Plasma endothelin in NIDDM patients with and without complications

OBJECTIVE: To measure plasma endothelin 1 (ET-1) levels in uncomplicated non-insulin-dependent diabetes mellitus (NIDDM) and investigate whether ET levels may be related to angiopathy, blood pressure, metabolic control, or duration of illness. RESEARCH DESIGN AND METHODS: Plasma levels of ET-1 were measured in 44 NIDDM patients, of whom 24 had uncomplicated diabetes, 20 had angiopathy, and 10 had hypertension. In 21 patients, the duration of illness was > 10 years, and in 23 the duration of illness was < 10 years. Serum creatinine levels, microalbuminuria, and HbA1c were determined simultaneously. Thirty normotensive healthy (nondiabetic) individuals (20 men and 10 women) served as control subjects. RESULTS: No significant statistical differences in plasma ET-1 levels were found among all diabetic patients, diabetic patients with and without angiopathy, diabetic patients with different durations of diabetes, and normal subjects. No significant correlation of plasma ET-1 with blood pressure, age, serum creatinine level, duration of diabetes, HbA1c, or diabetic complications was found. CONCLUSIONS: Plasma ET-1 levels are similar in patients with NIDDM and healthy subjects and do not seem to act as a marker of diabetic complications.     

Retinopathy and vision loss in insulin-dependent diabetes in Europe. The EURODIAB IDDM Complications Study

PURPOSE: To assess the frequency of retinopathy and vision loss in patients with insulin-dependent diabetes mellitus and their relations to potentially modifiable risk factors. METHODS: The authors conducted a multicenter cross-sectional study of diabetic complications and their risk factors using standardized methods of assessment. The sample was comprised of 3250 insulin-dependent diabetic patients (1668 men, 1582 women) aged 15 to 60 years with mean (standard deviation) duration of diabetes of 14.7 (9.3) years from 31 European diabetes centers; 2991 of the patients were eligible for retinal photography. Visual acuity was measured using the Snellen chart. Retinopathy was evaluated by retinal photographs (two fields per eye) graded at a central facility. Glycated hemoglobin (HbA1c), cholesterol, triglyceride, fibrinogen, von Willebrand factor, and urinary albumin excretion rate were assessed at a single location. RESULTS: Corrected visual acuity was greater than or equal to 1.0 in both eyes in 69.7% of patients and less than or equal to 0.1 in the best eye in 2.3%. Factors significantly related to vision loss were age, duration of diabetes, glycated hemoglobin (HbA1c), and level of retinopathy. Mild nonproliferative retinopathy was found in 25.8% of the patients, moderate-severe nonproliferative retinopathy in 9.8% of the patients, and proliferative retinopathy in 10.6% of the patients. After adjustment for age, duration of diabetes, HbA1c, and albumin excretion rate, significant risk factors for moderate-severe nonproliferative retinopathy were blood pressure and triglyceride, and risk factors for proliferative retinopathy were triglyceride and fibrinogen. CONCLUSION: Vision loss is a common complication of patients with insulin-dependent diabetes, with diabetic retinopathy an important cause. Apart from poor glycemic control, several other potentially modifiable risk factors for retinopathy may be important, including elevated blood pressure, plasma triglyceride, and fibrinogen. In view of the possible barriers to the full implementation of strict glycemic control in this type of diabetes, additional strategies for the prevention and slowing of progression of retinopathy should be investigated, such as blood pressure and lipid lowering therapies.     

