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Vol. 52. Núm. 9.
Páginas 484-492 (Noviembre 2005)
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Vol. 52. Núm. 9.
Páginas 484-492 (Noviembre 2005)
Originales
Acceso a texto completo
Complicaciones crónicas, factores de riesgo cardiovascular y HbA1c en la diabetes mellitus tipo 1 a los 14 años de diagnóstico
Chronic complications, cardiovascular risk factors and HbA1c values in type 1 diabetes mellitus 14 years after diagnosis
Visitas
...
A. Martínez-Riquelme��
Autor para correspondencia
amparitomartinez@hotmail.com

Correspondencia: Dra. A. Martínez-Riquelme. Las Huertas, 9, 3.° B. Majadahonda 28220. Madrid. España.
, C. Castell, C. Mabres, M. Lara, el Grupo Para el Estudio de la Diabetes en Cataluña
Associació Catalana de Diabetes y Consell Assesor para la Diabetes en Cataluña. Barcelona. España
Información del artículo
Objetivo

Estudiar el grado de control glucémico (HbA1c) y prevalencia de complicaciones crónicas micro y macrovasculares, así como sus interrelaciones, en una cohorte de pacientes con diabetes mellitus tipo 1 (DM1) a los 14 años de diagnóstico.

Pacientes y métodos

Se estudió a 138 pacientes diagnosticados de DM1, edad (media±DE) 27,2±6,5 años [límite 13 a 42 años] y duración de la enfermedad de 14 años. Se revisaron, por un mismo equipo investigador, las historias clínicas y se realizaron cuestionarios estandarizados para neuropatía periférica, disautonomía y macroangiopatía, examen neurológico y vascular, estudio de fondo de ojo mediante retinografía bilateral amidriática, evaluación de la función autonómica cardíaca mediante sistema computarizado portátil y electrocardiograma. La determinación de la HbA1c se realizó mediante inmunoensayo en sangre capilar.

Resultados

El 89,8% de los pacientes estaba sometido a tratamiento con inyección múltiple de insulina o mediante bomba de insulina, dosis de insulina diaria media de 0,75±0,20 U/kg. El número de determinaciones de glucemia capilar fue de 18,2±11,65/ semana. La HbA1c obtenida fue de 8,3±1,44% [límite 5,2 a 13,1%] (valor de referencia para población no diabética: 5,0±0,4%), el 85,5% presentaba una HbA1c>7% (media±5DE) en relación negativa con el número de determinaciones de glucemia por semana (r=-0,31, p<0,001). La prevalencia de nefropatía fue del 9,4% a los 14 años del diagnóstico de la DM1, con una incidencia antes de 5 años del 0,9% (el 90% en fase de microalbuminuria y un 10% como macroalbuminuria). La incidencia acumulada de retinopatía simple (incipiente y de fondo) a los 5, 10 y 14 años del diagnóstico fue del 1,8%, 10% y 17,5% respectivamente, y para la retinopatía avanzada del 0, 1,5 y 1,5%, respectivamente. La prevalencia de neuropatía periférica somática clínica fue del 21,0%, y es más frecuente en mujeres. La función autonómica cardíaca fue anormal en el 12,4%, con mayor presión arterial diastólica (74±11,3 frente a 67±8,4 mmHg, p=0,04). No se encontró ningún caso de macroangiopatía. Los individuos con al menos alguna complicación microangiopática mostraban una HbA1c mayor (8,6±1,5% frente a 8,0±1,5%; p=0,045), y ésta aumentaba a medida que lo hacía el número de complicaciones (p<0,01).

Conclusiones

La presencia de complicaciones microvasculares en nuestra población es elevada y el 89,9% presenta un control glucémico malo, a pesar del tratamiento insulínico intensivo. La relación establecida entre grado de control glucémico con la aparición y/o progresión de las complicaciones crónicas de la DM1 hace necesario un control más estricto tanto de la glucemia como de los factores de riesgo de enfermedad cardiovascular en nuestra población de personas con DM1.

Palabras clave:
Diabetes mellitus tipo 1
HbA1c
Complicaciones microvasculares
Aims

To evaluate glycemic control (HbA1c) and the prevalence of chronic micro- and macrovascular complications, as well as the interrelations among them, in patients with type 1 diabetes mellitus (DM1) 14 years after diagnosis.

