The Diabetic Neuropathies

Electromyography Laboratory, Columbia University College of Physicians and Surgeons, Columbia Presbyterian Medical Center, 710 West 168th Street, 13th Floor, New York, NY 10032, USA.
The Neurologist (Impact Factor: 1.16). 12/2004; 10(6):311-22. DOI: 10.1097/01.nrl.0000144733.61110.25
Source: PubMed


Diabetes remains the most common cause of neuropathy in the United States and is a significant source of morbidity and mortality, accounting for substantial suffering and billions of dollars in health care expenditures each year.
Our insight into the pathophysiology of the diabetic neuropathies has increased considerably over the last decade. aided by advances in the basic science of diabetes itself. A wide variety of potential mechanisms for nerve injury in diabetes has been identified, including the polyol pathway of glucose metabolism, oxidative nerve injury, the deposition of advanced glycosylation end products within the nerve and the effects of vascular insufficiency, among others. Diabetic neuropathy may take a variety of clinical forms beyond the well-known distal symmetric neuropathy, many of which are often misdiagnosed or overlooked entirely, sometimes with serious consequences for the patient. Proper therapy after diagnosis is also critical and may include not only primary management, but also treatment of painful diabetic neuropathy through an expanding repertoire of increasingly effective pharmacologic agents. Though primary treatment trials have not yet provided effective therapies, ongoing and future trials offer continuing promise.
The diabetic neuropathies are exceedingly common, but often improperly diagnosed and incompletely treated. A proper understanding of the mechanisms underlying these diseases and the clinical recognition of their various forms is highly important as appropriate primary and symptomatic management can substantially reduce the morbidity and mortality associated with these disorders.

