Mortality in perinatally HIV-infected young people in England following transition to adult care: an HIV Young Persons Network (HYPNet) audit

OBJECTIVES

Mortality in young people with perinatally acquired HIV infection (PHIV) following transfer to adult care has not been characterized in the UK. We conducted a multicentre audit to establish the number of deaths and associated factors.

METHODS

Fourteen adult clinics caring for infected young people reported deaths to 30 September 2011 on a proforma. Deaths were matched to the Collaborative HIV Paediatric Study, a clinical database of HIV-infected children in the UK/Ireland, to describe clinical characteristics in paediatric care of those who died post-transition.

RESULTS

Eleven deaths were reported from 14 clinics which cared for 248 adults with PHIV. For the 11 deaths, the median age at transfer to adult care was 17 years (range 15-21 years), and at death was 21 years (range 17-24 years). Causes of death were suicide (two patients), advanced HIV disease (seven patients) and bronchiectasis (one patient), with one cause missing. At death, the median CD4 count was 27 cells/μL (range 0-630 cells/μL); five patients were on antiretroviral therapy (ART) but only two had a viral load < 50 HIV-1 RNA copies/mL. Nine had poor adherence when in paediatric care, continuing into adult care despite multidisciplinary support. Eight had ART resistance, although all had potentially suppressive regimens available. Nine had mental health diagnoses.

CONCLUSIONS

Our findings highlight the complex medical and psychosocial issues faced by some adults with PHIV, with nine of the 11 deaths in our study being associated with poor adherence and advanced HIV disease. Novel adherence interventions and mental health support are required for this vulnerable cohort.

Trends in attendances to genitourinary medicine services by older women

We sought to analyse reasons for attendance of older women (defined as aged 46 years and over) to genitourinary (GU) medicine services at two UK clinics. We used KC60 coding data to count new episode attendances by year from 1998 to 2008 and to further dissect reason for attendance in 2827 new episodes during 2003–2008. The total number of new episodes of attendance in older women increased from 167 in 1998 to 701 in 2008. Within this overall increase, there was a stable proportion of acute sexually transmitted infections (STIs) over time, alongside significant increases in the proportion of women requesting STI screening and HIV testing and those attending GU medicine for other reasons, such as dermatological or gynaecological complaints. In our clinic population it was encouraging to see that older women increasingly use GU medicine services for STI screening and HIV testing. Services may need to adapt to older women's specific health-care needs.

Microscopy for symptomatic men: not all symptoms are born equal

Summary

We reviewed microscopy results for symptomatic male patients in order to identify clinical correlates of urethritis as diagnosed by same-day microscopy. Higher polymorph counts were found in patients presenting with discharge, or discharge together with dysuria, but dysuria without discharge was strongly associated with negative urethral microscopy. Symptoms were strongly linked to microscopy outcome but partnerships were not linked to either symptoms or outcome.

The need for innovative sexually transmitted infection screening initiatives for young men: evidence from genitourinary medicine clinics across England

The study objectives were to ascertain behavioural, access-related, health-seeking factors and sexually transmitted infection (STI) prevalence in young men (<25 years) attending genitourinary (GU) medicine clinics and compare them with older men (≥25 years) and young women (<25 years). Between October 2004 and March 2005, 4600 new attendees at seven sociodemographically and geographically contrasting GU medicine clinics across England completed questionnaires, which were linked to routine clinical data. Young men waited significantly less time to be seen in clinic compared with older men and young women. They were less likely to report symptoms than older men ( P = 0.021) yet more likely to be diagnosed with chlamydia ( P = 0.001) and gonorrhoea ( P = 0.007). They were also more likely to be diagnosed with an acute STI relative to young women ( P = 0.007). Our data confirm the need to make comprehensive STI screening readily available for young men and to develop effective and innovative screening strategies in different settings.

Evidence for pulsatile secretion of human atrial natriuretic peptide in healthy subjects

The secretion pattern of human atrial natriuretic peptide (hANP) was investigated in 8 healthy male volunteers. Blood was drawn in 2 minute intervals for 90 minutes and in a second study in 4 minute intervals for 180 minutes. Base-line hANP plasma levels varied in a pulsatile secretion pattern of regular pulses every 9 +/- 1 minutes. Additionally long-term oscillations of 34 +/- 4 minutes were found. These data suggest that under basal conditions hANP varies in a pulsatile fashion.

