J. Exp. Biomed. Sci. 2011, 17(4): 313~319 Diabetes affects Peripheral Nerve and Heart Function Jeong-Min Ku 1, Hwa-Sik Choi 2, Kyung-Yae Hyun 3, Seong-Min Moon 1, Dae-Sik Kim 4 and Seok-Cheol Choi 1, 1 Department of Clinical Laboratory Science, College of Health Sciences, Catholic University of Pusan, Busan 609-757, Korea, 2 Department of Clinical Laboratory Science, Shinheung College, Uijeongbu 480-701, Korea, 3 Department of Clinical Laboratory Science, Dong Eui University, Busan 614-714, Korea, 4 Department of Clinical Laboratory Science, Dongnam Health College, Suwon 440-714, Korea Diabetes mellitus (DM) leads to a variety of complications and thus we have retrospectively studied to investigate problems of nerve conduction velocity (NCV) study and the heart in the patients with type-ii DM. Blood glucose and blood pressure levels were higher in DM group than in Non-DM group. We found that several latencies were delayed in motor conduction study of upper (median and ulnar nerve) and lower extremities (peroneal and tibial nerve), whereas amplitudes and NCVs were decreased in DM group compared with Non-DM group. Latencies of sensory conduction study in upper and lower extremities (sural nerve) were delayed, while amplitudes and NCVs were lower in DM group than in Non-DM group. Abnormal percent of the electrocardiogram was higher in DM group than in Non-DM group. This retrospective study suggests that type-ii DM can cause a damage effect on the peripheral nerve and the heart function. Key Words: Diabetes mellitus, Nerve conduction velocity study, Electrocardiogram 서 당뇨병은인슐린저항성및혈당의비정상적증가를특징으로하는대표적대사성질환으로전세계적인보건문제로대두되고있다. 1997년의통계에서전세계인구중약 1억 2천만명의유병률을보였고일부연구는 2010년에이르러 2억만명이상으로증가할것으로추정하였다 (Vinik and Vinik, 2003). 게다가 Zimmet et al. (2001) 은한국을포함한아시아국가에서매년 1% 씩의새로운당뇨병환자의발생증가율을보여향후전세계인구중약 10억명이당뇨병으로인해심각한의학적문제에봉착할것으로예측하였다. 당뇨병은의학적으로분명한진단이결정되기전초기의보편적전구증세로대사이상증이흔히온다. 이러한대사이상증후군으로는복부비만, 고혈압, 인슐린저항성, 죽종형성지질이상증 (atherogenic dyslipidemia), 혈액응고촉진경향등이있 론 * 접수일 : 2011년 10월 22일 / 수정일 : 2011년 12월 31일채택일 : 2011년 12월 31일 교신저자 : 최석철, ( 우 ) 609-757, 부산시금정구부곡3동 9, 부산가톨릭대학교임상병리학과 Tel: 051-510-0564, Fax: 051-510-0568 e-mail: scchoi@cup.ac.kr 다 (Vinik and Viaik, 2003). 당뇨병의유형중인슐린의존성 I형보다인슐린비의존성 II형당뇨병이다양한합병증을유발하므로특히임상적문제가되고있다. 