;54(3):22937.
Scheffel RS, Bortolanza D, Weber CS, Costa LA, Canani LH, Santos KG, et al.
Prevalence of micro and macroangiopatic chronic complications and their risk
factors in the care of out patients with type 2 diabetes mellitus. Rev Assoc Med
Bras. 2004;50(3):2637.
Bleyer AJ, Sedor JR, Freedman BI, OBrien A, Russell GB, Graley J, et al. Risk
factors for development and progression of diabetic kidney disease and
treatment patterns among diabetic siblings of patients with diabetic kidney
disease. Am J Kidney Dis. 2008;51(1):2937.
Dyck PJ. Detection, characterization and staging of polyneuropathy: assessed
in diabetics. Muscle Nerve. 1988;11:2132.
Rahman S, Rahman T, Ismail AA, Rashid AR. Diabetes-associated
macrovasculopathy: pathophysiology and pathogenesis. Diabetes Obes
Metab. 2007;9(6):76780.
Adeghate E, Schattner P, Dunn E. An update on the etiology and epidemiology
of diabetes mellitus. Ann N Y Acad Sci. 2006;1084:129.
Azimi-Nezhad M, Ghayour-Mobarhan M, Parizadeh MR, Safarian M, Esmaeili
H, Parizadeh SM, et al. Prevalence of type 2 diabetes mellitus in Iran and its
relationship with gender, urbanisation, education, marital status and
occupation. Singapore Med J. 2008;49(7):5716.
14. Somaratne JB, Whalley GA, Bagg W, Doughty RN. Early detection and
signicance of structural cardiovascular abnormalities in patients with Type 2
Diabetes Mellitus. Expert Rev Cardiovasc Ther. 2008;6(1):10925.
Harzallah F, Ncibi N, Alberti H, Ben Brahim A, Smadhi H, Kanoun F, et al.
Clinical and metabolic characteristics of newly diagnosed diabetes patients:
experience of a university hospital in Tunis. Diabetes Metab.
2006;32(6):6325.
Weerasuriya N, Siribaddana S, Dissanayake A, Subasinghe Z, Wariyapola D,
Fernando DJ. Long-term complications in newly diagnosed Sri Lankan patients
with type 2 diabetes mellitus. QJM 1998;91(6):43943.
Osterby R, Gall MA, Schmitz A, Nielsen FS, Nyberg G, Parving HH. Glomerular
structure and function in proteinuric type 2 (non-insulin-dependent) diabetic
patients. Diabetologia 1993;36(10):106470.
Matthews DR, Stratton IM, Aldington SJ, Holman RR, Kohner EM. UK
Prospective Diabetes Study Group. Risks of progression of retinopathy and
vision loss related to tight blood pressure control in type 2 Diabetes Mellitus:
UKPDS 69. Arch Ophthalmol. 2004;122(11):163140.
Funatsu H, Yamashita H. Pathogenesis of diabetic retinopathy and the reninangiotensin system. Ophthalmic Physiol Opt. 2003;23(6):495501.
Zander E, Heinke P, Herfurth S, Reindel J, Ostermann FE, Kerner W. Relations
between diabetic retinopathy and cardiovascular neuropathya crosssectional study in IDDM and NIDDM patients. Exp Clin Endocrinol Diabetes
1997;105(6):31922.
Sprafka JM, Bender AP, Jagger HG. Prevalence of hypertension and associated
risk factors among diabetic individuals. The Three-City Study. Diabetes Care.
1988;11(1):1722.