Increase of serum insulin and stable c-peptide concentrations with exhaustive incremental graded exercise during acute hypoxia in sedentary subjects

Hypoxia was shown to reduce insulin concentrations at rest and during exercise. However, some studies have also demonstrated increases in the hormone associated with arterial desaturation. This study was conducted in order to decide [1] whether acute alveolar hypoxia increased or decreased the circulating insulin levels, and [2] to elucidate whether interactions of insulin with other hormones were of relevance in this respect. Glucose (GLU), insulin (INS), c-peptide (CP), adrenaline and noradrenaline (CATs), atrial natriuretic peptide (ANP) and cortisol (CORT) as well as the capillary blood gases were determined in 15 healthy fasting male volunteers (age: 26.2 +/- 2.8 years, body mass index: 22.4 +/- 2.7 kg.m-2). On two separate test days the subjects breathed, in random order, either normal air (N) or a gas mixture with reduced oxygen content (H; FIO2: 0.14). Measurements were made at rest as well as during an incremental cycle exercise in a supine position (increments of 6 min and 50 W) at 100 W and 150 W, at volitional exhaustion (N: 227 +/- 36 W; H: 200 +/- 32 W) as well as in the 5th min of recovery. Arterial desaturation was seen throughout on H-day. At rest all hormones and GLU were normal and showed no influence of H. During exercise INS remained constant on N-day, increased on H-day and was significantly higher with H than with N, most pronounced at 150 W and at volitional exhaustion with 20%, respectively. For CP and GLU no significant exercise-induced changes were seen on either test day and no influence of H was detected.(ABSTRACT TRUNCATED AT 250 WORDS)

Vertically acquired HIV diagnosed in adolescence and early adulthood in the United Kingdom and Ireland: findings from national surveillance

OBJECTIVE

The aim of the study was to describe the characteristics of young people with vertically acquired HIV diagnosed aged > or =13 years.

METHODS

A retrospective review of HIV diagnoses reported to well-established national paediatric and adult HIV surveillance systems in the United Kingdom/Ireland was conducted.

RESULTS

Forty-two young people with vertically acquired HIV diagnosed aged > or =13 years were identified; 23 (55%) were female, 40 (95%) were black African and 36 (86%) were born in sub-Saharan Africa. The median age at HIV diagnosis was 14 years (range, 13-20 years). Half of the patients presented with symptoms; the remainder were screened for HIV following diagnosis of a relative. The median CD4 count at diagnosis was 210 cells/microL (range, 0-689 cells/microL), 12 patients (29%) were diagnosed with AIDS at HIV diagnosis or subsequently, and 34 (81%) started combination antiretroviral therapy (ART), most (31 of 34) within a year of diagnosis.

CONCLUSION

A small number of young people with vertically acquired HIV survive childhood without ART and are diagnosed at age > or =13 years in the United Kingdom/Ireland. Half of the patients were asymptomatic, highlighting the importance of considering HIV testing for all offspring of HIV-infected women, regardless of age or symptoms. Increased awareness among clinicians and parents is required to reduce delayed presentation with advanced disease and to avoid onward transmission as these young people become sexually active.

Is vaginal microscopy an essential tool for the management of women presenting with vaginal discharge?

Point-of-care microscopy is the gold standard for the diagnosis of vaginal discharge in genitourinary (GU) medicine clinics but not used in primary care settings and reproductive health clinics to which many patients present. In our GU medicine clinic setting, we conducted an audit to assess the utility of microscopy of vaginal secretions versus clinical diagnosis alone for the differential diagnosis of uncomplicated lower vaginal infections. Clinical diagnosis (including pH) of bacterial vaginosis had a sensitivity between 85% and 88% at two clinic sites. Our results suggest that it may be safe and more cost-effective to restrict vaginal microscopy to a subgroup of women presenting with vaginal discharge.

