The Changes And Significance Of Prostacyclin,Prostacyclin Synthase In Patients With Type 2 Diabetic Foot Ulcers

BackgroundDiabetic foot is a pathological state of the foot and lower extremities destroyed in the patients with diabetics. This state can lead to infections,disability and amputation. The most common states of diabetic foot are ulcers and gangrene. The ulcers can be deep or shallow,with or without infection.In many countries,diabetic foot ulcer and gangrene are important causes of death or disability in non-traumatic amputation. In Western countries,5% -10% of diabetic patients have varying degrees of foot ulcers,the amputation rate is about 1%. Amputation rate in patients with diabetes is 15 times as that of the non-diabetes. Patients with diabetic foot had to face to a serious decline in the quality of life,and treatment is difficult and takes a long time,high medical costs must to be placed on it. Patients and the community bear huge burden.Etiology of the diabetic foot can be neurological or ischemic in nature. These two factors are often at the same time. In particular,ischemic factors,once occur,to a large extent affected the limb's blood supply,oxygen supply,not only increase difficulties in healing ulcers,but also the significantly make higher disability rate and death rate .While the ischemic pathology based on factors of lower extremity arterial sclerosis,abnormal systolic and diastolic function in the cycle,increased platelet aggregation,coagulation abnormalities,that lead to the formation of thrombosis.T2DFU patients with arteriosclerosis is reported to be closely related to endothelial dysfunction . Prostacyclin (PGI2) is the main vasoactive substances that producted by vascular endothelial cells.,accounts for about 66% of total production. PGI2 is the strongest endogenous platelet inhibitors,and it has a stronger effect in relaxing blood vessels. Although there are a number of research articles about PGI2 and PGIS in diabetic patients,but few articles report their coverage with the impact of T2DFU . It is not clear whether ischemic changes in T2DFU are accompanied by systemic change of PGI2 ,or purely accompanied by local change of lower extremity .【Objection】To observe the metabolite of PGI2 (6-keto-PGF1a) in plasma and its related factors,to explore changes in PGI2 levels in T2DFU,and the predictive value of occuration,development and the judgement of the treatment and prognosis of T2DFU .And by studying prostacyclin synthase (PGIS) and PGI2 activity changes in the muscle tissue of patients,more deep analysis on their impact on the T2DFU can be developed. Hope to be helpful to the prevention and the treatment of diabetic foot ulcers in clinical programs ,and to reduce disability and mortality of T2DFU.【Materials】Part I:Measurement and analysis of prostacyclinThis part of study include three groups:the gangrenes and the non-gangrenes of the patients with type 2 diabetic foot ulcers(T2DFU) and the control group:60 patients hospitalized in our endocrinology unit with type 2 diabetic foot ulcers diagnosed by 1999 WHO criteria were included into the present study,among 34 male and 26 female,age( 56±8.13y).All patients were classified by Wagner,among grade I: 7 cases,grade II :13 cases,grade III:14cases,grade IV :18 cases,grade V :8 cases.The patients were devided into two groups: the gangrenes 26cases(grade IV,V)and non-gangrenes 34casess(grade I～III).Controle group:select 35 healthy cases enrolled in body examination in the same period,among 18 male and 17 female,age( 55±7.82y).Part II:Measurement and analysis of prostacyclin synthaseThis part of study also contained three groups:the muscle tissue taken from the edge of ulcers and the remote from the ulcers of amputation,and muscle tissue taken from the control group:Chose 10 cases had amputation operations among the T2DFU group of part I test. among 6 male and 4 female,age(57±9.54y).And the control group contained 10 patients suffered from amputation but non-diabetic in the same period, among 6 male and 4 female,age(55±8.28y).All cases did not have haematology system diseases,cancer or other serious diseases,and they had normal liver and renal function.All of them had not take some medicine to inflect prostaglandin metabolism or to distend blood vesselslike like aspirin in these two weeks.【Methods】Part I:Measurement and analysis of prostacyclin1 Collected the clinical material and experimental data of all cases,include:sex,age,BMI,duration of diabetes,blood pressure,TG,TC,(HDL-C),LDL-C,FPG,2hPG,Insulin,creatinine,transaminase etc.2 Use the method of radioimmunoassay to test the level of plasma 6-keto-PGF1a in all cases and that in the homogenization supernatant of tissue taken from the edge of ulcers and amputation,and analysis the correlation with the he clinical material.3 Used color Doppler to test the conditions of crural vascular obliteration and the function of blood vessel endothelium,and analysis the correlation with the level of plasma 6-keto-PGF1a.Part II:Measurement and analysis of prostacyclin synthase.Use the immunohistochemical technique to test the activity of prostacyclin synthase in the muscle tissue taken from the edge of ulcers and amputation in three groups,and analysis the correlation with the level of plasma 6-keto-PGF1a. 