Pre-eclampsia is a potent risk factor for deterioration of retinopathy during pregnancy in Type 1 diabetic patients

The aim of the present study was to examine the influence of pregnancy on deterioration of retinopathy in patients with Type 1 diabetes mellitus. Sixty-five pregnant Type 1 diabetic women attending the University Hospital in Lund were studied retrospectively. The degree of retinopathy, and levels of HbA1c and blood pressure 12 months before, during, and 6 months after pregnancy were compared of those of 56 non-pregnant Type 1 diabetic women matched for age and duration of diabetes. For all patients, sight-threatening deterioration of retinopathy did not differ between the pregnancy group (9/65) and the control group (6/56). Over time, pregnant patients had lower HbA1c levels than controls (p < 0.001). Pregnant patients with sight-threatening deterioration of retinopathy had higher HbA1c levels than those without (p = 0.028 and the decrement in HbA1c between the 6-14th and the 20th week of gestation was more pronounced (p = 0.006). In those patients who developed pre-eclampsia during pregnancy, deterioration of retinopathy ocurred more frequently compared to those without pre-eclampsia (4/8 vs 5/65; p = 0.005). In conclusion, sight-threatening deterioration of retinopathy was not more common during pregnancy in IDDM patients than among age- and duration-matched control patients. In pregnant patients, deterioration of retinopathy was associated with the pregestational degree of metabolic control as well as with a rapidly improved glycaemic control acheived during pregnancy. Among those in whom deterioration occurred during pregnancy, pre-eclampsia was a potent risk factor.     

Blood glutathione in various phases of insulin-dependent diabetes mellitus in children

Reduced glutathione (GSH) in whole blood was studied in 15 insulin-dependent juvenile diabetic patients at onset of diabetes (group A). In 5 of these patients the blood GSH concentration was followed during the first month after onset. The blood GSH content was also analyzed in 16 children with insulin-dependent diabetes mellitus (IDDM) with a duration of diabetes of more than 2 years (group B), and in a control group of 76 healthy children (group C). The GSH levels in groups A, B and C were 48.3 +/- 5.7, 47.1 +/- 4.6 and 47.6 +/- 4.3 mg/100 ml erythrocytes, respectively. Thus, there were no significant differences between the patients and the control group. In group A, there were no significant differences in blood GSH values at onset and 1 month later.     

Retinopathy in African Americans and whites with insulin-dependent diabetes mellitus

BACKGROUND: The development and progression of diabetic retinopathy in African Americans with insulin-dependent diabetes mellitus is not known. METHODS: Two hundred subjects with insulin-dependent diabetes mellitus with duration of diabetes 16 years or less at first visit were studied; 58 were African Americans and 142 were whites. All had gradable stereoscopic color fundus photographs (seven standard fields) from at least two visits (mean time between first and second visit was 4.1 years). Subjects with hemoglobinopathy or proliferative retinopathy or subjects who had evidence of treatment for proliferative retinopathy at first visit were excluded. Masked grading of photographs was conducted using the modified Airlie House classification scheme. RESULTS: African Americans were older, heavier, had higher systolic blood pressure (all P < .05), and marginally higher hemoglobin A1 (HbA1) values (P = .06) than the whites at first visit. African Americans had a lower rate of two steps or more progression from preexistent retinopathy (19%) than whites (43%). Progression to proliferative retinopathy or treatment was similar by race. Multivariate analysis predicting development oe progression of retinopathy, while controlling for length of follow-up, found higher HbA1 (odds ratio [OR] = 2.15), longer duration of insulin-dependent diabetes mellitus (OR = 1.69), higher serum creatinine concentration (OR = 1.59), and white race (OR = 2.62) to be independent risk factors. CONCLUSIONS: These data suggest a previously unsuspected reduction in the adjusted risk for development and progression of retinopathy in African Americans. The reason for this apparently reduced risk are not known.     