Patients and methods

A total of 138 DM1 patients, with a mean age of 27.2±6.5 years (range 13 to 42 years), diagnosed between 1987 and 1988 (14 years from onset) were evaluated. Patients completed standardized questionnaires evaluating peripheral neuropathy, autonomic disease and vascular diabetes complications. All patients were evaluated by the same team. The medical records of all the patients were reviewed. Neurological and vascular clinical examination and bilateral amydriatic retinography were performed. Autonomic cardiac function was evaluated by a portable computer device and electrocardiogram. HbA1c was determined by immunoassay in capillary blood.

Results

A total of 89.8% of the patients were under intensive insulin treatment (subcutaneous injections or continuous insulin pump). The mean daily insulin dose was 0.75±0.20 U/kg. The mean number of weekly capillary glycemic determinations was 18.2±11.65. HbA1c was 8.3±1.44% (range 5.2 to 13.1%; non-diabetic reference value 5.0±0.4%); 85.5% of the patients were in control (HbA1c>5 SD), and the degree was negatively associated with the number of glycemic assessments per week (r=−0.31, p<0.001). The prevalence of nephropathy was 9.4% at 14 years after diagnosis and the incidence within 5 years after onset was 0.9%; 90% of the patients showed microalbuminuria and 10% showed macroalbuminuria. The cumulative incidence of simple retinopathy (incipient and background) at 5, 10 and 14 years after diagnosis was 1.8%, 10% and 17.5%, respectively, and that of advanced retinopathy was 0%, 1.5% and 1.5%, respectively. The prevalence of clinical somatic neuropathy was 21.0% and was more frequent in women. Autonomic cardiac function was abnormal in 12.4% of patients, who had higher than normal diastolic blood pressure (74±11.3 versus 67±8.4 mmHg, p=0.045). No macrovascular complications were observed. Patients with at least one microvascular complication had higher HbA1c values than those without microvascular complications (8.6±1.5% vs. 8.1±1.4%, p=045), and the greater the number of complications the greater the difference (p<0.01).

Conclusions

The prevalence of chronic microvascular complications in our DM1 patients is high, and 89.9% have poor glycemic control despite intensive insulin treatment. Given the established relationship between glycemic control and the onset or progression of chronic diabetes complications, stricter glycemic control and reduction of cardiovascular risk factors are required in our diabetic population.

