Pathogenesis and course of renal disease in IDDM/NIDDM: differences and similarities

In the past the opinion prevailed that renal prognosis was less adverse in non-insulin-dependent diabetes mellitus (NIDDM) as compared with insulin-dependent diabetes mellitus (IDDM). This notion has to be revised in the light of recent evidence, based on epidemiologic data of NIDDM patients reaching endstage renal failure and a comparison of the cumulative prevalence of proteinuria and renal failure, respectively, in NIDDM as compared with IDDM. It has also been established that initial renal hemodynamic changes are quite comparable in NIDDM and in IDDM. It follows that past complacency about the renal sequelae of NIDDM is no longer justified and that preventive measures to interfere with the development of diabetic nephropathy are similarly important in NIDDM and IDDM.

[Nephropathy and hypertension in type II diabetes]

BACKGROUND

In Germany nephropathy in patients with type II diabetes has become the most frequent single cause of uremia requiring renal replacement therapy. This calls for effective measures of prevention.

DIABETIC NEPHROPATHY AND HYPERTENSION

In patients with established diabetic nephropathy, hypertension is the most important pathogenetic factor which is susceptible to therapeutic intervention. Some pathogenetic mechanisms are discussed which impact on antihypertensive therapy. Interaction between hypertension and diabetic nephropathy is analyzed.

CONCLUSION

Diabetic nephropathy in patients with type II diabetes has become the most frequent cause of endstage renal failure in Germany. Preventive measures, i. e. near normal glycemia and particularly antihypertensive treatment, have been proven to interfere with progression of renal failure in diabetic nephropathy. Early recognition is possible by testing for urinary albumin (microalbuminuria). In patients with diabetic nephropathy, blood pressure should be lowered to values well within the range of normotension by dietary salt restriction and antihypertensive drug therapy.

Nephropathy of type II diabetes: evidence for hereditary factors?

Family studies point to an important genetic element in the genesis of diabetic nephropathy, but it is not known whether renal abnormalities are present prior to the onset of diabetes. To address this issue we examined all consecutive patients suffering from type II diabetes with a duration of more than 10 years who attended a diabetes outpatient clinic. Ninety-four patients had nephropathy, 307 did not. All offspring who were phenotypically normal (no hypertension, normal oral glucose tolerance, non-smoking) and agreed to participate were examined, 26 from nephropathic and 30 from non-nephropathic diabetic parents. They were compared with 30 offspring matched for age, gender and BMI from non-diabetic parents as controls. We measured urinary albumin excretion under baseline conditions and at several time points after ingestion of 300 g cooked beef and submaximal treadmill exercise, respectively. In addition, casual blood pressure, ambulatory blood pressure, urinary albumin and urinary alpha-1-microglobulin were measured. Primary renal disease was excluded by clinical examination. Under baseline conditions, median urinary albumin excretion rate (AER; microgram/min) was significantly (P < 0.005) higher in offspring of nephropathic type II diabetic patients (7.8; range 1.04 to 19.5) than in the offspring of non-nephropathic type II diabetic patients (4.8; 0.36 to 17.5) and controls (4.4; 0.16 to 18.4). Submaximal treadmill exercise caused a greater proportional increase of AER in offspring of nephropathic type II diabetics (median 16-fold) than in offspring of non-nephropathic diabetic patients (6.3-fold) or controls (4.8-fold). In offspring of nephropathic diabetic patients casual and particularly ambulatory systolic blood pressures were significantly higher, but AER was not correlated with blood pressure. In summary, higher values, albeit within the normal range, for baseline and postexercise albuminuria were noted in phenotypically normal offspring of parents with type II diabetes and nephropathy. The observation suggests that changes in transglomerular albumin traffic are demonstrable prior to the onset of diabetes and diabetic nephropathy in subjects with a potential genetic predisposition to these conditions.

Excess of DD homozygotes in haemodialysed patients with type II diabetes. The Diabetic Nephropathy Study Group

The role of the insertion/deletion polymorphism of the angiotensin-converting enzyme (ACE) gene in the genesis of diabetic nephropathy has been controversial. It has recently been proposed that progression occurs more rapidly in individuals with diabetic and non-diabetic renal disease who are homozygous for the D allele. We studied 658 patients with type II diabetes, 347 without diabetic nephropathy and 311 with various stages of diabetic nephropathy, and determined the I/D polymorphism of the ACE gene. Patients at the extremes of renal risk, i.e. normotensive patients without antihypertensive treatment and without nephropathy (n = 144), vs patients on dialysis (n = 61), differed with respect to genotype (DD 36.8% vs 57.4%; P = 0.007) and allele frequencies (D 0.59 vs 0.76; P < 0.001). In contrast, patients with and without presumed nephropathy as assessed by albuminuria did not differ with respect to DD genotype. In conclusion, in this study, which was limited by sample size, patients with the highest renal risk more frequently had the DD genotype. This would be compatible with a greater risk of (or rate of) progression to end-stage renal failure.