Elevation of plasma leptin levels during pregnancy in normal and diabetic women

The impact of pregnancy and food intake on plasma leptin levels was investigated in insulin-dependent diabetes mellitus (IDDM) patients and healthy normal-weight women. Fourteen women with IDDM and 11 women with no diabetes or family history of diabetes were served a 707-kcal lunch in gestational weeks 34 to 38. Six breast-feeding women from each group were examined a second time within 1 month after delivery. Leptin levels were not different in the two groups either during pregnancy or postpartum. In addition to a positive correlation to body mass index (BMI), leptin levels tended to correlate with gestational weight gain. The leptin concentration during pregnancy was higher than the postpartum level, which was within the range of previously reported levels in non-obese nonpregnant women. Ingestion of the test meal did not affect leptin levels and there were no relationships between leptin and insulin or glucose, for either basal or postprandial (60-minute) levels. Only the insulin dose taken by the diabetic women correlated to leptin level. During pregnancy, there is an augmented energy expenditure and maternal metabolism is altered to increase fat stores. The present observation that leptin levels were elevated in pregnant women suggests an additional role for leptin in the accumulation of body fat.     

Frequency of diabetes in family members of probands with non-insulin-dependent diabetes mellitus

OBJECTIVES: To describe the prevalence of known diabetes in a multi-ethnic community in South Auckland, New Zealand, in relation to family history of diabetes and past history of diabetes in pregnancy. DESIGN: A cross-sectional, household survey comparing ascertainment with local general practice diabetes registers where they existed. SETTING: An inner-city community with a high proportion of Maori, Pacific Islands people and Europeans. SUBJECTS: A total of 55,518 residents (91% response). Comparison with diabetes registers showed 91% ascertainment of known diabetic residents. More detailed interviews with 176/214 (82%) Europeans, 286/336 (85%) Maori and 495/585 (85%) Pacific Islands people with known diabetes. Fifty subjects had insulin-dependent diabetes mellitus on clinical criteria and were excluded from analyses. MAIN OUTCOME MEASURES: Prevalence of diabetes. RESULTS: Those with non-insulin-dependent diabetes mellitus were more likely to have a diabetic mother than father (Europeans, 21.7% vs. 9.9%; Maori, 17.6 vs. 11.4%; Pacific Islands, 15.7 vs. 5.3%). Diabetic women had a similar likelihood of having a diabetic father as diabetic men but were 1.84 times as likely to have a diabetic mother (95% CI, 1.27-2.69). Diabetic women with past diabetes in pregnancy had 2.05 (95% CI, 1.01-4.15) times the chance of a diabetic offspring as women who had not had past diabetes in pregnancy, who in turn had 2.69 (95% CI, 1.17-6.18) times the likelihood of having a diabetic offspring as diabetic men. CONCLUSIONS: The mother is a more important conduit for inheritance of diabetes than the father in these three ethnic groups. A history of diabetes in pregnancy confers an extra risk to the offspring above this usual maternal excess.     

Autonomic neuropathy in diabetic children

OBJECTIVE: Evaluate the presence of cardiovascular autonomic nerve dysfunction in children and adolescents with insulin-dependent diabetes mellitus. METHODOLOGY: We studied 110 patients (54 male, 56 female) and 100 healthy sex and age-matched children. Autonomic nerve function was assessed by standard cardiovascular reflex tests: (1) Fall in systolic blood pressure in response to standing. (2) Heart rate in response to standing. (3) Beat-to-beat rate variation during deep breathing. (4) Quotient of heart rate during and after Valsalva manoeuvre. (5) Change in blood pressure response to sustained handgrip. The coefficient of variation of heart rate was determined from 150 systoles using a microcomputer-based technique. The lower limits of normal were defined according to statistical analysis taking into account the relationship between heart rate variability and age. RESULTS: Forty-seven of the 110 diabetic children and adolescents studied showed one or more abnormal tests for cardiovascular autonomic dysfunction; many patients had an abnormality in more than one test. Twenty-two patients showed early involvement, 18 patients had definite and 7 severe involvement. No correlation was found between sex, glycaemic control, duration of diabetes or presence of retinopathy and persistent microalbuminuria and the autonomic nerve function. CONCLUSIONS: In the paediatric age group also, autonomic nerve dysfunction can be present in asymptomatic diabetic patients. Heart rate variation during Valsalva manoeuvre and maximum/minimum 30:15 ratio are the most sensitive indices to detect autonomic abnormalities in children.     