11 Reads
  • Source
    • "Peripheral diabetic neuropathy (PDN), being one of the most frequent and troublesome complications of diabetes mellitus [1], is often accompanied with various pain syndromes [2– 5]. Impairment of Ca 2+ homeostasis [6] [7] [8] [9] and remodeling of voltage-and ligand-gated ion channels [10] [11] [12] in nociceptive neurons under PDN have been implicated in altered nociception . "
    [Show abstract] [Hide abstract]
    ABSTRACT: T-type Ca(2+) channels are known as important participants of nociception and their remodeling contributes to diabetes-induced alterations of pain sensation. In this work we have established that about 30% of rat nonpeptidergic thermal C-type nociceptive (NTCN) neurons of segments L4-L6 express a slow T-type Ca(2+) current (T-current) while a fast T-current is expressed in the other 70% of these neurons. Streptozotocin-induced diabetes in young rats resulted in thermal hyperalgesia, hypoalgesia, or normalgesia 5-6 weeks after the induction. Our results show that NTCN neurons obtained from hyperalgesic animals do not express the slow T-current. Meanwhile, the fraction of neurons expressing the slow T-current did not significantly change in the hypo- and normalgesic diabetic groups. Moreover, the peak current density of fast T-current was significantly increased only in the neurons of hyperalgesic group. In contrast, the peak current density of slow T-current was significantly decreased in the hypo- and normalgesic groups. Experimental diabetes also resulted in a depolarizing shift of steady-state inactivation of fast T-current in the hyperalgesic group and slow T-current in the hypo- and normalgesic groups. We suggest that the observed changes may contribute to expression of different types of peripheral diabetic neuropathy occurring during the development of diabetes mellitus.
    Neural Plasticity 02/2014; 2014:938235. DOI:10.1155/2014/938235 · 3.58 Impact Factor
  • Source
    • "Peripheral diabetic neuropathy (PDN) is one of the earliest, the most frequent and troublesome complications of diabetes mellitus occurring in about 66% of patients with type 1 diabetes [1]. As in humans, development of PDN in rats is accompanied with various alterations in pain sensation (hyper-, hypoalgesia, allodynia) or leaves pain sensation unchanged (normalgesia) [2] [3] [4] [5] and these alterations may be considered as manifestation of different PDN types. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Streptozotocin (STZ)-induced type 1 diabetes in rats leads to the development of peripheral diabetic neuropathy (PDN) manifested as thermal hyperalgesia at early stages (4th week) followed by hypoalgesia after 8 weeks of diabetes development. Here we found that 6-7 week STZ-diabetic rats developed either thermal hyper- (18%), hypo- (25%) or normalgesic (57%) types of PDN. These developmentally similar diabetic rats were studied in order to analyze mechanisms potentially underlying different thermal nociception. The proportion of IB4-positive capsaicin-sensitive small DRG neurons, strongly involved in thermal nociception, was not altered under different types of PDN implying differential changes at cellular and molecular level. We further focused on properties of T-type calcium and TRPV1 channels, which are known to be involved in Ca(2+) signalling and pathological nociception. Indeed, TRPV1-mediated signalling in these neurons was downregulated under hypo- and normalgesia and upregulated under hyperalgesia. A complex interplay between diabetes-induced changes in functional expression of Ca(v)3.2 T-type calcium channels and depolarizing shift of their steady-state inactivation resulted in upregulation of these channels under hyper- and normalgesia and their downregulation under hypoalgesia. As a result, T-type window current was increased by several times under hyperalgesia partially underlying the increased resting [Ca(2+)](i) observed in the hyperalgesic rats. At the same time Ca(v)3.2-dependent Ca(2+) signaling was upregulated in all types of PDN. These findings indicate that alterations in functioning of Ca(v)3.2 T-type and TRPV1 channels, specific for each type of PDN, may underlie the variety of pain syndromes induced by type 1 diabetes.
    Biochimica et Biophysica Acta 01/2013; 1832(5). DOI:10.1016/j.bbadis.2013.01.017 · 4.66 Impact Factor
  • Source
    • "Some patients with diabetic neuropathy develop severe pain, which can be extremely difficult to treat. This painful signal is believed to originate in the PNS; however, the exact peripheral mechanisms underlying diabetic hyperalgesia are not well understood (Calcutt, 2002; Schmader, 2002; Gooch and Podwall, 2004; Ørstavik et al., 2006; Ziegler, 2008). A subset of nociceptive primary sensory neurons can exhibit high frequency firing to sustained mechanical stimulation under diabetic conditions, suggesting that the increased firing in nociceptors may contribute to the exaggerated pain seen in diabetic neuropathy (Chen and Levine, 2001, 2003). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Painful diabetic neuropathy is a common complication of diabetes mellitus and can affect many aspects of life and severely limit patients' daily functions. Signals of painful diabetic neuropathy are believed to originate in the peripheral nervous system. However, its peripheral mechanism of hyperalgesia has remained elusive. Numerous studies have accumulated that polymodal nociceptive C-fibres play a crucial role in the generation and conduction of pain signals and sensitization of which following injury or inflammation leads to marked hyperalgesia. Traditionally, the number of nociceptive primary afferent firings is believed to be determined at the free nerve endings, while the extended main axon of unmyelinated C-fibres only involves the reliable and faithful propagation of firing series to the central terminals. We challenged this classic view by showing that conduction of action potential can fail to occur in response to repetitive activity when they travel down the main axon of polymodal nociceptive C-fibres. Quantitative analysis of conduction failure revealed that the degree of conduction failure displays a frequency-dependent manner. Local administration of low threshold, rapidly activating potassium current blocker, α-dendrotoxin (0.5 nM) and persistent sodium current blocker, low doses of tetrodotoxin (<100 nM) on the main axon of C-fibres can reciprocally regulate the degree of conduction failure, confirming that conduction failure did occur along the main axon of polymodal nociceptive C-fibres. Following streptozotocin-induced diabetes, a subset of polymodal nociceptive C-fibres exhibited high-firing-frequency to suprathreshold mechanical stimulation, which account for about one-third of the whole population of polymodal nociceptive C-fibres tested. These high-firing-frequency polymodal nociceptive C-fibres in rats with diabetes displayed a marked reduction of conduction failure. Delivery of low concentrations of tetrodotoxin and Nav1.8 selective blocker, A-803467 on the main axon of C-fibres was found to markedly enhance the conduction failure in a dose-dependent manner in diabetic rats. Upregulated expression of sodium channel subunits Nav1.7 and Nav1.8 in both small dorsal root ganglion neurons and peripheral C-fibres as well as enhanced transient and persistent sodium current and increased excitability in small dorsal root ganglion neurons from diabetic rats might underlie the reduced conduction failure in the diabetic high-firing-frequency polymodal nociceptive C-fibres. This study shed new light on the functional capability in the pain signals processing for the main axon of polymodal nociceptive C-fibres and revealed a novel mechanism underlying diabetic hyperalgesia.
    Brain 02/2012; 135(Pt 2):359-75. DOI:10.1093/brain/awr345 · 9.20 Impact Factor
Show more