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Response: Features of Long-Standing Korean Type 2 Diabetes Mellitus Patients with Diabetic Retinopathy: A Study Based on Standardized Clinical Data (Diabetes Metab J 2017;41:393-404)
Sang Youl Rhee, Jeong-Taek Wooorcid
Diabetes & Metabolism Journal 2017;41(6):494-495.
DOI: https://doi.org/10.4093/dmj.2017.41.6.494
Published online: December 19, 2017
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Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, Seoul, Korea.

Corresponding author: Jeong-Taek Woo. Department of Endocrinology and Metabolism, Kyung Hee University School of Medicine, 23 Kyungheedae-ro, Dongdaemun-gu, Seoul 02447, Korea. jtwoomd@khmc.or.kr

Copyright © 2017 Korean Diabetes Association

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

We appreciate the interests and comments on our manuscript, “Features of long-standing Korean type 2 diabetes mellitus patients with diabetic retinopathy: a study based on standardized clinical data,” which was published in Diabetes & Metabolism Journal (DMJ).
Diabetic retinopathy (DR) and macular edema (ME) are important diabetic microvascular complications that severely impair the quality of life of patients with type 2 diabetes mellitus (T2DM) through severe visual loss or blindness [1]. Several studies have shown that it is possible to improve the quality of life of patients and the clinical course of DR and ME through strict control of blood glucose and other related risk factors [2]. However, the screening rate for diabetic ophthalmopathy is not sufficient in many countries including Korea, and proper treatment and management are still unsatisfactory [13].
We have previous planned a study to understand the clinical characteristics of diabetic ophthalmopathy in Koreans. We recruited 183 T2DM patients with disease duration of 15 years or longer and compared their characteristics according to the presence or grade of DR and presence or absence of ME [4]. This approach not only identifies the risk factors for diabetic ophthalmopathy but also identifies the characteristics of the subjects who did not experience complications even after a long period of disease.
In our study, proliferative DR (PDR) subjects were significantly younger than non-DR subjects, while duration of disease was significantly longer [4]. These results show that diabetes mellitus (DM) patients at younger ages may be at a higher risk of developing future microvascular complications. Since the incidence of DM in young age is continually increasing in Korea, public health problems caused by DR are expected to become severer in the future [5]. In this study, we considered all parameters that were found to be significant among the baseline characteristics of the subjects, as well as those already known as risk factors for existing DR, as a confounder, when performing multivariate logistic regression analyses. Patients with acute illness that may affect the outcome at the time of the study or those who were difficult to observe over the long term were excluded from the study.
Second, in our study, the odds ratio (OR) of PDR to glycated hemoglobin was 0.998 (95% confidence interval, 0.682 to 1.462). We also agree that glycemic control is one of the most important modifiable factors for the prevention of DM ophthalmopathy. However, baseline fasting glucose and glycosylated hemoglobin did not reflect the long-term glycemic burden in T2DM patients who had a long duration of disease in our study.
Third, insulin is a growth factor that acts on the insulin-like growth factor 1 (IGF-1) receptor-mediated pathway and is known to be one of the potential risk factors of DR. In fact, the Diabetes Control and Complications Trial (DCCT) study showed increased risk of DR after about a year of intensive treatment with insulin [6]. Other studies have also shown a significant association between insulin use and increased risk of retinopathy [7]. Our study also showed similar results. In a previous study, it was reported that IGF-1 reduction through pituitary ablation can prevent retinopathy aggravation, suggesting the presence of causality [8]. However, since our research was conducted as a cross-sectional study, it is difficult to think that our research results are sufficiently high. As mentioned, it is difficult to rule out the possibility that the ORs for insulin may be high due to the effects of unadjusted factors. In the future, we will conduct a longer observation study based on the implications obtained from the present study. We will try to gather a higher level of evidence by referring to the research design that you sent us.
Thank you again for your letter.

CONFLICTS OF INTEREST: No potential conflict of interest relevant to this article was reported.

  • 1. Cheung N, Mitchell P, Wong TY. Diabetic retinopathy. Lancet 2010;376:124-136. ArticlePubMed
  • 2. Yun JS, Lim TS, Cha SA, Ahn YB, Song KH, Choi JA, Kwon J, Jee D, Cho YK, Park YM, Ko SH. Clinical course and risk factors of diabetic retinopathy in patients with type 2 diabetes mellitus in Korea. Diabetes Metab J 2016;40:482-493. ArticlePubMedPMCPDF
  • 3. Rhee SY, Chon S, Kwon MK, Park IeB, Ahn KJ, Kim IJ, Kim SH, Lee HW, Koh KS, Kim DM, Baik SH, Lee KW, Nam MS, Park YS, Woo JT, Kim YS. Prevalence of chronic complications in Korean patients with type 2 diabetes mellitus based on the Korean National Diabetes Program. Diabetes Metab J 2011;35:504-512. ArticlePubMedPMC
  • 4. Park S, Rhee SY, Jeong SJ, Kim K, Chon S, Yu SY, Woo JT. Features of long-standing Korean type 2 diabetes mellitus patients with diabetic retinopathy: a study based on standardized clinical data. Diabetes Metab J 2017;41:393-404. ArticlePubMedPMCPDF
  • 5. Cho EH, Shin D, Cho KH, Hur J. Prevalences and management of diabetes and pre-diabetes among Korean teenagers and young adults: results from the Korea National Health and Nutrition Examination Survey 2005-2014. J Korean Med Sci 2017;32:1984-1990. ArticlePubMedPMCPDF
  • 6. Diabetes Control and Complications Trial Research Group. Nathan DM, Genuth S, Lachin J, Cleary P, Crofford O, Davis M, Rand L, Siebert C. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-986. ArticlePubMed
  • 7. Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis (Lond) 2015;2:17. ArticlePubMedPMC
  • 8. Sharp PS, Fallon TJ, Brazier OJ, Sandler L, Joplin GF, Kohner EM. Long-term follow-up of patients who underwent yttrium-90 pituitary implantation for treatment of proliferative diabetic retinopathy. Diabetologia 1987;30:199-207. ArticlePubMedPDF

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        Response: Features of Long-Standing Korean Type 2 Diabetes Mellitus Patients with Diabetic Retinopathy: A Study Based on Standardized Clinical Data (Diabetes Metab J 2017;41:393-404)
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