Microalbuminuria: prognostic and therapeutic implications in diabetic and hypertensive pregnancy

Microalbuminuria is defined as urinary excretion of albumin that is persistently above normal, although below the sensitivity of conventional semiquantative test strips. Several studies have reported that Type 1 diabetic patients with microalbuminuria are apparently more likely to develop diabetic nephropathy eventually progressing to renal failure. Microalbuminuria is also a strong predictor of mortality in Type 2 diabetes, and is correlated with increased blood pressure in patients with benign essential hypertension. Radioimmunoassay revealed a significantly higher urinary albumin excretion rate in normal pregnant women in the third trimester of pregnancy, compared to the second and first, and compared to non-pregnant women. Microalbuminuria was found in 30% of women who had a record of gestational diabetes mellitus. Published results are controversial regarding the assumption that microalbuminuria is an early predictor of pregnancy-induced hypertensive complications.     

Quantitative evaluation of flow in the portal vein. Comparison of bolus tracking magnetic resonance and Doppler color ultrasound]

We have attempted to identify any characteristics which could be used to predict the development of cerebral edema in four children under 5 years of age with new onset insulin-dependent diabetes mellitus and diabetic ketoacidosis. We retrospectively analysed and compared the concentration of serum sodium (corrected for serum glucose value) and effective serum osmolality of these 4 children with values of 10 age-matched controls with new onset insulin-dependent diabetes mellitus who did not develop cerebral edema during treatment of diabetic ketoacidosis. The initial serum sodium values of the two groups were not statistically different. Patients who developed cerebral edema had lower initial serum glucose values and effective serum osmolality. During treatment, patients who developed cerebral edema had consistently lower mean serum sodium and osmolality than controls at each 4-h interval after the first 4 h of therapy. Serum sodium and osmolality declined progressively after the initiation of therapy in cerebral edema patients, while remaining stable in controls. These data suggest that children who develop cerebral edema during treatment for diabetic ketoacidosis initially may have a relatively normal serum osmolality and subsequently develop progressive hyponatremia and/or a trend of declining serum sodium before developing cerebral edema.     

The prevalence of clinical diabetic polyneuropathy in Spain: a study in primary care and hospital clinic groups. Neuropathy Spanish Study Group of the Spanish Diabetes Society (SDS)

A multiregional cross-sectional study of clinical diabetic polyneuropathy (DPN) was carried out among Spanish diabetes patients using a standard system for scoring symptoms and signs of polyneuropathy. The main patient sample comprised 2644 patients (54.7% women) aged 15-74 years (mean 57.2 +/- 0.3 years), 86.9% of whom had Type II (non-insulin-dependent) diabetes mellitus and 29.4% were attending hospital clinics. Mean duration of diabetes since diagnosis was 10.2 +/- 0.2 years. The prevalence of DPN was 22.7% (95% confidence interval 21.2-24.3%) in the whole sample, 12.9% (9.4-16.5%) among patients with Type I (insulin-dependent) diabetes mellitus and 24.1% (22.4-25.9%) among patients with Type II diabetes; there was no significant difference in prevalence between men and women. Prevalence increased with age (from < 5% in the 15- to 19-year-old age group to 29.5% in the 70- to 74-year-old group) and with duration of diabetes since diagnosis (from 14.2% among those with duration < 5 years to 44.2% among those with duration > 30 years). In a supplementary sample of 161 diabetic patients aged 75 to 79 years (excluded from the main sample to prevent confusion between diabetes-induced and ageing-induced neuropathies), prevalence was 37.8%. Ninety-three patients (3.3%) had or had had foot ulcers and 21 of these 93 (0.7%) had undergone amputation; 90.8% of ulcerated patients had Type II diabetes, and 54% had DPN (in most cases with loss of perception of vibration), as against a prevalence of DPN of 19.9% among patients without ulcers. We conclude that nearly a quarter of Spanish diabetic patients have DPN; that over 90% of DPN patients have Type II diabetes; that the prevalence of DPN increases with age and with the duration of the disease, and that the risk of foot ulcers among DPN patients is about three times the risk among diabetic patients without DPN. We accordingly emphasize the responsibility of primary care physicians to try to prevent diabetic foot lesions by early diagnosis of DPN.     