Would offering rapid point-of-care testing or non-invasive methods improve uptake of HIV testing among high-risk genitourinary medicine clinic attendees? A patient perspective

While most genitourinary (GU) medicine clinics achieve a high uptake for testing HIV in new patients, they may still miss testing those at highest risk. Point-of-care testing (POCT) and salivary samples are acceptable and feasible but have not yet been shown to increase uptake among high-risk patients (HRP). This study aimed to describe reasons why HRP decline HIV testing and whether offering POCT along with standard testing would increase the uptake of testing HIV in two London GU medicine clinics. Anonymous self-administered questionnaires were offered to all new and rebooked patients. Eight hundred and ninety-nine questionnaires were analysed of which 598 were HRP. Uptake of HIV testing was 77.1 % among HRP and 65.8% among the rest. A total of 51.1 % of HRP who declined HIV testing said they would be more likely to accept a POCT and 32.8% a salivary test. Introduction of rapid POCT for HIV would increase patient's choice and may increase the likelihood of HRP accepting an HIV test.

Sexual behaviour, condom use, and disclosure of HIV status in HIV infected heterosexual individuals attending an inner London HIV clinic

BACKGROUND

The National Strategy for Sexual Health and HIV for England (2001) emphasised the role of HIV services in reducing secondary transmission of HIV through prevention work with HIV infected people.

OBJECTIVE

To determine the sexual behaviour, condom use, and disclosure of HIV status of HIV infected heterosexuals attending an inner London HIV clinic.

DESIGN

Cross sectional questionnaire study of heterosexual HIV infected individuals attending an HIV outpatient clinic.

METHODS

We collected demographic data for all respondents and sexual behaviour data for those sexually active over the past year using a self administered questionnaire. Viral load and CD4 count for responders and age, sex, ethnicity, viral load, and CD4 count for non-responders were obtained from the clinic database.

RESULTS

The response rate was 47.3% (n = 142). 100 participants reported being sexually active in the past year, of whom 73% used condoms when they last had vaginal sex. Knowledge of partner's HIV status was the only variable significantly associated with the participant disclosing their HIV status to their partner (p<0.001). In those who had disclosed their status, only knowledge of partner's HIV status was significantly associated with condom use (p = 0.03).

CONCLUSIONS

Issues relating to non-disclosure and partner notification in HIV infected heterosexuals will need to be better understood to improve sexual health in this group and to reduce onward transmission of HIV.

Prevalence of Chlamydia trachomatis in sexual contacts of gonorrhoea

The British national and local clinic guidelines recommend epidemiological treatment for Chlamydia trachomatis (CT) in patients with gonococcal infection but not their contacts. We aimed to determine the prevalence of CT amongst all gonorrhoea contacts attending over a 30 months period through a retrospective notes review. Of 223 contacts, gonorrhoea was diagnosed in 110 (49.3%) while CT was diagnosed in 54 (24.2%). CT was significantly more prevalent in younger people [(37.8% of contacts <25 years versus 9.6% of contacts >/=25 years (P = 0.000)]. All patients with CT identified as heterosexual except one. Amongst heterosexuals, there was no significant difference in the prevalence between males and females, being 31.6% and 27.8% respectively (P = 0.5995). CT was prevalent in 29.1% of N. gonorrhoeae positive contacts and 19.5% of N. gonorrhoeae negative contacts (p = 0.0935). The high prevalence suggests that epidemiological treatment for CT in gonorrhoea contacts is indicated.

Intensivierte Insulintherapie des Typ-2-Diabetes mellitus: Prä- oder postprandiale Injektion von Aspart-Insulin?

BACKGROUND AND OBJECTIVE

Intensified insulin therapy using rapid acting insulin analogues is advocated in younger type 2 diabetic patients at risk of developing diabetic complications. Most patients prefer postprandial insulin injections. So far, however, there were no data on glycemic control by postprandial aspart insulin in patients with type 2 diabetes.

PATIENTS AND METHODS

To compare blood glucose responsiveness to preprandial vs. postprandial aspart injections, a randomised open intraindividual cross-over trial was carried out. Blood glucose was measured before and one hour after the three main meals and at bedtime. 18 insulin-naive patients with type 2 diabetes (age, 60 +/- 3 years (mean +/- SEM), known duration of the disease, 7 +/- 2 years) participated at this study.

RESULTS

Both with preprandial and postprandial injections of aspart insulin, the averages of the 7-point blood glucose profiles (8.27 +/- 0.50 vs. 8.5 +/- 0.61 mmol/l) were similar. With postprandial aspart insulin, however, 84 % of the blood glucose levels measured one hour after breakfast exceeded > 10 mmol/l in comparison to 38 % with preprandial aspart insulin (p < 0.05). Patients injected similar amounts of basal and aspart insulin on both experimental days (insulin glargin, 11 +/- 3 U, aspart insulin, 23 +/- 2 vs. 25 +/- 2 U/day, p = 0.4843).