선행연구에따르면무증상 II형당뇨병환자의경우합병증으로망막병증 (retinopathy), 신장병증 (nephropathy), 신경병증 (neuropathy) 에대한검사를스크린테스트로받을것을흔히권고한다 (American diabetes association, 2007). 그러나 II형당뇨병의주요합병증은관상동맥심장질환으로해마다발병위험률이증가하고있다. 심혈관질환은 II형당뇨병환자의가장중요한합병질병이며이들환자사망의약 2/3의원인이되고있다 (Adult treatment panel III, 2002). 최근의여러연구들은다양한방법으로 II형당뇨병으로인한합병증발생및병태생리학적영향에관해연구해왔으나, 보편적방법을통한당뇨병이신경생리학에미치는영향에관한연구는부족한실정이다. 따라서본연구의저자들은신경생리학분야에서일상적으로반드시사용해야하는신경전도속도검사와임상의다양한분야에서보편적으로적용하고있는심전도를이용하여 II형당뇨병이말초신경계와심장기능에어떤영향을미치는지조사하여향후당뇨병관리및합병증치료의기초자료로활용하고자이연구를시행하게되었다. - 313 -
재료및방법대상 2000년 ~2007년까지 'A' 병원을내원한당뇨환자 121 명 ( 당뇨그룹 ) 과비당뇨환자 ( 일반감기등의환자, 비당뇨그룹 ) 114 명을대상으로하였고전체대상자들중뇌졸중, 심혈관질환으로인한수술, 암치료등을포함한심각한기왕력이있는환자들은연구에서제외시켰다. 이연구는환자의과거기록차트의자료들만을순수하게분석하였고추가적검체채취나검사들은실시하지않고후향적으로실시하였다. 본연구는부산가톨릭대학교의 IRB (Institution al Review Board for Human Research Catholic University of Pusan) 에따라실시하였다. 방법기본변수. 모든환자들을대상으로나이, 성비, 공복시혈당, 수축기혈압, 확장기혈압, 당뇨병유병기간을조사비교하였다 (Table 1). 신경전도검사. 환자군과대조군모두에대해상지및하지의운동신경과감각신경전도검사및 F-wave 검사 ( 후기반응 ) 를시행하였다. 신경전도검사는검사실실온을 26 이상유지한상태에서 Neuropack M1 EP/EMG Measuring system MEB-9200 (Nihon Kohden Co., Japan) 을사용하여상지에서는정중신경및척골신경을, 하지에서는비골신경, 후경골신경, 비복신경을구획별로나누어측정하였는데, 정중신경과척골신경감각신경전도검사는정방향방법 (orthodromic method) 을, 비복신경은역방향방법 (antidromic method) 을사용하여검사하였다. 검출자극, 자극전극및접지전극은모두상품화된 Alpine biomed 사의 Pre-Gellded Disposalble Surface Electrode를사용하였다. 감각신경전도검사의경우 0.2 msec의 square wave pulse로자극하였고필터는 20~2,000 Hz, sweep speed는 2 msec/division, sensitivity는 50 μv/division으로하였다. 운동신경전도검사의경우필터는 2~10,000 Hz, sweep speed는 3 msec/division, sensitivity는 10 mv/division으로하였다. 운동및감각신경의잠복기, 복합근활동전위 (compound muscle action potential, CMAP), 감각전위진폭, F-파최소잠복기를측정하였다. 지배하는원위부근육에근육팽대부- 건방법으로부착하고환자에게주의를집중시킨후자극하여검사오차를최소화하였다. 처음에는최소자극강도로원위부를자극한후점차강도를높여최대상자극까지올려서복합근활동전위 (CMAP) 를기록하였다. 근위부를최대상자극으로자극하여복합근활동전위의전도시간 (msec) 과, 진폭 (mv) 을기록하였다. 근위부와원위부에서복합근활동전위의잠복기와진폭을측정하고필요시복합근활동전위의지속시간과모양도관찰하였다. 활성전극의중심과자극전극간의거리를 mm로측정한후운동신경전도속도를아래공식에의해계산하였다. 운동신경전도속도 (m/sec) = 두자극점사이의거리 (mm) [ 근위잠복기 (msec)-원위잠복기 (mes)] 감각신경전도검사. 해부학적지침에따라정확한부위에기록전극을부착한후정방향감각신경전도검사에서는원위부신경섬유를최대상자극하고, 역방향감각신경전도검사에서는근위신경섬유를최대상자극하였다. 활성전극은기록전극쪽에두고복합신경활동전위를기록하였다. 만일복합신경활동전위가쉽게기록되지않을시 signal average를사용하였다. 자극점에서잠복기를기록하고진폭의지속기간을측정하고파형을보며활성자극전극의중심에서활성기록전극의중심까지의거리를 mm 로계측하여감각신경전도속도를아래공식으로구하였다. 감각신경전도속도 (m/sec) = 활동자극전극과활동기록전극사이의거리 (mm) 잠복기 (msec) F-파검사. 검사하고자하는상지및하지의신경이지배하는원위부근육에근육팽대부- 건방법으로기록전극을부착한후활성전극을척수방향으로두고원위부를자극하였다. 차단반응을피하기위해 2초이상의간격을두고한번씩최대상자극을가하여적어도 10회이상의 F-파를기록한후제일짧은잠복기를측정하였다. 심전도검사전체연구대상자들에대해 ECG-9620 series 모델 (Nihon Koden Co., Japan) 로심전도를기록하였다. 운동신경전도검사. 기록전극은검사하고자하는신경이 - 314 -
