PECULIARITIES OF INSULIN RESISTANCE SYNDROME IN NON-ALCOHOLIC STEATOGEPATITIS ON THE BACKGROUND OF TYPE 2 DIABETES MELLITUS DEPENDING ON THE STAGE OF DIABETIC KIDNEY DISEASE

Objective. To study the interaction of changes in glucose and insulin homeostasis, the degree of IR and insulin sensitivity, the degree of glycosylation of hemoglobin on the clinical course of NASH on the background of diabetes mellitus depending on the presence of DKD and its stage. Material and methods. 108 patients with NASH with comorbid diabetes were examined. The average age of patients was (58.2 ± 6.1) years. There were 63 women (58.3%) and 45 men (41.7%). Depending on the presence of DKD, 4 groups of patients were formed

Редакційна рада: К.М.Амосова (Київ), В.В.Бойко (Харків), А.І.Гоженко (Одеса), В.М.Запорожан (Одеса), В.М.Коваленко (Київ), З.М.Митник (Київ), В.І.Паньків (Київ), В.П.Черних (Харків), Збігнев Копанські (Польща), Дірк Брутцерт (Бельгія), Раду Крістіан Дабіша (Румунія) Objective.To study the interaction of changes in glucose and insulin homeostasis, the degree of IR and insulin sensitivity, the degree of glycosylation of hemoglobin on the clinical course of NASH on the background of diabetes mellitus depending on the presence of DKD and its stage.Material and methods.108 patients with NASH with comorbid diabetes were examined.The average age of patients was (58.2 ± 6.1) years.There were 63 women (58.3%) and 45 men (41.7%).Depending on the presence of DKD, 4 groups of patients were formed, which were randomized by age, sex, activity of cytolytic syndrome of NASH depending on the stage of DKD.The comparison group consisted of 30 healthy individuals (PHP) of the appropriate age and sex.The degree of hepatic steatosis and its nature were determined using a ratified kit "SteatoTest", "ASH" and "NASH-Test" (BioPredictive, France) in the laboratory Sinevo.The stage of liver fibrosis was determined by using a set of markers for quantitative biochemical evaluation of fibrosis "FibroTest" (BioPredictive, France) in the laboratory Sinevo.Calculation of the glomerular filtration rate (GFR) was performed using a GFR calculator of the Institute of Nephrology of the National Academy of Medical Sciences of Ukraine on the average of three calculated indicators: creatinine clearance according to the Cockcroft-Golt formula, MDRD and CKD EPI.Determination of the stages of DKD was carried out according to the classification of C.E. Mogensen (1983).Results.In patients with NASH, diabetes mellitus and DKD I-II st.found a probable decrease in the content of albumin in the blood by 9.0% (p <0.05), GFR and the content of albumin in the urine, on the contrary, probably increased 1.5 times (p <0.05) compared with the indicator in PHP, which indicates the phenomenon of hyperfiltration and inherent in the initial stage of DKD.In patients with NASH, diabetes mellitus and DKD III found a probable decrease in the content of albumin in the blood by 1.2 times (p <0.05), GFR and albuminuria were significantly increased by 1.4 times and 11.7 times (p <0.05), respectively, compared with PHP.In patients with NASH, diabetes mellitus and DKD IV found a significant decrease in the content of albumin in the blood by 1.4 times (p <0.05), the content of albumin in the blood was probably increased by 30.2 times (p <0.05) compared with the indicator in the PHP, and the GFR -on the contrary, it was significantly reduced -1.7 times (p <0.05), which indicates the progression of CKD and DKD.Introduction.The article presents a theoretical generalization of the results of the study of insulin resistance syndrome (IR) in patients with non-alcoholic steatohepatitis (NASH) in comorbidity with type 2 diabetes mellitus (DM2) in the presence of diabetic kidney disease (DKD) and depending on its stage.It was found that disorders of glucose homeostasis due to IR is one of the significant risk factors for the progression of NASH and diabetes mellitus in the presence of DKD I-IV centuries.insulin content -2.9 times vs. 1.9 times, glycosylated hemoglobin -2.3 vs. 1.6 times) and the degree of IR (increase in HOMA 3.4 times vs. 2.2 times) under these conditions are more significant in comparable with the course of NASH with diabetes mellitus in the absence of DKD (p <0,05).Indicators of postprandial and supracardial glycemia and insulinemia, as well as the degree of IR in patients with NASH and the background of diabetes mellitus2 with DKD IV. affect the increase in the intensity of cytolysis, cholestasis, mesenchymal inflammation, contribute to the development of hepatic steatosis, as well as renal dysfunction (GFR) (p <0,05).The progression of DKD from stage I-II to stage IV on the background of diabetes mellitus2 and NASH depends on the level of hyperglycemia and the degree of IR (p <0.05).