Early detection of diabetes in visitors to a health fair according to new definition of diabetes

Based upon epidemiological studies it is assumed that the prevalence of diabetes mellitus is approximately 8 million patients in Germany. Since a significant increase of risk for diabetes and in parallel an increase of vascular and mortality risk was observed even with slight hyperglycaemia, the World Health Organization (WHO) and the American Diabetes Association (ADA) formulated new criteria for diagnosis in 1997. One way to record endangered and asymptomatic diabetic patients is to appeal for public health checks, propagated by mass media. During a public health day in Dresden, Germany, a simple examination of the state of health was carried out, including determination of the BMI, blood pressure, and blood glucose. As a result, in this population already selected already for health orientation (n = 513; 366 women, 147 men; age: 64.5 +/- 13.6, range: 7-97) 152 subjects (110 women, 42 men) were found with hyperglycaemia (capillary blood glucose between 6.1 and 11.1 mmol/l) who should be controlled regarding their plasma glucose levels, and 3 newly detected diabetic subjects (total of diabetic patients: 23 females/15 males) were discovered 50% of the participants had a BMI of over 25 kg/m2. Our results indicate that the possibilities for preventive checkups for subjects on risk and early diagnosis of diabetes mellitus should be offered on a much broader basis for the entire population.     

Determinants of the limits of agreement between the sphygmomanometer and the SpaceLabs 90207 device for blood pressure measurement in health volunteers and insulin-dependent diabetic patients

OBJECTIVE: To compare the limits of agreement between the SpaceLabs 90207 oscillometric blood pressure measurement device and the sphygmomanometer for patients with insulin-dependent diabetes mellitus (IDDM) versus healthy control subjects. DESIGN: A retrospective analysis of six simultaneous blood pressure measurements in 106 IDDM patients aged 32.6+/-12.0 years (mean +/- SD) and 92 healthy control subjects aged 27.1+/-8.9 years with the SpaceLabs device and a sphygmomanometer. RESULTS: For both groups, overestimation of the systolic blood pressure occurred with the SpaceLabs device, being more severe for the IDDM group (1.7 mmHg more overestimation, P= 0.009). Mean arterial blood pressure was underestimated for the control group and overestimated for the IDDM group (2.7 mmHg underestimation and 0.8 mmHg overestimation, respectively). Diastolic blood pressures for both groups were underestimated by use of the SpaceLabs device, but less severely so for the IDDM group (4.2 mmHg, P< 0.0001 less underestimation). Multiple regression analysis revealed that these differences were mainly due to the presence of diabetes. Other determinants of these limits of agreement were age (for control group subjects) and duration of diabetes (for IDDM group patients). CONCLUSION: Limits of agreement between the SpaceLabs 90207 device and the sphygmomanometer differ between IDDM patients and healthy controls. These limits are influenced by the presence of diabetes, age and duration of diabetes. Available protocols for the evaluation of automated blood pressure measurement devices of the British Hypertension Society and the Association for the Advancement of Medical Instrumentation do not consider limits of agreement in subpopulations such as diabetic patients. Therefore, we recommend that tests for the limits of agreement of blood pressure measurement devices for subgroups should be added to these protocols.     