CONCLUSION

Both preprandial and postprandial insulin aspart can be allowed to well-controlled type 2 diabetic patients. However, patients will benefit from the recommendation to inject insulin aspart immediately before meal if food with a high glycemic index such as the continental breakfast is to be consumed.

Gonorrhoea in young heterosexuals attending urban STD clinics in Britain: a cross-sectional survey

Young people in the UK bear the brunt of sexually transmitted infections, in particular of gonorrhoea. We aimed to assess whether young people with gonorrhoea (under 21 years) attending sexual health clinics differed from older individuals with gonorrhoea in their behavioural and clinical characteristics and management outcomes. The results of this cross-sectional study suggest that young people were more likely to be female (66.2% vs 34.1%), have concurrent infection with Chlamydia trachomatis (55.4% vs 30.2%) and a history of recent gonococcal infection (81.3% vs 35.5%) if they ever had gonorrhoea. Young women were more likely to experience treatment delay and not to attend for follow-up than older women. Resistance to ciprofloxacin was high in both age groups but the prevalence of penicillinase-producing Neisseria gonorrhoeae was higher in older patients (11.5% vs 1.3%). Different management protocols for young and older patients with gonorrhoea may need to be considered.

How useful are high vaginal swabs in general practice? Results of a multicentre study

Vulvovaginal symptoms are a common reason for consultation with a general practitioner (GP). High vaginal swabs (HVS) are used to investigate symptoms, but their usefulness is poorly evaluated and microbiological tests performed vary between laboratories. In this multicentre study of 797 women with genital symptoms attending GPs, diagnostic yield of HVS was poor except for Candida spp. (22%). There is an urgent need to establish the most cost-effective approach for the management of these women.

[Intensified conventional insulin therapy in patients with type 2 diabetes mellitus. Positive long-term effects of insulin lispro on metabolic control and microalbuminuria]

AIMS

It was decided to demonstrate by the present observations to which extent beneficial long-term effects on metabolic control, body weight and microalbuminuria can be attained by applying intensive insulin therapy (IIT) to type 2 diabetic patients, particularly when using insulin lispro.

METHODS

In our observational study, clinical data were evaluated during 6, 12 and 36 months after participation in our structured inpatient insulin treatment and teaching programme in 25 patients with conventional insulin therapy (CT), in 10 patients with IIT using human normal insulin and in 15 patients with IIT using insulin lispro who all could be followed for 3 years in our outpatient diabetic clinic.

RESULTS

In the CT-treated patients, HbA1c decreased from 10.2 +/- 0.4% to 7.6 +/- 0.2% (average +/- SEM) after 3 years. Body weight increased from 27.8 +/- 0.9 kg/m2 to 28.6 +/- 0.9 kg/m2, insulin dose increased from 29 +/- 3 U/day to 48 +/- 5 U/day (all p < 0.05), urinary albumin concentration was only transiently reduced. In the IIT-treated patients using human normal insulin, HbA1c fell from 10.6 +/- 0.8% to 7.9 +/- 0.5%, body weight increased from 27.8 +/- 1.4 kg/m2 to 29.8 +/- 1.3 kg/m2, urinary albumin concentration was reduced from 26 +/- 10 mg/l to 13 +/- 3 mg/l (all p < 0.05). Insulin dose increased only slightly from 57 +/- 6 U/day to 63 +/- 7 U/day. In the IIT-treated patients using insulin lispro HbA1c fell from 8.4 +/- 0.5% to 6.7 +/- 0.3%, body weight increased from 27.6 +/- 1.0 kg/m2 to 28.7 +/- 1.3 kg/m2, insulin dose from 36 +/- 5 U/day to 50 +/- 7 U/day, urinary albumin concentration was reduced from 23 +/- 4 mg/l to 13 +/- 4 mg/l (all p < 0.05). Blood pressure remained uninfluenced by insulin therapy.

CONCLUSION

In our patients, we observed a beneficial long-term effect on metabolic control of IIT-treatment using insulin lispro, which was evident over the complete 3-year observation period, together with an only moderate increase in insulin dose and a clinically acceptable increase in body weight, but a remarkable reduction of microalbuminuria. Thus, clinical outcome was superior to that in patients treated with CT or IIT using human normal insulin.