자료분석및통계처리 모든자료는평균 ± 표준편차로표시하였고양그룹간의비교에는 unpaired t-test를적용하였고심전도소견및신경전도검사에서무반응 (no response) 발생률비교에는 F-test를적용하였다 (SPSS version 19). P 0.05일때통계적으로유의한차이가있는것으로인정하였다. 기본변수 Table 1. Characteristics of Non-DM and DM group 결 양그룹간의나이와성비는유의한차이가없었으나 (P>0.05) 공복시혈당, 수축기혈압, 확장기혈압, 당뇨병력은당뇨그룹이비당뇨그룹보다유의하게더높았거나길었다 (P<0.05, Table 1). 상지의정중신경운동전도속도 종말잠복기, 손목- 팔꿈치잠복기, 팔꿈치-겨드랑이잠복기, F-파잠복기모두당뇨그룹이비당뇨그룹보다유의하게연장되었고 (P<0.05, P<0.01, P<0.001) 손목진폭, 팔꿈치진폭, 겨드랑이진폭, 팔꿈치전도속도, 팔꿈치- 겨드랑이전도속도모두당뇨그룹이비당뇨그룹보다낮거나느렸다 (P<0.001, P<0.000, Table 2). 상지의척골신경운동전도속도 Non-DM (n=121) 종말잠복기, 손목- 팔꿈치잠복기, 팔꿈치-겨드랑이잠복기, F-파모두당뇨그룹이비당뇨그룹보다유의하게연장되었고 (P<0.05, P<0.000), 손목진폭, 팔꿈치진폭, 과 Group DM (n=114) Age 59.90±10.75 61.84±9.66 Sex (M : F) 62 : 59 59 : 55 Glucose level (mg/dl) 108.66±23.82 230.40±113.43 * SBP (mmhg) 125.89±18.70 135.03±15.26 * DBP (mmhg) 81.06±8.51 83.58±10.03 * DM-period (year) 0 16.37±13.42 * Data were expressed the mean ± standard deviation (SD). *, P<0.05 (compared with Non-DM group). Abbreviation: M, male; F, female; SBP, systolic blood pressure; DBP, diastolic blood pressure; DM-period, the period suffering from diabetes mellitus. Table 2. Comparison of motor conduction study of median nerve in upper extremities between two groups 겨드랑이진폭, 손목-팔꿈치전도속도, 팔꿈치-겨드랑이전도속도모두당뇨그룹이비당뇨그룹보다유의하게낮거나느려졌다 (P<0.000, Table 3). 하지의비골신경운동전도속도 종말잠복기, 발목종아리뼈머리잠복기, F-파잠복기는당뇨그룹이비당뇨그룹보다유의하게연장되었고 (P< 0.05), 발목진폭, 종아리뼈머리진폭, 오금진폭, 발목종아리뼈머리전도속도및종아리뼈머리- 오금전도속도는당뇨그룹이비당뇨그룹보다유의하게낮거나느렸다 (P<0.000, Table 4). 하지의경골신경운동전도속도 3.23±0.66 vs 3.16±0.58 vs 3.94±1.40 3.62±1.40 ** 7.27±0.78 vs 7.23±0.73 vs 8.35±1.89 7.95±2.22 ** 9.27±0.93 vs 10.51±2.18 9.14±0.84 vs 9.91±2.67 * 25.69±3.75 vs 26.14±3.82 vs 26.79±7.67 * 26.06±8.04 15.74±3.61 vs 15.35±3.49 vs 13.23±5.34 12.81±4.88 14.80±3.49 vs 14.19±3.61 vs 12.37±5.11 11.72±4.65 14.15±3.48 vs 13.94±3.41 vs 11.77±4.90 11.21±4.55 56.68±3.43 vs 51.37±8.17 56.43±3.02 vs 48.79±10.81 59.80±4.23 vs 62.24±4.81 vs 54.27±8.79 54.54±10.28 *, P<0.05; **, P<0.01;, P<0.001;, P<0.000 (compared with Non-DM group). Abbreviation: T, terminal; W-E, wrist-elbow; E-A, elbow-axillary; W, wrist; E, elbow; A, axillary; NCV, nerve conduction velocity. 종말잠복기, 발목-오금잠복기, F-파잠복기모두당뇨그룹이비당뇨그룹보다유의하게연장되었고 (P<0.05, P<0.000), 발목진폭, 오금진폭, 발목-오금전도속도는당뇨그룹이비당뇨그룹보다낮거나느렸다 (P<0.000, Table 5). - 315 -