Today, non-alcoholic steatosis of the liver and NASH are considered the most common liver pathology, which in developed countries is observed in 20-30% of the adult population [5,1,6,7].It is proved that the most common cause of NASH is obesity and diabetes mellitus 2 [8,9,10].The combination of NASH and DМ2 increases the risk of liver cirrhosis and hepatocellular carcinoma by 2-2.5 times [2,11].
Diabetic nephropathya severe complication of diabetes is one of the leading causes of end-stage renal disease in industrialized countries [12,13,4,14].Since 2007, the National Foundation for Kidney Disease Initiative to Improve the Quality of Kidney Disease Treatment (K / DOQI) has proposed the use of the term "diabetic kidney disease" instead of "diabetic nephropathy" [12].Diabetic kidney disease (DKD) or DN is a type of diffuse or focal glomerulosclerosis, Kimmelstil-Wilson syndrome [15,14].In addition, patients with diabetes often develop non-specific renal lesions such as asymptomatic bacteriuria, pyelonephritis, renal carbuncle, apostematous nephritis, renal abscess, renal tuberculosis, necrotic papillitis or papillary necrosis, which significantly aggravate the disease.DN is 40% of complications in diabetes mellitus1 and 5-15% -among patients with diabetes mellitus2.On average, 20-30% of patients with diabetes of both types have DN, but among patients with diabetes mellitus much less often develops chronic renal failure on the background of DN [12,13].
The main pathogenetic basis of NASH on the background of diabetes mellitus on the background of diabetes mellitus is a violation of the sensitivity of insulin receptors to membranes of insulin-sensitive organs (liver and skeletal muscle) to the hormone, disorders of transport and utilization of glucose from the circulatory system with the formation of all glycogen.species of metabolism in a healthy body [1,2,6,11].It has been proved that in diabetes mellitus 2 the organism is rebuilt into an alternative energy supply -by catabolism of fat in visceral fat depots, as a result of which a significant amount of free fatty acids (FFA) enters the systemic circulation and is sent to the liver [1,9,7].Due to significant inhibition of β-oxidation of FFA in hepatocytes in DМ2, neutral fat in the form of triacylglycerols (TG) accumulates in hepatocytes and forms the pathomorphological basis of micro-or macrovesicular steatosis of the liver and, at the same time, deepens [16].At the same time, the effect of DKD depending on its stage on the glycemic and insulin profile, the state of IR in NASH on the background of diabetes mellitus is still poorly understood, although The aim of the study was to examine the interaction of changes in glucose and insulin homeostasis, the degree of IR and insulin sensitivity, the degree of glycosylation of hemoglobin on the clinical course of NASH on the background of diabetes mellitus depending on the presence of DKD and its stage.
Material and methods.108 patients with NASH with comorbid diabetes mellitus2 were examined.The average age of patients (58.2 ± 6.1) years.There were 63 women (58.3%) and 45 men (41.7%).Depending on the presence of DKD, 4 groups of patients were formed, which were randomized by age, sex, activity of cytolytic syndrome of NASH depending on the stage of DKD.The division into groups of examined patients is given in table.1.The comparison group consisted of 30 practically healthy people (PHP) of the appropriate age and sex.
The diagnosis of NASH was established in accordance with the unified clinical protocol approved by the Order of the Ministry of Health of Ukraine № 826 of 06.11.2014, in the presence of criteria for exclusion of chronic diffuse liver disease of viral, hereditary, autoimmune or drug origin as the cause of cytolytic, cholestatic and mesenchymal also the results of ultrasonographic (USG) examination of the liver.The degree of hepatic steatosis and its nature were determined using a ratified kit "SteatoTest", "ASH" and "NASH-Test" (BioPredictive, France) in the laboratory Synevo.The stage of liver fibrosis was determined by using a set of markers for quantitative biochemical evaluation of fibrosis "FibroTest" (BioPredictive, France) in the laboratory Synevo.
Diagnosis of type 2 diabetes was performed in accordance with the unified clinical protocol approved by the Order of the Ministry of Health of Ukraine № 1118 of 21.12.2012.Diagnosis and treatment of CKD was carried out according to the recommendations of clinical guidelines SI "Institute of Nephrology NAMS of Ukraine" (2012).Calculation of the glomerular filtration rate (GFR) was performed using a GFR calculator of the Institute of Nephrology of the National Academy of Medical Sciences of Ukraine on the average of three calculated indicators: creatinine clearance according to the Cockcroft-Golt formula, MDRD and CKD EPI [9].Determination of the stages of CKD was carried out according to the classification of C.E. Mogensen (1983) [12,13].