Age and family relationship accentuate the risk of insulin-dependent diabetes mellitus (IDDM) in relatives of patients with IDDM

The international community of diabetologists is rapidly becoming involved in intervention trials aimed at preventing insulin-dependent diabetes in high risk relatives. Whereas age and relationship to a proband with insulin-dependent diabetes mellitus interacting with detected islet cell autoantibodies (ICA) are risk factors, their independent contribution to that risk remains unclear. In a prospective study of 6851 nondiabetic relatives of 2742 probands conducted between 1979-1993, we found age, but not relationship, to be a dramatic risk variable in ICA-positive persons as estimated by the Cox regression model. The 5-yr risk of insulin-dependent diabetes mellitus was 66% for those found to have ICA detectable before age 10 yr, falling progressively to less than 16% for ICA-positive relatives over age 40 yr. In ICA-negative relatives, age and relationship are independent prognostic variables.     

Diabetes and hypertension: the bad companions

DIABETES AND HYPERTENSION: Diabetes mellitus and hypertension are interrelated diseases that strongly predispose people to atherosclerotic cardiovascular disease. Hypertension is about twice as frequent in individuals with diabetes as in those without. The prevalence of coexisting hypertension and diabetes appears to be increasing in industrialized nations because populations are aging, and both hypertension and non-insulin-dependent diabetes mellitus (NIDDM) increase with age. An estimated 35-75% of diabetic cardiovascular and renal complications can be attributed to hypertension. ESSENTIAL HYPERTENSION: Essential hypertension accounts for the majority of hypertension in individuals with diabetes, particularly those with NIDDM, who constitute over 90% of those with a dual diagnosis of diabetes and hypertension. Diabetic nephropathy, which occurs after 15 years of diabetes in one-third of those with insulin-dependent diabetes and 20% of those with NIDDM, is an important contributing factor to the development of hypertension in the diabetic. New investigations should focus increasingly on identifying appropriate antihypertensive agents that not only lower blood pressure but also reduce cardiovascular risk and retard the rate of progression of diabetic renal disease.     

Mortality risk by body weight and weight change in people with NIDDM. The WHO Multinational Study of Vascular Disease in Diabetes

OBJECTIVE: Care guidelines for people with non-insulin-dependent diabetes mellitus (NIDDM) emphasize the importance of weight loss in reducing mortality risk. However, existing evidence regarding the relationship between weight and mortality and the effects of weight change is conflicting. We examined these relationships in the World Health Organization Multinational Study of Vascular Disease in Diabetes. RESEARCH DESIGN AND METHODS: This was a cohort study of 1,416 men and 1,544 women. Baseline examinations were performed in 1975 through 1977, a morbidity follow-up was performed in 1983, and a mortality follow-up continued until 1988. Data were analyzed according to geographical groups: Europeans, East Asians, and Native Americans. The relationship between weight change and mortality was analyzed for Europeans only. RESULTS: Generally, body mass index (BMI) was positively associated with age, blood pressure, and cholesterol but was negatively associated with duration of diabetes, prevalence of retinopathy, and use of insulin. There was no clear relationship between BMI and mortality across the geographical groups. In Europeans, weight loss in the leanest subjects at baseline (BMI < 26 kg/m2) was associated with a threefold increase in mortality risk compared with those who had maintained a steady weight (relative risk [RR] 3.05, 95% confidence interval [CI] 1.26-7.36). Only in the most obese group was weight loss associated with a reduction in mortality risk (BMI > 29 kg/m2, RR 0.84, 95% CI 0.40-1.74). CONCLUSIONS: The positive association of BMI with age, blood pressure, and cholesterol and the negative association with duration of diabetes, retinopathy, and use of insulin may explain why there is no strong relationship between BMI and mortality in NIDDM. Weight loss, particularly in the relatively lean diabetic person, may be associated with an increased mortality risk.     