Risk factors for development of diabetic nephropathy: a review

Recently evidence has accumulated that diabetic nephropathy clusters in families, both in insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetic patients. Furthermore, hypertension and cardiovascular accidents are found more frequently in families of NIDDM with diabetic nephropathy. Some observations in offspring of NIDDM patients with diabetic nephropathy point to high urinary albumin excretion and slightly greater blood pressure values, both within the normal range compared to offspring of patients without diabetic nephropathy. Further follow-up is required to assess whether these findings are indicative of a possible genetic predisposition to diabetic nephropathy.

Angiotensinogen gene M235T polymorphism is not associated with diabetic nephropathy. The Diabetic Nephropathy Study Group

BACKGROUND

There is agreement that a family history of hypertension (HT), is a predictor for the risk of diabetic nephropathy (DN) in patients with type 2 diabetes, and possibly also type 1 diabetes. It follows that genes related to the risk of hypertension must also be considered candidate genes for DN. The 235T allele of the angiotensinogen gene was found to be related to primary HT.

METHODS

To examine whether it is predictive for DN as well, we examined the angiotensinogen gene polymorphism in 230 healthy local controls, 423 patients with type 1 diabetes (n = 180 with DN; n = 243 without DN) and 663 patients with type 2 diabetes (n = 310 with DN; n = 353 without DN). The angiotensinogen gene M235T polymorphism was determined using PCR amplification.

RESULTS

The following results were obtained (i) no significant difference of genotype distribution (type 1: MM/MT/TT (%) 27.6/57.2/15.2 vs 27.2/56.1/16.7 (P = 0.92); type 2; MM/MT/TT (%) 31.7/48.2/2/20.1 vs. 32.9/46.8/20.3 (P = 0.93) or allele frequencies (type 1: M 0.56 vs. 0.55 (P = 0.795); type 2; M 0.56 vs. 0.56 (P = 0.86)) was found, between diabetic patients with or without DN, (ii) no difference was found between normotensive and hypertensive diabetic patients.

CONCLUSION

The data argue against a role of the angiotensinogen gene M235T polymorphism in the manifestation of diabetic nephropathy or hypertension in diabetic patients.

[Albumin excretion with urine in a population of healthy individuals]

Increased urine albumin excretion is the significant prognostic factor for diabetes, hypertension and coronary artery disease. Divergences of the evaluation of albuminuria in different ethnic groups were found. The aim of our study was to evaluate albumin excretion in large group of healthy individuals. 301 healthy subjects (110 female and 191 male), age 20-60 years (mean 32.9 +/- 9.7), were admitted. A questionnaire including data concerning familial history, smoking habits was fulfilled. Subsequently nighttime urine sample was collected in all examined subjects and albumin to creatinine ratio (A/K) was counted. A/K value varied between 0.03-14.1 mg/mmol of creatinine median 1.18. Significantly higher albuminuria in female v male group was found (respectively 1.39; 0.14-14.1 and 1.03; 0.03-11.4 p < 0.05). Reference value for albuminuria was estimated at 3.35 mg/mmol in whole group, and respectively 4 mg/mmol in female and 2.6 mg/mmol in male. There were not differences in A/K ratio in relation to familial history however smoking men excreted more albumin v non smoking (respectively 1.27, 0.03-11.4 and 0.95, 0.14-14.1 mg/mmol p < 0.005). Performed analysis allowed to calculate the value for albuminuria in healthy subjects. Analysis also showed significant influence of gender and smoking habits and no influence of familial history for albumin excretion.

