Direct measurement of capillary blood flow in the diabetic neuropathic foot

The two major components of the microcirculation in the diabetic neuropathic foot have been examined in detail. Nutritive capillary blood flow was measured directly using the non-invasive technique of television microscopy, applied to the toe nailfold. Arteriovenous shunt flow was assessed using the technique of laser Doppler flowmetry, applied to the toe pulp. Fourteen diabetic patients with peripheral and autonomic neuropathy, 11 with no clinical evidence of neuropathy and 14 normal subjects were studied. Laser Doppler flowmetry (predominantly arteriovenous shunt flow) was increased more than three-fold (p less than 0.01) in the diabetic patients with neuropathy compared to control subjects, (median 3.57, interquartile range 2.00-5.32 volts vs median 0.93, interquartile range 0.47-2.36 volts, respectively). There was no evidence of skin capillary closure. The calculated capillary blood flow (erythrocyte flux) was significantly increased in the diabetic neuropathic patients compared to control subjects (median 76.4, interquartile range 34.4-109.8 picolitres/s vs median 23.2, range 8.0-44.8 picolitres/s, p less than 0.01). This study demonstrates that foot skin capillary blood flow is increased in diabetic patients with neuropathy. There is, therefore, no evidence to support the supposition that capillary ischaemia, either secondary to a "capillary steal phenomenon" or "advanced microangiopathy", is a feature of diabetic neuropathy under resting conditions.