Decreased fertility among HIV-1-infected women attending antenatal clinics in three African cities

Population HIV prevalence estimates rely heavily on sentinel surveillance in antenatal clinics (ANCs), but because HIV reduces fertility, these estimates are biased. To aid interpretation of such data, we estimated HIV-associated fertility reduction among pregnant women in ANCs in Yaoundé (Cameroon), Kisumu (Kenya), and Ndola (Zambia). Data collection followed existing HIV sentinel surveillance procedures as far as possible. HIV prevalence among the women was 5.5% in Yaoundé, 30.6% in Kisumu, and 27.3% in Ndola. The birth interval was prolonged in HIV-positive multiparous women compared with HIV-negative multiparous women in all three sites: adjusted hazard ratios of pregnancy were 0.84 (95% confidence interval [CI]: 0.62-1.1) in Yaoundé, 0.82 (95% CI: 0.70-0.96) in Kisumu, and 0.74 (95% CI: 0.61-0.90) in Ndola, implying estimated reductions in the risk of pregnancy in HIV-positive women of between 16% and 26%. For primiparous women, the interval between sexual debut and birth was longer in HIV-positive women than in HIV-negative women in all sites, although the association was lost in Ndola after adjusting for age and other factors. Consistent results in different study sites help in the development of standard methods for improving ANC-based surveillance estimates of HIV prevalence. These may be easier to devise for multiparous women than for primiparous women.

[Therapy of diabetic nephropathy. Effects of ACE inhibition on microcirculation]

The development of diabetic microangiopathies is of decisive importance for the long-term prognosis of diabetes mellitus. For example, diabetic nephropathy is one of the the most common causes of terminal kidney failure. Primary prevention of diabetic nephropathy is best achieved by establishing good metabolic control. To ensure early pharmacological intervention of incipient diabetic nephropathy, screening for microalbuminuria is recommended at least once a year. A major element in the pathogenesis of diabetic nephropathy is a disordered microcirculation characterized by abnormal hemodynamics with elevated capillary pressure and microvascular resistance. Angiotensin converting enzyme inhibitors (ACE inhibitors) effectively act on these pathophysiological events by dilation of the vasa efferentia of the glomeruli. By means of videocapillaroscopy and laser doppler imaging also distinct changes in microcirculation can be detected. Investigations with these methods provided evidence that ACE inhibitors might also be useful in the primary prevention of diabetic nephropathy. Therefore, ACE inhibitors are useful pharmaceutical agents in the treatment of diabetic nephropathy.

Clinical evidence for a neuromodulator action of endothelin in the hypothalamic-pituitary-adrenal axis in man

In order to investigate whether the ubiquitous signalling peptide endothelin might also act as a neuromodulator in the stimulation of the hypothalamic-pituitary-adrenal axis, 15 patients (4 female, 11 male, aged 35-67 years) with hypopituitarism were investigated and the results were compared to those of 8 healthy male volunteers (aged 24-31 years). Patients and controls received double-blind in random order either 0.1 IE per kg body weight regular insulin (insulin induced hypoglycemia) or 1 ml 0.9% sodium chloride (placebo) on 2 separate days. Control subjects only received on an additional day 0.1 IE per kg body weight regular insulin plus glucose 10% (euglycemic hyperinsulinemic glucose clamp). In control subjects hypoglycemia resulted in a significant increase in adrenocorticotropin (ACTH) and cortisol which was preceded by an increase in circulating endothelin levels (p < 0.01 vs placebo and euglycemic clamp) while endothelin, ACTH and cortisol remained unchanged both after placebo and in the euglycemic hyperinsulinemic clamp. In contrast, patients with hypopituitarism showed neither changes in circulating endothelin levels nor a stimulation of the hypothalamic-pituitary-adrenal axis during insulin-induced hypoglycemia. These data demonstrate that 1) endothelin levels are enhanced by metabolic stress 2) the responsiveness of endothelin levels to metabolic stress is linked to the presence of an intact pituitary gland and 3) endothelin might be involved in the stimulation of the hypothalamic-pituitary-adrenal axis.