Table 3. Comparison of motor conduction study of ulnar nerve in upper extremities between two groups 상지의정중신경감각전도속도 두번째손가락 ( 검지 )-손목잠복기, 손바닥손목잠복기, 손목-팔꿈치잠복기, 팔꿈치-겨드랑이잠복기는당뇨그룹이비당뇨그룹보다유의하게연장되었다 (P<0.05, P<0.001, P<0.000). 검지진폭, 손바닥진폭, 손목진폭, 팔꿈치진폭, 그리고, 검지-손목전도속도, 손바닥-손목전도속도, 손목-팔꿈치전도속도, 팔꿈치-겨드랑이전도속도는당뇨그룹이비당뇨그룹보다유의하게낮거나느렸다 (P<0.001, P<0.000, Table 6). 상지의척골신경감각전도속도 검지-손목잠복기, 손목-팔꿈치잠복기, 팔꿈치-겨드랑이잠복기는당뇨그룹이비당뇨그룹에비해유의하게연장되었다 (P<0.05, P<0.000), 검지진폭, 손목진폭, 팔꿈치진폭, 그리고검지-손목전도속도, 손목-팔꿈치전도속도, 팔꿈치-겨드랑이전도속도는당뇨그룹이비당뇨그룹보다유의하게낮거나느렸다 (P<0.000, Table 7). 하지의비복신경감각전도속도 2.20±0.30 vs 2.50±0.49 2.23±0.29 vs 2.54±0.33 6.38±0.62 vs 7.28±1.36 6.36±0.69 vs 7.19±0.97 8.52±0.76 vs 8.51±0.79 vs 9.72±1.79 9.41±1.51 25.13±2.64 vs 25.30±2.02 vs 26.31±6.68 * 28.06±3.26 15.99±3.06 vs 15.89±2.96 vs 13.44±3.95 13.88±3.39 14.88±2.72 vs 14.92±2.95 vs 12.20±4.03 12.87±3.39 26.37±13.90 vs 14.04±2.89 vs 11.41±3.76 12.73±5.17 * 57.68±3.46 vs 57.59±3.59 vs 51.81±6.17 51.91±4.89 59.84±6.40 vs 59.58±4.49 vs 54.54±7.80 54.36±6.60 Abbreviation: T, terminal; W-E, wrist-elbow; E-A, elbow-axillary; W, wrist; E, elbow; A, axillary; NCV, nerve conduction velocity. 종말잠복기는양그룹간에유의한차이가없었으나 Table 4. Comparison of motor conduction study of peroneal nerve in lower extremities between two groups AFH-latency (msec) FHPF-latency (msec) FH-amplitude (mv) PF-amplitude (mv) AFH-NCV (m/sec) 3.73±0.72 vs 4.20±1.57 * 3.81±0.79 vs 4.09±1.92 10.12±1.65 vs 11.25±3.67 * 10.27±1.64 vs 10.82±4.52 12.12±3.87 vs 13.01±4.19 11.96±1.92 vs 12.50±5.15 43.61±12.37 vs 45.48±8.62 vs 40.53±13.16 * 32.07±25.49 7.67±3.80 vs 7.36±3.10 vs 3.05±2.57 2.98±2.43 6.77±3.36 vs 6.40±2.82 vs 3.05±2.57 2.53±2.16 6.48±3.29 vs 6.12±2.68 vs 2.99±2.51 2.44±2.11 44.30±6.25 vs 44.58±6.28 vs 36.30±10.84 34.68±13.59 49.58±8.47 vs 48.69±8.21 vs FHPF-NCV (m/sec) 41.57±12.72 38.61±14.87 Abbreviation: T, terminal; AFH, ankle-fibular head; FHPF, fibular head-popliteal fossa; A, ankle; FH, fibular head; PF, popliteal fossa; NCV, nerve conduction velocity. Table 5. Comparison of motor conduction study of tibial nerve in lower extremities between two groups APF-latency (msec) PF-amplitude (mv) APF-NCV (m/sec) 3.61±0.60 vs 3.63±0.56 vs 4.07±0.71 4.23±1.10 11.27±1.18 vs 11.52±1.16 vs 12.79±1.90 13.37±2.34 47.14±3.69 vs 47.46±3.64 vs 50.28±58.15 * 49.33±14.18 21.59±7.16 vs 21.47±7.50 vs 12.48±6.53 13.61±7.26 15.62±5.30 vs 8.55±4.76 15.58±5.66 vs 9.27±5.15 46.32±3.63 vs 39.56±6.24 55.03±6.48 vs 5.03±0.62 Abbreviation: T, terminal; APF, ankle-popliteal fossa; A, ankle; PF, popliteal fossa; NCV, nerve conduction velocity. (P>0.00) 진폭과전도속도는당뇨그룹이비당뇨그룹보다유의하게낮거나느렸다 (P<0.001, P<0.000, Table 8). - 316 -
Table 6. Comparison of sensory conduction study of median nerve in upper extremities between two groups DW-latency (msec) PW-latency (msec) D-amplitude (mv) P-amplitude (mv) DW-NCV (m/sec) PW-NCV (m/sec) 심전도소견 전체대상중정상심전도소견을보인사례는당뇨그룹이비당뇨그룹보다유의하게낮았다 (P<0.01). 비정상소견은당뇨그룹이더높았다 (P<0.01). 비정상소견의종류로는비정상 T파출현, 좌각전섬유속블록, 우축편위, 좌축편위, 심방세동, 심실조기수축, 심실비대등이있었으며이모든소견들은당뇨그룹이비당뇨그룹보다유의하게높았다 (P<0.05, P<0.01, Table 9). 고 3.01±1.42 vs 2.99±1.11 본연구에서나타난신경전도속도의결과들은거의대부분의경우당뇨그룹이비당뇨그룹에비해잠복기는연장되었고진폭은낮았고전도속도는느리게나타남으로 찰 2.80±0.43 vs 3.00±1.09 * 1.96±0.52 vs 2.20±0.80 * 2.14±0.93 vs 2.23±0.91 3.86±0.34 vs 3.77±0.37 vs 4.18±0.50 4.06±0.72 1.98±0.22 vs 1.90±0.23 vs 2.13±0.31 1.99±0.28 * 30.81±17.90 vs 39.03±20.79 vs 19.52±16.34 26.83±23.69 120.14±21.57 vs 95.76±49.04 vs 63.34±55.91 51.23±41.63 48.46±32.84 vs 48.13±19.07 vs 31.74±15.55 35.49±20.34 90.49±65.12 vs 66.58±48.00 vs 61.67±48.53 66.64±48.29 43.67±6.36 vs 48.99±41.82 vs 35.20±13.07 36.75±13.07 37.65±6.75 vs 39.19±6.23 vs 31.08±10.96 31.33±11.86 56.34±3.00 vs 57.34±3.00 vs 52.70±4.30 52.09±7.99 57.39±2.80 vs 58.84±2.93 vs 53.13±6.81 55.04±4.67 *, P<0.05;, P<0.001;, P<0.000 (compared with Non-DM group). Abbreviation: DW, digiti 2-wrist; PW, palm-wrist; WE, wristelbow; EA, elbow-axillary; D, digiti 2; P, palm; W, wrist; E, elbow; NCV, nerve conduction velocity. Table 7. Comparison of sensory conduction study of ulnar nerve in upper extremities between two groups DW-latency (msec) D-amplitude (mv) DW-NCV (m/sec) 3.90±0.80 vs 2.39±0.61 2.33±0.22 vs 2.54±0.33 4.17±0.46 vs 4.40±1.01 * 4.15±0.52 vs 4.56±0.60 2.03±0.56 vs 1.93±0.67 vs 2.20±0.32 * 2.11±0.40 * 18.92±9.79 vs 17.47±8.83 vs 12.30±8.83 10.63±6.72 41.20±17.29 vs 44.12±39.50 vs 23.11±16.14 24.68±15.39 48.71±32.28 vs 39.76±25.13 vs 26.66±24.36 