Increased prevalence of salt sensitivity of blood pressure in IDDM with and without microalbuminuria

In insulin-dependent diabetes mellitus (IDDM) elevated exchangeable sodium (Na) levels are found even in the absence of hypertension, but it is not known whether this is associated with increased sensitivity of blood pressure to sodium level. To clarify this issue we compared 30 patients with IDDM (19 without and 11 with microalbuminuria, i.e. more than 30 mg albumin/day) and 30 control subjects matched for age, gender and body mass index. The subjects were studied on the 4th day of a low-salt diet (20 mmol/day) under in-patient conditions and were subsequently changed to the same diet with a high-salt supplement, yielding a total daily intake of 220 mmol Na/day. Circadian blood pressure, plasma renin activity (PRA), plasma atrial natriuretic factor (p-ANF), plasma cyclic guanosine 5'-phosphate (p-cGMP) and urinary albumin were measured. The proportion of salt-sensitive subjects, i.e. showing increment of mean arterial pressure > or = 3 mmHg on high-salt diet, was 43% in diabetic patients (50% of diabetic patients with and 37% without microalbuminuria) and 17% in control subjects (p < 0.05). Lying and standing PRA levels on low- or high-salt diet were significantly lower in diabetic patients than in control subjects. Salt-sensitive diabetic patients had significantly higher lying ANF on high-salt (38.7 +/- 4.2 pmol/l vs 20.1 +/- 2.3 pmol/l, p < 0.005) than on low-salt diet. The results suggest that (i) the prevalence of sodium sensitivity is high in IDDM (ii) sodium sensitivity is found even in the absence of nephropathy as indicated by albuminuria.

[Use of fructosamine serum level measurements for diagnosis of insulin-dependent diabetic in pregnancy]

In this study it has been tested the usefulness of serum glycosyl protein (fructosamine) to diagnose diabetic pregnant women requiring insulin therapy. The analysis was performed on the base of obtained results of glucose tolerance test, glycemia level in diurnal profile, fructosamine level and its relationship to albumin level and total protein amount in serum pregnant women with carbohydrates intolerance. Calculated specificity and sensitivity of above mentioned measurements was too low. We can not concluded that it is necessary to include insulin-therapy in diabetic pregnancy on the base of fructosamine serum level even corrected by protein or albumin serum level.

[Does an association between angiotensin I converting enzyme gene polymorphism and the prevalence of diabetic nephropathy in patients with diabetes type II exist?]

In type I diabetic patients association has been found between the insertion/deletion (I/D) polymorphism in the gene of angiotensin converting enzyme and the presence of diabetic nephropathy. The aim of that study was to assess this association in a cohort of type II diabetics. We examined 109 patients of more than 10 years duration of type II diabetes. Nephropathy (defined as at least confirmed albuminuria > 30 mg/24h) was present in 37 subjects. The I/D polymorphism was analyzed with PCR technique. Allele frequencies in the overall diabetic population did not differ significantly from the normal population. Distribution of genotypes was not significantly different between examined patients with and those without nephropathy. We conclude that the distribution of ACE gene polymorphism is similar in diabetic subjects and in general population and there is not association between I/D polymorphism and nephropathy in type II diabetic patients.

[Activity of the renin-angiotensin-aldosterone system in euglycemic type I diabetic patients on intensive insulin treatment without diabetic neuropathy]

Arterial hypertension increase progression of late diabetic complications. Renin-angiotensin-aldosterone system plays an important role in the regulation of arterial pressure. The aim of the study was the assessment of plasma renin activity (PRA) and aldosterone (aldo) in type I euglycaemic diabetic patients on intensive insulin treatment without autonomic neuropathy. 30 type I diabetic patients (including 11 with nephropathy defined as urinary albumin excretion > 30 mg/24 h and 19 without albuminuria) were admitted into the trial. Mean age 31.9 + 1.4 years, duration time of disease was 9.1 + 1.5 years, HbA1c level 7.6 + 0.25%; GFR 124.7 + 3.9 ml/min/1.73 m2 (135.8 + 5.1 in subgroup with nephropathy and 118.2 + 5.08 in non-nephropathic group). Blood samples were taken during normal sodium intake (120 mmol/24 h) after 0.5 h supine. PRA was significantly lower in type I diabetics vs control (0.27 + 0.04, 0.61 + 0.09 pmol/l/s respectively-p < 0.005). PRA was significantly lower both in nephropathic and non-nephropathic diabetic group vs control (respectively 0.22 + 0.06 and 0.31 + 0.05-p < 0.05). Aldo in diabetic patients and in subgroups with and without nephropathy was significantly lower vs controls (respectively 173 + 12.9, 165.1 + 14.4, 182.1 + 18.8 and 257.1 + 24.1 pmol/l; p < 0.01, p < 0.05). Significant differences in hormonal changes between diabetic patients with and without nephropathy were not found. Basing upon the results we conclude that in euglycemic intensively insulin treated type I diabetic patients without neuropathy presented decreased level of PRA and aldo. Early stage of diabetic nephropathy does not influence the examined hormones level.