Chemoprophylaxis of diabetic nephropathy in the elderly

Renal disease in elderly diabetic patients is costly in terms of morbidity, mortality and medical payments. Therefore, prevention of diabetic nephropathy has become a prominent goal in the treatment of diabetic patients. Preventive treatment should begin not later than at the stage of persistent microalbuminuria, and regular screening for microalbuminuria is recommended for both elderly and younger diabetic patients. Improved metabolic control, through diet and hypoglycaemic therapy, has been demonstrated to lower urinary albumin excretion. The target level of glycated haemoglobin is < 8%, or < 2% higher than the upper limit of normal in nondiabetic people. Insulin therapy has no adverse effects on renal indices, unless it increases bodyweight and consequently raises blood pressure. To preserve renal function in elderly diabetic patients, blood pressure should be kept well below 140/90 mm Hg. Treatment with ACE inhibitors may be the 'gold standard' intervention, and should be initiated at the lowest possible dosage and then titrated until the maximum tolerated dosage has been reached. Nonchronotropic calcium antagonists have been shown to be as effective as ACE inhibitors with regard to their effects on blood pressure, renal haemodynamics and urinary albumin excretion. Most dihydropyridines have been found to increase or to have no effect on urinary albumin excretion despite significant blood pressure reduction. A renoprotective action of diuretics is generally unlikely, with the possible exception of indapamide. Although beta-blockers are effective antihypertensive agents, they may not adequately preserve kidney function in diabetic patients. Because beta-blocker treatment may mask the symptoms of hypoglycaemia, they should be reserved for patients with coronary artery disease or arrhythmias.

Hormonal modifications in patients admitted to an internal intensive care unit for acute hypoxaemic respiratory failure

To clarify which endocrine modifications can be observed in acute hypoxaemic respiratory failure, 15 severely ill male patients [PAT; median age: 61 (range: 48 years); median height: 173 (range: 12) cm; median mass: 73 (range 31) kg] were investigated immediately upon admission to an intensive care unit (ICU) for this clinical disorder. Before starting treatment, the blood gases were measured and a number of selected hormones with special relevance for an ICU setting were determined. These are known to be modified by acute hypoxaemia in healthy subjects and to possess glucoregulatory properties, or an influence upon cardiocirculation or the vascular volume regulation: insulin, cortisol, adrenaline, noradrenaline, atrial natriuretic peptide, renin, aldosterone, angiotensin converting enzyme, and endothelin-I (ET). To elucidate whether potential endocrine changes resulted from acute hypoxaemia alone, the underlying disease, or unspecific influences connected with the ICU setting, all measurements were compared to those of a completely healthy reference group (REF) with comparable acute experimental hypoxaemia. The latter state was achieved by having the REF breathe a gas mixture with the oxygen content reduced to 14% (H). In the REF, neither the medians nor the distribution of endocrinologic measurements were modified significantly by acute hypoxaemia. In the PAT, the medians were increased considerably, yet with a slight diminution of ET. The distribution of individual values was considerably broader than in the REF with H. In conclusion, considerable increases in the means of the above hormones, with the exception of ET, can be registered in severely ill patients admitted to ICUs with acute hypoxaemic failure. However, such modifications cannot be considered attributable exclusively to acute arterial hypoxaemia. The underlying clinical disorders, such as septicaemia or an unspecific endocrine epiphenomenon, including severe and not only hypoxaemic stress, seem to be predominant.

[Urinary albumin excretion by patients with type 2 diabetes mellitus. Effect of blood pressure and metabolic regulation]

BACKGROUND

There is still controversy as to whether increased urinary albumin excretion (UAE) in patients with type 2 diabetes mellitus may have similar pathognomonic relevance as in type 1 diabetes and whether improved metabolic control may beneficially influence increased UAE in type 2 diabetic patients to the same extent as in type 1 diabetic patients.

PATIENTS AND METHODS

In a cross-sectional study in 234 patients with type 2 diabetes (age, 64 +/- 1 years, known duration of diabetes, 14 +/- 1 years) UAE, haemoglobin A1, blood pressure, cholesterol, triglyceride and creatinine levels were measured and signs of retinopathy were evaluated. Results were compared with the findings in 247 patients with type 1 diabetes (age, 39 +/- 1 years, duration of diabetes, 15 +/- 1 years). In a longitudinal study, UAE, haemoglobin A1, blood pressure, cholesterol, triglyceride and creatinine levels were measured in 41 patients with type 2 diabetes and secondary failure of oral hypoglycemic treatment (age, 62 +/- 1 years, known duration of diabetes, 11 +/- 1 years) before and after 2-year insulin treatment.