The state of carbohydrate metabolism was determined by the level of fasting blood glucose and blood glucose 2 hours after a meal (postprandial (p / p) glucose) by glucose oxidase method; fasting insulin content (DRG System) by enzyme-linked immunosorbent assay (ELISA); content of glycosylated hemoglobin (HbA1c) in the blood using standard reagent kits "Simko Ltd" (Lviv).The degree of IR was determined by the value of the body mass index (BMI), HOMA-IR index and tissue sensitivity index to insulin (S) (DR Matthews et al.) [17], which was calculated using the HOMA2 Calculator Version 2.2 Diabetes Trials Unit University of Oxford (United Kingdom).
Statistical analysis of the results was performed according to the type of study and the types of numerical data that were obtained.The normality of the distribution was checked using Liliefors, Shapiro-Wilk tests and the method of direct visual evaluation of histograms of the distribution of eigenvalues.Quantitative values that had a normal distribution are presented as mean (M) ± standard deviation (S).Discrete values are presented in the form of absolute and relative frequencies (percentage of observations to the total number of subjects).For comparisons of data that had a normal distribution, we used parametric tests with the assessment of Student's ttest, Fisher's F-test.In the case of an abnormal distribution, the calculation of the Mann-Whitney rank U-test was used, and for multiple comparison, the Wilcoxon T-test was used (in the case of the study of dependent groups).Pearson correlation analysis in the parametric distribution and Spearman's rank correlation coefficient in the case of the distribution of indicators that were significantly different from the normal one were used to assess the degree of dependence between the variables.For statistical and graphical analysis of the obtained results we used software packages Statistica for Windows version 8.0 (Stat Soft inc., USA), Microsoft Excel 2007 (Microsoft, USA).
Research results and their discussion.Analysis of renal function in patients with NASH with diabetes without DКD (1 group) indicates a normal level of albumin in the blood, normal GFR and albuminuria (Table 2).At the same time, in patients with NASH, diabetes mellitus and DКD I-II.(Group 2) found a In patients with NASH, diabetes mellitus and DКD IV. (Group 4) found a significant decrease in the content of albumin in the blood by 1.4 times (p <0.05), the content of albumin in the blood was probably increased by 30.2 times (p <0.05) compared with the PHP (Table 2), and the GFR index -on the contrary was significantly reduced -1.7 times (p <0.05), which indicates the progression of CKD and DКD.
The results of glycemia, insulinemia and IR indices in patients with NASH with diabetes mellitus2 are shown in table 3. The analysis of studies showed that patients of all groups found a significant probable increase in fasting glycemia: in group 1 -1.6 times, in 2 -in 1.8 times, in group 3 -2.5 times and in group 4 -2.7 times (p <0.05) compared to the indicator in PHP.Examination of the insulin content in the blood on an empty stomach revealed a probable hyperinsulinemia, which in patients of the 1st group exceeded the indicator in the group of PHP in 1.9 times, in patients of the 2nd group -in 2.4 times, in the 3rd group -in 2.9 times and the 4th group -3.3 times (p <0.05) (table 3).
The above processes resulted in significant changes in IR and peripheral tissue sensitivity to insulin.
In particular, the violation of peripheral tissue sensitivity to insulin in patients with NASH and diabetes mellitus indicates a probable increase in the HOMA IR index (respectively in groups 1, 2, 3 and 4 -2.2 times, 2.7, 3.5 and 4.0 times (p <0,05)), as well as an adequate decrease in S (p <0,05) with a significant difference between 1, 2 and 3, 4 groups (p <0,05) (Table 3 ).At the same time, there was no difference between the indicator of another marker of IR -BMI in patients of different groups (p> 0.05), but the indicator in all groups of patients exceeded the data in PHP by 1.3 times (p <0.05) (table 3).
Analysis of glucose and insulin homeostasis in relation to markers of liver damage, indicators of functional status of the liver and kidneys in patients with NASH with diabetes mellitus2 and DKD IV. indicates that postprandial and supracardiac hyperglycemia and insulinemia, as well as the degree of IR in a weak to medium strength relationship increase with increasing intensity of cytolysis, cholestasis, mesenchymal inflammation, and are factors of mutual burden of NASH and DM2 with DKD due to induction of induction markers of НCN (albumin content in the blood -a weak negative link), contribute to the development of hepatic steatosis (strong correlation with the steato test), renal dysfunction (weak-medium strength with blood creatinine, albuminuria and moderate negative negative GFR) (p <0.05) (table 4).