[Effect of health resort treatment on the circadian rhythm of follicle-stimulating hormone (FSH), lutropin (LH), and testosterone in male patients with diabetes mellitus]

In diabetic patients disturbances of pituitary-gonadal axis are observed. The aim of the study was to investigate whether in male diabetic patients the circadian rhythms of FSH, LH and testosterone are maintained normal and whether the treatment in a health resort affects the circadian rhythms of investigated hormones. The study regards 5 male patients with insulin dependent diabetes mellitus type I and in 10 male patients with diabetes mellitus type II. In order to assess the circadian rhythm serum FSH, LH and testosterone were determined four times a day at 6.00, 12.00, 18.00 and 24.00. Serum concentration of FSH and LH was determined by LIA and testosterone by RIA. The investigation was done twice: on the third day of a health resort treatment and then on the 23rd day of the treatment. The results were analysed using the Cosinor test. It has been shown that the circadian rhythm of LH, FSH and testosterone is maintained in diabetic patients. During the health resort treatment the midline value (mesor) of serum concentration and the amplitude of of circadian rhythms of LH and testosterone increased in diabetic patients, whereas the FSH circadian rhythm did not change. During the health resort treatment a significant change of testosterone circadian rhythm acrophase from 7.32 to 5.16 was observed in diabetic patients.

Platelet aggregation in IgE-mediated allergy with elevated soluble Fc epsilon RII/CD23 level

In 25 house dust mite-sensitive patients with perennial allergic rhinitis, an analysis of platelet aggregation tests (dual-channel aggregometer, Chronolog Corp, 345 model) induced by adenosine diphosphate (ADP) was carried out. The levels of total serum IgE specific antibodies against Dermatophagoides pteronyssinus and the soluble form of the low affinity IgE receptor (sFc epsilon RII/sCD23) were estimated as well. The study was carried out in a dynamic state, before and after 2 years of treatment with specific immunotherapy. We observed a significantly diminished platelet aggregation response, which partially improved after treatment. The results of this study suggest that platelet hyporesponsiveness might be involved in the pathogenesis of house dust mite hypersensitivity.

[Myoglobinuria. Clinical aspects]

General data is presented on myoglobin structure and function, the pathomechanism of myoglobinuria and on its main causes. Attention was also paid to the most serious result of massive rhabdomyolysis-acute renal failure, taking into account the mechanism of its development. Apart from traumatic causes of myoglobinuria and myoglobinaemia, where the usefulness of these determinations is unquestionable, certain other diseases were compared in which the determination of the concentration of this haemoprotein is of important practical aspect.

[Retrospective analysis of secondary failure of oral hypoglycemic drugs in patients with diabetes type II]

The analysis of the incidence and risk factors of oral antidiabetic drugs secondary failure (sf) in type II diabetic patients was carried out in the study. The population of 1262 patients who felt into diabetes between 1980 and 1984 year from Zabrze area was analyzed retrospectively. The analysis was done in relation to 1989 year (after 10 year of the observation). In 194 (15%) of patients secondary failure was diagnosed. Sf appeared in 150 (17%) women and 44 (11%) men (p < 0.005). Multi factor analysis confirmed the higher susceptibility of females to the appearance of sf. Analysis also showed that significant risk factor of sf is the diagnosis of diabetes in 6th life decade in the patients with normal body mass. The percentage of sf varied between 5.1% and 19.5%. Performed analysis showed the higher sf incidence in female group and the influence of age at the moment of diagnosis in non obese patient son the appearance of sf.

[Adenosine. Evaluation of diagnostic efficiency and therapeutic use in paroxysmal supraventricular tachycardia]

Paroxysmal supraventricular tachycardias are an important therapeutic problem and belong to the most frequently occurring arrhythmias. On the basis of a literature review the authors describe an alternative method of treatment of these conditions with adenosine and point also to its additional applications. The diagnostic use of adenosine and its safety in rhythmic undefined tachycardias with broad ventricular complexes is a therapeutic model worth of popularization.

[Does hypoglycemic treatment with gliclazide and gliquidone affect platelet function in type II diabetic patients?]