RESULTS

In the cross-sectional study, 39% of the type 2 diabetic patients had increased UAE, 27% had microalbuminuria, in contrast to 21% and 14%, respectively, of the type 1 diabetic patients (p < 0.01). In type 2 diabetes, macroalbuminuria was detected after an average of 15 +/- 2 years in contrast to 25 +/- 2 years in type 1 diabetes (p < 0.01). In comparison to macroalbuminuric type 1 diabetic patients, macroalbuminuric type 2 diabetes patients exhibited a lower prevalence of renal insufficiency (30 vs. 53%, p < 0.05) as well as of retinopathy (59 vs. 88%, p < 0.05), but a higher prevalence of hypertension (93 vs. 65%, p < 0.05) as well as of hyperlipidaemia (p < 0.01). There was a significant relation between UAE and haemoglobin A1 in patients with type 1 diabetes (p < 0.01) which could not be demonstrated in type 2 diabetic patients. In the longitudinal study, UAE fell from 86 +/- 28 to 51 +/- 16 mg/24 hours (p < 0.05) and the prevalence of UAE of more than 30 mg/24 hours decreased from 45 to 25% (p < 0.05) after 2-year insulin treatment, while blood pressure remained constant and haemoglobin A1 fell from 12.3 +/- 0.4 to 8.8 +/- 0.3% (p < 0.01). In comparison to patients with normal or normalized UAE after 2 years, patients with persistently elevated UAE had more advanced kidney disease (p < 0.05), more pronounced insulin resistance and a higher prevalence of calculated mean arterial blood pressure above 103 mm Hg and of haemoglobin A1 higher than 9% (normal, < 7%) in the course of the study (p < 0.05).

CONCLUSION

In patients with both type 2 and type 1 diabetes mellitus, increased UAE is a marker for the nephropathy-related sequelae of long-term hyperglycaemia. In type 2 diabetic patients, however, the frequently pre-existing hypertension as well as other disease mechanism of the "metabolic syndrome" ("syndrome X") may additionally determine course and progression of diabetic kidney disease.

Chronic angiotensin-converting enzyme inhibition may improve sodium excretion in cardiac transplant hypertension

Cyclosporine-associated hypertension (CAH) may be mediated in part by sodium and volume retention. To investigate this issue, we studied the effects of a calcium antagonist, nitrendipine (NIT, 10-20 mg b.i.d.), and a converting enzyme inhibitor, lisinopril (LIS, 10-20 mg o.d.), on blood pressure (office BP, 24 hr ambulatory BP), excretion of an acute sodium load (200 mmol/2 hr i.v.), glomerular filtration rate (insulin clearance), cumulative dopamine excretion, plasma atrial natriuretic peptide (ANP), and endothelin excretion in 8 patients with CAH after cardiac transplantation in a double-blind, randomized, crossover trial for 6 weeks. Five patients received a diuretic during the trial at a constant dose. Office diastolic BP (DBP) decreased significantly with LIS from 97 +/- 6 to 87 +/- 9 mmHg and with NIT from 96 +/- 7 to 92 +/- 12 mmHg. Ambulatory 24 hr DBP decreased significantly from 96 +/- 7 mmHg to 86 +/- 10 mmHg (LIS) and to 84 +/- 11 mmHg (NIT). Ambulatory DBP during the day was lowered significantly from 98 +/- 11 mmHg to 87 +/- 10 mmHg (LIS) and to 88 +/- 9 mmHg (NIT) and during the night from 95 +/- 9 mmHg to 86 +/- 8 mmHg (LIS) and to 79 +/- 7 mmHg (NIT). Cumulative sodium excretion 6 hr after an acute sodium load increased to 52 +/- 39 mmol (placebo), 96 +/- 44 mmol (LIS, P < 0.05 vs. placebo), and 71 +/- 34 mmol (NIT). Glomerular filtration rate, cumulative dopamine excretion, ANP, and endothelin excretion did not differ between either treatment group. We conclude, that: (1) both drugs were similar in lowering office BP and during the day, but NIT tended to be more effective during the night; and (2) cumulative sodium excretion during LIS was significantly increased compared with placebo. There was a similar trend during NIT also. Therefore, it is possible that chronic angiotensin-converting enzyme inhibition and possibly calcium antagonists might improve the sodium-retaining state in CAH independent of differences in blood pressure, ANP, dopamine, or renal function.