Key words:
Type 1 diabetes mellitus
HbA1c
Microvascular complications
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Bibliografía
[1.]
DCCT Research Group: the effect of intensive diabetes treatment on the development and progression of long-term complications in insulin-dependent diabetes mellitus: the Diabetes Control and Complications Trial.
New Eng J Med, 329 (1993), pp. 977-986
[2.]
DCCT Research Group: prevention of neuropathy.
The effect of intensive diabetes therapy on the development and progression of neuropathy in the DCCT.
Ann Intern Med, 22 (1995), pp. 564-568
[3.]
DCCT Research Group: effect of intensive therapy on the development of nephropathy in the DCCT.
Kidney Int, 47 (1995), pp. 1703-1720
[4.]
DCCT Research Group: the effect of intensive diabetes treatment on the progression of diabetic retinopathy in insulin-dependant diabetes mellitus.
Arch Ophthalmol, 113 (1995), pp. 36-51
[5.]
DCCT Research Group: the effect of intensive diabetes management on macro-vascular events and risk factors in the DCCT.
Am J Cardiol, 75 (1995), pp. 894-903
[6.]
The epidemiology of Diabetes Interventions and Complications (EDIC): design, implementation, and preliminary results of a long-term follow-up of the Diabetes Control and Complications Trial.
Diabetes Care, 22 (1999), pp. 99-111
[7.]
I. Mühlhauser, H. Overmann, R. Bender, V. Jörgens, M. Berger.
Predictors of mortality and end-stage diabetic complications in patients with type 1 diabetes mellitus on insulin therapy.
Diabet Med, 17 (2000), pp. 727-734
[8.]
U. Weis, B. Turner, J. Gibney, G.F. Watts, V. Burke, K.M. Shaw, et al.
Long-term predictors of coronary artery disease and mortality in type 1 diabetes.
Q J Med, 94 (2001), pp. 623-630
[9.]
I. Mühlhauser, H. Overmann, R. Bender, U. Bott, V. Jörgens, M. Grüsser, et al.
Cigarette smoking and progression of retinopathy and nephropathy in Type 1 diabetes.
[10.]
E. Esmatjes, F. De Alvaro.
Incidence of diabetic nephropathy in type 1 diabetic patients in Spain: “Estudio Diamante”.
Diabetes Res Clin Pract, 57 (2002), pp. 35-43
[11.]
P. Hovind, P. Rossing, L. Tarnow, H. Parving.
Smoking and progression of diabetic nephropathy in type 1 diabetes.
Diabetes Care, 26 (2003), pp. 911-916
[12.]
L.J. Scott, J.H. Warran, L.S. Hanna, L.M.B. Laffel, L. Ryan, A.S. Krolewski.
A nonlinear effect of hyperglycemia and current cigarette smoking are major determinants of the onset of microalbuminuria in Type 1 Diabetes.
Diabetes, 50 (2001), pp. 2842-2849
[13.]
European IDDM Policy Group 1993.
Consensus guidelines for the management of insulin-dependent (Type 1) diabetes.
Diabet Med, 10 (1993), pp. 990-1005
[14.]
C.E. Mogensen, O. Schmitz.
The diabetic kidney: from hyperfiltration and microalbuminuria to end-stage renal failure.
Med Clin North Am, 72 (1988), pp. 1465-1492
[15.]
G.C. Viberti, R.W. Bilous, D. Mackintosh, H. Keen.
Monitoring glomerular function in diabetic nephropathy: a prospective study.
Am J Med, 74 (1983), pp. 256-264
[16.]
A.J. Bakker.
Detection of microalbuminuria. Receiver operating characteristic curve analysis favors albumin-to-creatinine ratio over albumine concentration.
Diabetes Care, 22 (1999), pp. 307-313
[17.]
Retinopathy Working Party.
A protocol for screening for diabetes retinopathy in Europe.
Diabetic Med, 8 (1991), pp. 263-267
[18.]
S.J. Aldington, E.M. Kohner, S. Meuer, R. Klein, A.K. Sjolie.
Methodology for retinal photography and assessment of diabetic retinopathy: the EURODIAB IDDM Complications Study.
Diabetologia, 38 (1995), pp. 437-444
[19.]
E.L. Feldman, M.J. Stevens, P.K. Thomas, M.B. Brown, N. Canal, D.A. Greene.
A practical two-step quantitative clinical and electrophysiological assessment for the diagnosis and staging of diabetic neuropathy.
Diabetes Care, 17 (1994), pp. 9
[20.]