21.91±18.49 44.41±5.48 vs 43.41±4.80 vs 39.46±9.39 39.92±4.02 56.09±3.42 vs 55.95±3.17 vs 49.85±4.80 51.01±4.67 59.07±3.50 vs 59.58±5.95 vs 54.86±4.81 55.48±4.76 Abbreviation: DW, digiti 5-wrist; WE, wrist-elbow; EA, elbowaxillary; D, digiti 5; W, wrist; E, elbow; NCV, nerve conduction velocity. Table 8. Comparison of sensory conduction study of sural nerve in lower extremities between two groups Amplitude (mv) NCV (m/sec) 3.30±0.31 vs 3.19±1.07 3.35±0.36 vs 3.22±1.20 14.33±9.57 vs 15.08±8.62 vs 8.80±8.75 9.29±8.87 40.67±.051 vs 34.04±11.21 40.39±3.68 vs 33.26±12.05, P<0.001;, P<0.000 (compared with Non-DM group). Abbreviation: T, terminal; NCV, nerve conduction velocity. 써당뇨병이말초신경계장애발생의주요원인이될수있다는점을확인할수있었다. 특히상지 ( 정중신경과척골신경 ) 및하지 ( 비골신경과후경골신경 ) 의말단잠복기는팔과다리신경의가장원위부를자극해서얻은잠복기로서이측정값의연장은당뇨병으로인한운동신경의심각한손상이발생하였음을시사하는소견이다. 당뇨그룹에있어또한상지및하지의특정구간별잠복시간의연장과특정부위의진폭감소, 전도속도의저하는당뇨 - 317 -
Table 9. Comparison of electrocardiogram findings between two groups Group Normal finding (%) 64.86 vs 47.54 ** Abnormal finding (%) 35.14 vs 52.46 ** Abnormal T wave (%) 11.71 vs 19.67 ** LAF block (%) 0 vs 1.63 * RAD (%) 0.90 vs 1.63 * LAD (%) 0 vs 3.27 * Atrial fibrillation (%) 0 vs 3.27 * VPC (%) 0.90 vs 8.19 * Ventricular hypertrophy (%) 0.90 vs 11.47 ** *, P<0.05; **, P<0.01 (compared with Non-DM group). Abbreviation: LAF, left anterior fascicular; RAD, right axis deviation; LAD, left axis deviation; VPC, ventricular premature contraction. 병이매우심각한말초신경장애를가져온다는중요한소견이된다. 특히흥미로운결과는당뇨그룹에있어하지의운동신경검사에서나타난진폭및전도속도의감소정도가상지의경우보다더심함에따라당뇨병환자들의경우하지부분에대한관리및주의가더필요할것으로판단된다. 50세이상의 II형당뇨병환자의경우단계적으로골반대퇴부근육의약화현상이갑자기발생할수있다 (Bansal et al., 2006). 당뇨병환자에있어신경병증의종류는팔다리의신경경색 (nerve infarction) 이고나머지하나는신경조임 (nerve entrapment) 이다. 신경경색의경우갑작스런통증시작의원인이되고뒤이어다양한약화현상및위축 (atrophy) 이일어난다. 1차적병태생리학은축삭 (axon) 의변성이고회복되기까지수개월이상의긴시간이소요되며가장잘영향받는부위는정중신경, 요골신경, 척골신경이다 (Bansal er al., 2006). 본연구에서조사된후기반응인 F-파잠복기의경우경골신경은당뇨그룹이비당뇨그룹보다연장됨으로써당뇨기인성근위부신경병증이발생되었음이시사되었다. 그러나비골신경의경우오히려당뇨그룹이상대적으로단축되었으므로이부분에대한연구가향후더필요할것으로판단된다. F파는원심성신경부위를자극하여구심성운동신경섬유와척수전각세포를돌아오는잠복기를측정하는검사법으로이값의연장은구심성신경의비정상을반영한다. 한편상지및하지의감각신경전도속도역시각부위의잠복기, 진폭, 그리고전도속도들이연장, 저하, 감소현상들을보임으로써당뇨병이운동신경뿐만아니라감각신경계에도심각한손상을일으킴을알수있었다. 최근의여러연구들역시당뇨병이신경세포섬유의손상과슈반세포의재수초화 (ensheathing) 와같은말초신경계의손상을유발한다고보고함으로써본연구의결과와매우일치된소견을보였다 (Viswanathan et al., 2004; Strotmeyer et al., 2008; Boyd et al., 2010). 