【Result】Part I:Measurement and analysis of prostacyclin1. Comparison of clinical data in diabetic foot ulcers and gangrene group of non-gangrenous group and the control group:1) There was no significant difference in their age,sex,Body mass index,blood pressure among three groups(P>0.05);2) The level of TG,TC,LDL-C,HbA1C,FPG,2hPG in two T2DFU groups were significantly higher than the control group. The level of HDL-C and plasma concentration of 6-keto-PGF1a in two T2DFU groups were significantly lower than the control group(P<0.05 or P<0.01);The duration of diabetes,The level of TG,HbA1C,FPG,2hPG in the gangrenes group was significantly higher than the non-gangrenes group;The level of FINS,2PINS in the non-gangrenes group. Is higher than the control group(P<0.05);The level of HDL-C and plasma concentration of 6-keto-PGF1αin the gangrenes group was significantly lower than the non-gangrenes group. (P<0.05 or P<0.01). There was no significant difference in their level of TC,HDL-C,LDL-C,FINS,2hPINS between two T2DFU groups. (P>0.05).2. Comparison of plasma ln(6-keto-PGF1a) in different degrees of T2DFU There was significant difference in plasma ln(6-keto-PGF1a) in different degree of T2DFU.There was a significant correlation between the severity of T2DFU and the level of plasma 6-keto-PGF1a(P<0.05).3. The correlation analysis of plasma ln (6-keto-PGF1a) associated with clinical data :1) There was no correlation between the level of plasma ln(6-keto-PGF1a )and sex,BMI,SBP,DBP,HDL-C,LDL-C(P>0.05);2) There was significantly negative correlation between the level of plasma ln (6-keto-PGF1a) and age,the Course of DM,TG,FPG,2hPG,HbA1C,FINS,2h PINS,ln(HOMA-IR)(P<0.05 or P<0.01). 4. Color Doppler detection of vascular occlusion of both lower extremities and vascular endothelial function in gangrene group,non-gangrenou group and the healthy control group. Analysis the correlation with the plasma ln (6-keto-PGF1a):1) ABI in the gangrenes group and non-gangrenes group were significantly lower than the control group. (P<0.05,P<0.01),and ABI in the gangrenes group was significantly lower than the non-gangrenes group(P<0.05);2) EDD in two T2DFU groups were significantly lower than the control group(P<0.01);EDD in the gangrenes group was significantly lower than the non-gangrenes group(P<0.01);3) ABI and EDD had positive correlation with the level of plasma ln (6-keto-PGF1a) (r=0.826,P<0.05 and r=0.895,P<0.01) .5. Comparison of homogenate supernatant ln (6-keto-PGF1a) in edge group,the remote group of T2DFU and control group:Homogenate supernatant ln (6-keto-PGF1a) in two T2DFU groups were significantly lower than the control group(P<0.01);that of the edge group of T2DFU was significantly lower than that of the remote group of T2DFU(P<0.05).Part II:Measurement and analysis of prostacyclin synthase(PGIS)1. Comparison of vascular endothelial PGIS expression (gray value with quantitative detection of Grey) in muscle tissues immunohistochemistry in the edge group,the remote group of T2DFU and control group,correlation Analysis with homogenate supernatant ln (6-keto-PGF1a):1) The Grey in the tissue of the edge group and the remote group of T2DFU were significantly higher than that of control group.(P<0.01,P<0.05);The Grey in the tissue of the edge group of T2DFU was significantly higher than that of the remote group of T2DFU. (P<0.05);That indicated the expression of PGIS was strongest in the control group,then in the the amputation part of the T2DFU;and was weakest in the edge of ulcers;2) There was significantly negative correlation between the Grey and homogenate supernatant ln (6-keto-PGF1a)(r=0.648,P<0.05);2. Comparison of vascular density of muscle tissue (VD) in the edge group,the remote group of T2DFU and control group:VD in two groups of T2DFU was significantly lower than that of the control group(P<0.01,P<0.05);VD in the edge group was significantly lower than that of the remote group of T2DFU(P<0.05).【Conclusions】The level of prostacyclin and prostacyclin synthase of the type 2 T2DFU patients is lower in plasma and local tissue than in the healthy.And there is significant negative correlation between the level of plasma 6-keto-PGF1a and the Course of DM,TG,glucose,Insulin.The level of prostacyclin and prostacyclin synthase can be a primary index to indicate the conditions of Arteriosclerosis and the function of blood vessel endothelium in type 2 diabetes. In clinical work,we can use medicine maked of prostacyclin and some analog ,or medicine to develop the activity of prostacyclin synthase to ameliorate the circulation of the diabetes,and to cure the T2DFU.