P.J. Dyck.
Detection, characterization and staging of polyneuropathy: assessed in diabetics.
Muscle Nerve, 11 (1988), pp. 21-32
[21.]
B.A. Perkins, D. Olaleye, B. Zinman, V. Bril.
Simple screening test for peripheral neuropathy in the diabetes clinic.
Diabetes Care, 24 (2001), pp. 250-256
[22.]
American Diabetes Association and American Academy of Neurology.
Report and recommendations of the San Antonio Conference on diabetic neuropathy.
Diabetes Care, 11 (1988), pp. 592-597
[23.]
D.J. Ewing, B.F. Clarke.
Diabetic autonomic neuropathy: a clinical viewpoint.
Diabetic Neuropathy,
[24.]
G. Vespasiani, M. Bruni, I. Meloncelli, L. Clementi, R. Amoretti, S. Branca, et al.
Validation of a computerised measurement system for guided routine evaluation of cardiovascular autonomic neuropathy.
Comp Meth Prog Biom, 51 (1996), pp. 211-216
[25.]
A.S. Krolewski, L.M.B. Laffel, M. Krolewski, M. Quinn, J.H. Warram.
Glycosilated hemoglobin and risk of microalbuminuria in patients with insulindependent diabetes mellitus.
N Engl J Med, 332 (1995), pp. 1251-1255
[26.]
J.H. Warram, G. Gearin, L. Laffel, A.S. Krolewski.
Effect of duration of type 1 diabetes in the prevalence of stages of diabetic nephropathy defined by albumin/creatinin ratio.
J Am Soc Nephrol, 7 (1996), pp. 930-937
[27.]
M. Krolewski, P. Eggers, J.H. Warram.
Magnitude of end-stage renal disease in IDDM: a 35-year follow-up study.
Kidney Int, 50 (1996), pp. 2041-2046
[28.]
A.F. Amos, D.J. McCarty, P. Zimmet.
The rising global burden of diabetes and its complications: estimates and projections to the year 2010.
Diabet Med, 14 (1997), pp. S7-S185
[29.]
E. Esmatjes, C. Castell, A. Goday, E. Montanya, J.M. Pou, I. Salinas, et al.
Prevalencia de nefropatía en la diabetes mellitus tipo 1.
Med Clin (Barc), 1 (1998), pp. 6-10
[30.]
H.H. Parving, E. Hommel, E. Mathiesen, P. Skøtt, B. Edsberg, M. Bahnsen, et al.
Prevalence of microalbuminuria, arterial hypertension, retinopathy and neuropathy in patients with insulin dependent diabetes.
Br Med J, 1 (1988), pp. 156-160
[31.]
J.N. Harvey, K. Rizvi, L. Craney, J. Messenger, R. Shah, P.A. Meadows.
Population- based survey and analysis of trends in the prevalence of diabetic nephropathy in Type 1 diabetes.
Diabet Med, 18 (2001), pp. 998-1002
[32.]
R. Mangili, G. Deferrari, U. Di Mario, O. Giampietro, R. Navalesi, R. Nosadini, et al.
Arterial hipertensión and microalbuminuria in IDDM: the Italian Microalbuminuria Study.
Diabetologia, 37 (1994), pp. 1015-1024
[33.]
A.S. Krolewski, J.H. Warram, A.R. Christlieb, E.J. Busick, C.R. Khan.
The changing natural history on nephropathy in type 1 diabetes.
Am J Med, 78 (1985), pp. 785-794
[34.]
M. Janner, S.E. Snill, P. Diem, K.A. Zuppinger, P.E. Mullis.
Persistent microalbuminuria in adolescents with type 1 diabetes mellitus is associated to early rather than late puberty –results of a prospective longitudinal study.
Eur J Pediatr, 153 (1994), pp. 403-408
[35.]
E. Bognetti, G. Calori, F. Meschi, P. Macellaro, R. Bonifanti, G. Ghiumello.
Prevalence and correlations of early microvascular complications in young type 1 diabetic patients: role of puberty.
J Pediatr Endocrinol Metab, 10 (1997), pp. 587-592
[36.]
M. Bojestij, H.J. Arnqvist, G. Hermansson, B.E. Kalberg, J. Ludvigsson.
Declining incidence of nephropathy in type 1 diabetes mellitus.
N Engl J Med, 330 (1994), pp. 15-18
[37.]
R. Klein, B.E.K. Klein, S.E. Moss, M.D. Davis, D.L. DeMets.
The Wisconsin Epidemiologic Study of Diabetic Retinopathy (II). Prevalence and risk of retinopathy when age at diagnostis is less than 30 years.
Arch Ophthalmol, 102 (1984), pp. 520-526
[38.]
R. Klein, B.E.K. Klein, S.E. Moss, M.D. Davis, D.L. DeMets.
The Wisconsin Epidemiologic Study of Diabetic Retinopathy (IX). Four year incidence and progression of diabetic retinopathy when age at diagnosis is less than 30 years.