당뇨병환자의약 10% 는지속적인통증에시달리며당뇨기인성신경병증의통증은자가적또는특정자극에의해심하게발생하여제어할수없을정도가된다 (Oh, 1993). 당뇨기인성신경병증환자들은전형적으로밤에더심하며마치화상, 바늘로찌르는듯한느낌, 총맞은느낌, 쑤심, 경련, 냉통, 따끔거림과같은느낌의통증을호소한다. 일부환자들은통증과함께주로작은섬유의신경병증이발생하며인슐린치료초기에감각이상증이발생할수도있다 (Tesfaye et al., 1996). 본연구에서조사된심전도의경우당뇨그룹이비당뇨그룹보다더높은비정상소견을보임으로써당뇨병이심장의기능에유해한영향을미침을알수있었다. Movahed et al. (2005) 은당뇨병이심방세동발생의가장강하고독립적위험인자라고보고함으로써본연구와일치된소견을보였다. 당뇨병환자들의경우심방세동, 심실세동, 갑작스런심정지사망발생률이매우높다 (Veglio et al., 2004; Aksnes et al., 2008). 특히장기간의심방세동은심장내혈전형성의중요한원인이되어때로는뇌경색발생과같은심각한합병증을이차적으로유도할수있다. 당뇨병환자들에있어심전도상소견은 QT 간격의연장과비정상 T파의출현을종종관찰할수있다 (Veglio et al., 2004). 본연구에서도비정상 T파의출현율이당뇨그룹에서더높게나타남으로써기존연구와일치되는소견을보였다. 당뇨병환자들에있어비정상 T파의보다높은출현기전은활동전압의연장에기인한다 (Aksnes et al., 2008). 지방산과글루코스대사의핵심조절인자인 peroxisome proliferator activated receptor α (PPARα) 가당뇨병환자의심장에서상향조절되어광범위한이온통로의 remodeling을유도한다 ( 대부분의 Ca 2+ -independent transient outward K + channel을포함하여 ) (Marionneau et al., 2008). 당뇨병환자의심장에있어 PPARα-과잉표현은좌심실비대나좌심실기능장애의원인이될수있다 (Barth와 Tomaselli, 2009). 본연구에서나타난심실조기수축, 심실비대, 심실비대와관련있는우축편위, 좌축편위의발생비율이당뇨그룹에서보다더높았음은이러한 - 318 -
여러기전에기인한것으로보인다. 또한당뇨병은작은혈관과큰혈관의변화를가져와서 (Stratton et al., 2000) 고혈압발생의원인이되며본연구에서도동일한결과를확인할수있었다. VanHoose et al. (2010) 역시당뇨병환자에있어 QTc 간격의연장, 심박수감소, R파진폭의증가와같은부정맥발생이더빈번함을보고하였고 Nichols et al. (2004) 은당뇨병이울혈성심부전발생의주요원인이될수있음을증명함으로써당뇨병이심혈관질환발생의큰위험인자가됨을시사하였다. 이상의연구결과를볼때당뇨병은심혈관질환및말초신경계장애병증발생의위험인자가됨을알수있었고향후당뇨병환자들에대한합병증의조기검사와예방을위한적극적관리가필요할것으로사료된다. REFERENCES Adult Trearment Panel III. Third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults Treatment Panel III: Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report Circulation 2002. 106: 31-43. Aksnes TA, Schmieder RE, Kjeldsen SE, Ghani S, Hua TA, Julius S. Impact of new-onset diabetes mellitus on development of AF and heart failure in high-risk hypertension (from the VALUE Trial). Am J Cardiol. 2008. 101: 634-638. American Diabetes Association. Standards of medical care in diabetes. Diabetes Care 2007. 30(suppl-1): S4-S41. Bansal V, Kalita J, Misra UK. Diabetic neuropathy. Postgrad Med J. 2006. 82: 95-100. Barth AS, Tomaselli GF. Cardiac Metabolism and Arrhythmias. Diabetes Care 2008. 31: 1767-1772. Boyd BS, Wnek L, Gray AT, Topp KS. Mechanosensitivity during lower extremity neurodynamic testing is diminished in individuals with Type 2 Diabetes Mellitus and peripheral neuropathy: a cross sectional study. BMC Neurology 2010. 