Thus, the most significant metabolic prerequisites for the development of NASH on the background of diabetes mellitus are probable fasting and postprandial hyperglycemia, hyperinsulinemia, increased hemoglobin glycosylation, tissue IR.One of the risk factors for the progression of NASH and the background of diabetes mellitus is the presence of DKD, as impaired carbohydrate metabolism and the degree of IR in these conditions are more significant compared to the course of NASH in the absence of DKD (p <0.05).The progression 4. The progression of DKD from stage I-II to IV on the background of diabetes mellitus in combination with NASH (in weak-medium strength interdependence) depends on the degree of supracardiac, postprandial hyperglycemia and the degree of IR (HOMA IR) (p <0.05).
The prospect of further research in this area is the search for drugs for adequate correction of carbohydrate metabolism, reducing the degree of IR and eliminating the manifestations of liver damage in the treatment of NASH on the background of diabetes mellitus 2 depending on the stage of НCN.

Table 2 Indicators of the functional state of the kidneys in patients with NASH, type 2 diabetes depending on the presence of DKD and its stage
-the difference is probable in comparison with the indicator in almost healthy individuals (p <0,05); **the difference is probable in comparison with the indicator in patients with NASH with diabetes mellitus2 (p <0.05); *** -the difference is significant in comparison with the rate in patients with NASH with diabetes mellitus, DKD I-II (p <0,05); # -the difference is significant in comparison with the indicator in patients with NASH with diabetes mellitus2, DKD III (p <0,05).

Table 3 Indicators of blood glucose and blood insulin, glycosylated hemoglobin, IR indices in patients with NASH, type 2 diabetes mellitus depending on the presence of DKD and the stage of DKD (M ± m)
Note: * -the difference is probable in comparison with the indicator in almost healthy individuals (p <0,05); **the difference is probable in comparison with the indicator in patients with NASH with diabetes mellitus2 (p <0.05); *** -the difference is significant in comparison with the rate in patients with NASH with diabetes mellitus, DKD I-II (p <0,05); # -the difference is significant in comparison with the indicator in patients with NASH with diabetes mellitus2, DKD III (p <0,05).

Table 4 Matrix of correlations of markers of damage and functional parameters of the liver, kidneys with indicators of glucose homeostasis and insulin content in the blood, indices of insulin resistance in patients with NASH
Note: * -the level of correlations is statistically significant (p <0.05).ofDKDfromstage I to IV on the background of DМ2 in comorbidity with NASH depends on the degree of supracardiac, postprandial hyperglycemia and the degree of IR (HOMA IR) (p <0,05).Conclusions 1. Metabolic prerequisites for the development of NASH on the background of diabetes mellitus are probable fasting and postprandial hyperglycemia (1.6 times, p <0.05), hyperinsulinemia (1.9 times, p <0.05), an increase in the degree of glycosylation of hemoglobin(1 , 6 times, p <0.05), tissue IR (increase in HOMA 2.2 times, p <0.05) compared with healthy individuals.2. Disorders of glucose homeostasis due to IR is one of the probable risk factors for the progression of NASH and diabetes mellitus in the presence of DHN I-IV centuries, as carbohydrate metabolism disorders (fasting hyperglycemia -2.3 times, p <0.05, insulin content -2.9 times, p <0.05, glycosylated hemoglobin -2.3 times, p <0.05) and the degree of IR (increase in HOMA 3.4 times, p <0.05)) under these conditions is more significant in comparison with the course of NASH with diabetes mellitus in the absence of DKD (p <0.05).3. Indicators of postprandial and supracardial glycemia and insulinemia, as well as the degree of IR in patients with NASH and diabetes mellitus2 with DKD IV. in weak-medium strength of the relationship affect Буковинський медичний вісник.2020.Т.24, №3 (95) ISSN 1684-7903 http://e-bmv.bsmu.edu.uaOriginal research 141 the increase in the intensity of cytolysis, cholestasis, mesenchymal inflammation, and are factors of mutual burden of NASH and CМ2 with DKD due to induction of hepatocyte damage, progression of НCN (blood albumin content -weak negative connection), contribute development of hepatic steatosis (strong correlation with steato-test index), renal dysfunction (positive weakmedium strength with blood creatinine, albuminuria and moderate strength negative with GFR) (p <0.05).