Arch Ophthalmol, 107 (1989), pp. 237-244
[39.]
R. Klein, B.E.K. Klein, S.E. Moss, K.J. Cruickshanks.
The Wisconsin Epidemiologic Study of Diabetic Retinopathy (XIV). Tenyear incidence and progression of diabetic retinopathy.
Arch Ophthalmol, 113 (1994), pp. 702-703
[40.]
R. Klein, B.E.K. Klein, S.E. Moss, K.J. Cruickshanks.
The Wisconsin Epidemiologic Study of Diabetic Retinopathy (XV). The long-term incidence of macular edema.
Ophthalmology, 102 (1995), pp. 7-16
[41.]
A.S. Krolewski, J.H. Warram, L.i. Rand, A.R. Christlieb, E.J. Busick, C.R. Khan.
Risk of proliferative retinopathy in juvenile-onset type 1 diabetes mellitus: a 40-year follow-up study.
Diabetes Care, 9 (1986), pp. 443-452
[42.]
M. Lövestam-Adrian, E. Agardh, C.D. Agardh.
The temporal development of retinopathy and nephropathy in type 1 diabetes mellitus during 15 years diabetes duration.
Diabet Res Clin Pract, 45 (1999), pp. 15-23
[43.]
M. Lövestam-Adrian, C.D. Agardh, O. Torffvit, E. Agardh.
Diabetic retinopathy, visual acuity, and medical risk indicators. A continuous 10-year follow-up study in type 1 diabetic patients under routine care.
J Diabet Compl, 15 (2001), pp. 287-294
[44.]
C.E. Kullberg, H.J. Arnqvist.
Good blood glucose control characterizes patients without retinopathy after long diabetes duration.
Diabet Med, 12 (1995), pp. 314-320
[45.]
M. Porta, A.K. Sjoelie, N. Chaturvedi, L. Stevens, R. Rottiers, M. Veglio, The EURODIAB Prospective Complications Study Group, et al.
Risk factors for progression to proliferative retinopathy in the EURODIAB Prospective Complications Study.
Diabetologia, 44 (2001), pp. 2203-2209
[46.]
F.J. Service, P.C. O’Brien.
The relation of glycaemia to the risk of development and progression of retinopathy in the Diabetic Control and Complication Trial.
Diabetologia, 44 (2001), pp. 1215-1220
[47.]
The Diabetes Control and Complications Trial Research Group.
The absence of a glycemic threshold for the development of long-term complications: the perspective of the Diabetes Control and Complications Trial.
Diabetes, 45 (1996), pp. 1289-1298
[48.]
J. Pirart.
Diabetes mellitus and its degenerative complications: a prospective study of 44,000 patients observed between 1947 and 1973.
Diabetes Care, 1 (1979), pp. 168-188
[49.]
A.J.M. Boulton, G. Knight, J. Drury, J.D. Ward.
The prevalence of symptomatic diabetic neuropathy in an insulin-treated population.
Diabetes Care, 8 (1985), pp. 125-128
[50.]
A.F. MacLeod, D.R. Williams, P.H. Sonksen.
A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population.
Diabetologia, 36 (1993), pp. 150-154
[51.]
D. Fedele, G. Comi, C. Coscelli, D. Cucinotta, E.L. Feldman, G. Ghirlanda, et al.
A multicenter study of the prevalence of diabetic neuropathy in Italy. Italian Diabetic Neuropathy Committee.
Diabetes Care, 20 (1997), pp. 836-843
[52.]
Cabezas-Cerrato and the Neuropathy Spanish study Group of the Spanish Diabetes Society.
The prevalence of clinical diabetic polyneuropathy in Spain: a study in primary care and hospital clinic groups.
Diabetologia, 41 (1998), pp. 9
[53.]
J.D. Ward, S. Tesfaye.
Pathogenesis of diabetic neuropathy.
2nd ed.,
[54.]
J. Watking, M.E. Edmonds.
Clinical features of diabetic neuropathy.
2nd ed.,
[55.]
G.M. Franklin, L.B. Khan, J. Baxter, J.A. Marshall, R.F. Hamman.
Sensory neuropathy in non-insulin dependent diabetes mellitus. The San Luis Valley Diabetes study.
Am J Epidemiol, 131 (1990), pp. 633-643
[56.]
M.J. Young, A.J.M. Boulton, A.F. MacLeod, D.R.R. Williams, P.H. Uusitupa Sonksen.
A multicentre study of prevalence of diabetic neuropathy in United Kingdom hospital clinic population.
Diabetologia, 36 (1993), pp. 150-154
[57.]
X. Bao, V. Wong, Q. Wang, L.C.K. Low.