10: 75-89. Marionneau C, Aimond F, Brunet S, Niwa N, Finck B, Kelly DP, Nerbonne JM. PPARalpha-mediated remodelling of repolarizing voltage-gated K+(Kv) channels in a mouse model of metaboliccardiomyopathy. J Mol Cell Cardiol. 2008. 44: 1002-1015. Movahed MR, Hashemzadeh MJammal MM. Diabetes mellitus is a strong, independent risk for atrial fibrillation and flutter in addition to other cardiovascular disease. Int J Cardiol. 2005. 105: 315-318. Nichols GA, Ephross SA, Gullion GA, Brown JR, Koro CE. The incidence of congestive heart failure in type 2 diabetes. Diabetes Care 2004. 27: 1879-1884. Oh SJ. Clinical electromyography: nerve conduction studies. In: Nerve conduction in polyneurophathies. Baltimore: Williams and Wilkins. 1993: 579-591. Stratton IM, Adler AI, Neil HAW, Matthews DR, Manley SE, Cull CA, Hadden D, Turner RC, Holman RR. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000. 321: 405-412. Strotmyer ES, de Rekeneire N, Schwartz AV, Faulkner KA, Renick H, Goodpaster BH, Shorr RI, Vinik AI, Harris TB, Newman AB. The relationship of reduced peripheral nerve function and diabetes with physical performance in older white and black adults. Diabetes Care 2008. 31: 1219-1221. Tesfaye S, Malik R Harris N. Arterio venous shunting and proliferating new vesells in acute painful neuropathy of rapid glycemic control (insulin neuritis). Diabetologia 1996. 39: 329-335. VanHoose L, Sawers Y, Loganathan R, Vacek JL, Stehno-Bittel L, Novikova L, AI-Jarrah M, Smirnova IV. Electrocardiographic changes with the onset of diabetes and the impact of aerobic exercise training in the Zucker Diabetic Fatty (ZDF) rat. Cardiovascular Diabetology. 2010. 9: 56-65. Veglio M, Chinaglia A, Cavallo-Perin P. QT interval, cardiovascular risk factors and risk of death in diabetes. J Endocrinol Invest. 2004. 27: 175-181. Vinik AI, Vinik E. Prevention of the complications of diabetes. Am J Manag Care 2003. 9(3 Suppl): S63-S80. Viswanathan V, Seena R, Nair MB, Snehalatha C, Bhoopathy RM, Ramachandran A. Nerve conduction abnormalities in different stages of glucose intolerance. Neurology India 2004. 52: 466-469. Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001. 414: 782-787. - 319 -