The estimation of the influence of gliclazide and gliquidone treatment on platelet function in type II diabetic patients was undertaken in the study. Aggregation parameters were assessed before and after the change of hypoglycemic therapy. Gliclazide was applied in the group I (11 patients, mean age 63.1 +/- 7.22 years, duration of diabetes 5.63 +/- 2.98 years), group II (19 patients, mean age 58.3 +/- 12.4 years, duration of diabetes 7.1 +/- 2.4) received gliquidone. The reference group consisted of 10 healthy volunteers (mean age 51.7 +/- 6.9). Aggregation parameters (threshold ADP concentration, intensity and velocity of the aggregation) were measured in examined groups of subjects. Metabolic control was estimated basing upon spectrophotometric measurement of fructosamine level. Significant increase in threshold ADP concentration (1.89 +/- 0.47 mumol/l before and 2.36 +/- 0.58 mumol/l after the treatment change p < 0.05) in group II was found. Threshold ADP concentration did not change significantly in group I (2.5 +/- 0.8 mumol/l before v 2.14 +/- 0.68 mumol/l after treatment). Significant decrease in the aggregation intensity was found in both groups (in group I 8.48 +/- 1.7 before v 6.39 +/- 2.17 after; in group II 7.35 +/- 1.73 before v 6.05 +/- 1.6 after 1 month treatment--both p < 0.05). The aggregation velocity did not change significantly (group I 61. +/- 11 before v 51.3 +/- 18.7 after, group II 63.2 +/- 14.8 and 62.8 +/- 13.7 respectively). Reference group values were ADP 2.7 +/- 0.16, intensity 6.22 +/- 0.53, velocity 63.2 +/- 2.2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Method of treatment and platelet aggregation in patients with diabetes mellitus type II]

Platelet aggregation after ADP administration in 84 diabetic patients and in 14 healthy subjects were examined. ADP concentration indispensable to start aggregation, velocity and intensivity of this process using Born method were measured. In diabetic patients (independently of kind of therapy) the increase platelet aggregation activity were found (significant difference between kind of insulin therapy).

Pulmonary complications of type 1 (insulin-dependent) diabetic patients

We have investigated the influence of diabetes mellitus including the presence of late complications of the pulmonary system. To check this relationship 31 Type 1 (insulin-dependent) diabetic patients (mean age 30.6 +/- 5.32 years, mean duration of diabetes 12.9 +/- 5.05 years) were admitted into the trial and compared with 18 control subjects. Pulmonary function tests were measured including spirometric parameters, diffusing capacity, specific diffusing capacity and dynamic compliance measured at 20 and 60 breaths per min. No disturbance of the spirometric parameters was observed in the diabetic patients. Diffusing capacity in the diabetic patients with complications was significantly lower than in both the diabetic patients without complications and the control group (81.2 +/- 16.2%, 104 +/- 13.7%, 99.3 +/- 2.8%; p < 0.001, p < 0.005 respectively). Specific diffusing capacity was significantly lower in the diabetic patients than in the control subjects (80.3 +/- 13.1% vs 89.4 +/- 12.9%; p < 0.05). In the group with late complications specific diffusing capacity was lower than in the group without complications (69.7 +/- 9.17%; 87.2 +/- 10.7%, respectively; p < 0.001). Dynamic compliance at 20 breaths per min in diabetic patients was 84.06 +/- 17.08% vs 95.2 +/- 11.59% in the control subjects (p < 0.05). It was particularly low in the group with late complications 80.6 +/- 13.2% and patients with metabolic poor control, 80.3 +/- 12.02% (both p < 0.005 vs the control group). Dynamic compliance at 60 breaths per min was 60.1 +/- 15.0% as compared to 83.2 +/- 13.3% in the control group (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of determining fructosamine levels in serum of pregnant patients with diabetes to evaluate the level of compensation for glycemia]

The results in 16 pregnant women with diabetes mellitus are analysed. All patients were treated with an intensive insulin-therapy at the Voivodeship Clinic for Diabetic Patients in Zabrze. Multipoint glycaemia profiles made by the treated patients as a self control were compared with serum fructosamine and HbAlC concentrations. A significant correlation of fructosamine levels with glycaemia and HbAlC levels was noted. No significant dependence of fructosamine and glycaemia fasting levels, incidence of hyperglycaemia and Schlichtkrull's Mw index was noted. Results suggest, that the fructosamine serum concentration is a useful marker of metabolic compensation in pregnant women with diabetes mellitus. It enables less frequent performance of the daily profiles of glycaemia by the patients.

[A proposed model of the treatment of diabetes mellitus in pregnancy]

A model of management of pregnant diabetic patients is proposed. Such a model has been implemented at the Voivodeship Out-patient Clinic for Diabetics. Proposed model includes recent data on diabetes mellitus complications and the effect of coexisting diseases on the mother and fetus health. Management was adapted to the real and potential possibilities of health service in Poland. A decrease in the rate of mortality of fetuses under 7% was achieved. It is worth emphasizing despite higher value than those reported in the literature.