Prevalence of peripheral neuropathy with insulin-dependent diabetes mellitus.
Pediatr Neurol, 20 (1999), pp. 204-209
[58.]
H.A.W. Neil.
The epidemiology of diabetic autonomic neuropathy.
Autonomic failure. A textbook of clinical disorders of the autonomic nervous system, pp. 682-697
[59.]
K. Karavanaki, A.G. Davies, M.H. Morgan, J.D. Baum.
Autonomic function in a cohort of children with diabetes.
J Pediatr Endocrinol Metab, 10 (1997), pp. 599-607
[60.]
K.C. Donahue.
Autonomic neuropathy: diagnosis and impact on health in adolescents with diabetes.
Horm Res, 50 (1998), pp. 33-37
[61.]
K. Karavanaki-Karanassiuo.
Autonomic neuropathy in children and adolescents with diabetes mellitus.
J Pediatr Endocrinol Met, 14 (2001), pp. 1379-1386
[62.]
M.A. Pfeifer, C.R. Weinberg, D.L. Cook, A. Reenan, J.B. Halter, J.W. Ensick, et al.
Autonomic neural dysfunction in recently diagnosed diabetes subjects.
Diabetes Care, 7 (1984), pp. 447-453
[63.]
M.D. Flynn, I.A. O’Brien, R.J. Corral.
The prevalence of autonomic and peripheral neuropathy in insulin-treated diabetic subjects.
Diabet Med, 12 (1995), pp. 310-313
[64.]
N.S. Levitt, K.B. Stansberry, S. Wynchank, A.I. Vinik.
The natural progression of autonomic neuropathy and autonomic function tests in a cohort of people with IDDM.
Diabetes Care, 7 (1996), pp. 751-754
[65.]
O. May, H. Arildsen, E.M. Damsgaard, H. Mickley.
Cardiovascular autonomic neuropathy in insulindependent diabetes mellitus: prevalence and estimated risk of coronary heart disease in the general population.
J Int Med, 248 (2000), pp. 483-491
[66.]
P. Kempler, S. Tesfaye, N. Chaturvedi, L.K. Stevens, D.J. Webb, S. Eaton, et al.
Blood pressure response to standing in the diagnosis of autonomic neuropathy: the EURODIAB IDDM Complications Study.
Arch Physiol Biochem, 109 (2001), pp. 215-222
[67.]
I.A.D. O’Brien, R.J.M. Corral.
Epidemiology of diabetes and its complication.
N Engl J Med, 318 (1988), pp. 1619-1620
[68.]
H.A.W. Neil, A.V. Thompson, S. John, S.T. McCarthy, J.I. Mann.
Diabetic autonomic neuropathy: the prevalence of impaired rate variability in a geographically defined population.
Diabetic Med, 6 (1989), pp. 20-24
[69.]
D. Ziegler, F.A. Gries, M. Spüler, F. Lessmann, The DiaCAN Multicenter Study Group.
The epidemiology of diabetic neuropathy.
Diabetic Med, 10 (1993), pp. 82S-86S
[70.]
H. Mølgaard, P.D. Christensen, K.E. Sørensen, C.K. Christensen, C.E. Mogensen.
Association of 24-h cardiac parasympathetic activity and degree of nephropathy in IDDM.
Diabetes, 41 (1992), pp. 812-817
[71.]
O. Torffit, A. Lindqvist, C.D. Agardh, O. Pahlm.
The association between diabetic nephropathy and autonomic nerve function in type 1 diabetic patients.
Scand J Clin Lab Invest, 57 (1997), pp. 183-192
[72.]
C.F. Clarke, M. Eason, A. Reilly, D. Boyce, G.A. Werther.
Autonomic nervous function in adolescents with type 1 diabetes mellitus: relationship to microalbuminuria.
Diabetic Medicine, 16 (1999), pp. 550-554
[73.]
P. Stella, D. Ellis, R.E. Maser, T.J. Orchard.
Cardiovascular autonomic neuropathy (expiration and inspiration ratio) in type 1 diabetes. Incidence and predictors.
J Diabetes Complications, 14 (2000), pp. 1-6
[74.]
V.A. Koivisto, L.K. Stevens, M. Mattock, P. Ebeling, M. Muggeo, J. Stephenson, et al.
Cardiovascular disease and its risk factors in IDDM in Europe.
Diabetes Care, 19 (1996), pp. 689-697
[75.]
M. Omar, A. Asmal.
Complications of early-onset insulin-dependent diabetes mellitus in blacks and indians.
S Afr Med J, 65 (1984), pp. 75-78

El proyecto fue financiado por los Laboratorios Lilly España, a través de una beca de la Associació Catalana de Diabetes (2001). El material utilizado fue suministrado por Laboratorios Bayer Diagnostics (DCA 2000®) y la Compañía Bloss Group.

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