Dynamic parameters of maternal amino acid metabolism and fetal growth

This study presents kinetic parameters of glycine metabolism during pregnancy and the influence of fuel availability on fetal growth. The kinetic studies were done on patients with gestational diabetes mellitus (diet treated) and pre-gestational diabetes mellitus (diet and insulin treated) that was accompanied by increased fetal growth and pregnancy-induced hypertension and, during the third trimester of pregnancy, by intrauterine growth retardation. Gas chromatography-mass spectrometry was used to determine the 15N enrichment of plasma glycine, and to calculate the pool sizes, turnover rate constants, fluxes and metabolic clearance rates. Glycine pool sizes in pre-gestational diabetes were significantly larger than those in normal, hypertensive and gestational diabetes pregnancies. Glycine turnover rate constants and metabolic clearance rates were not significantly different between the normal pregnant women, the hypertensive, and the two diabetic groups of pregnant women. Glycine fluxes were significantly higher in the pre-gestational diabetic pregnant women than in those with gestational diabetes, hypertension, and normal pregnancy. Pre-gestational diabetic pregnant women delivered fetuses with higher birthweights than the other three groups. Fetal birthweight of the hypertensive women was significantly lower than among the normal and diabetic women. Stable isotope methodology using labeled amino acids provides a powerful tool for clinical studies of maternal protein metabolism and its relationship to fetal growth.     

Role of an outpatient clinic in screening chronic complications of diabetes: a model for diabetes managed care

The purpose of this study was to evaluate the need for an outpatient clinic for screening chronic complications of diabetes mellitus and to explore the major risk factors for such complications. A total of 558 patients (293 men and 265 women, aged 61.4 +/- 10.0 yr) with non-insulin-dependent diabetes mellitus were recruited. All examinations were performed in all patients except for those with previously known complications. A nonmydriatic fundus camera was used to detect retinopathy. Microalbuminuria was detected with a semiquantitative method. A monofilament, semiquantitative tuning fork and neurometer were used to detect peripheral neuropathy. The relationships of demographic and metabolic factors with diabetic complications were analyzed. Among the 558 patients, 443 (79.3%) were found to have at least one chronic complication. Less than half (41.5%) of patients had been identified as having a complication(s) before screening. The rates of undiagnosed complications ranged from 46.7% to 83.4% for each complication. The duration of diabetes, hemoglobin A1c (HbA1c), and systolic blood pressure (BP) were strongly associated with microvascular complications (p = 0.009, 0.018 and 0.037, respectively). The microvascular complication rates reached a plateau when HbA1c reached 8.0% at least among patients with a systolic BP of less than 130 mmHg. Our findings indicate that undiagnosed complications (average, 58.5%) can be found with routine screening, increasing the chances for prompt attention and early intervention. The duration of diabetes, HbA1c, and systolic BP were strongly associated with microvascular complications. Diabetes care can be improved by the implementation of a screening clinic in daily practice. Identification of the specific risk factors in a defined population in specific clinical settings will allow early modification of interventions for optimal diabetes care.     

Ambulatory blood pressure measurement in type-II diabetic patients with autonomic neuropathy

The aim of our study was to access the 24-hr ambulatory blood pressure (BP) in diabetic patients with autonomic neuropathy (AN). Twenty-two NIDDM patients without hypertension, being treated with sulfonylureas, were studied. The 24-hr ambulatory blood pressure recordings were performed using portable non-invasive automatic system. Autonomic neuropathy was assessed by standard cardiovascular reflex tests. There were ten patients with and 12 without AN, matched for age, body mass index, duration of diabetes and glycemic control. Mean BP increased at night in four of the subjects with AN and decreased in the remaining 18 patients. The group of subjects with nocturnal increases in BP had more severe autonomic nerve dysfunction compared with those with decreases in nocturnal BP. No significant difference between clinical and ambulatory day-time measurements was found. In three patients with AN after 5 weeks intensified therapy. 24-hr BP did not show any significant difference.     

Microalbuminuria in non-insulin-dependent diabetes mellitus. Implications for renal survival

Microvascular and macrovascular disease cause considerable mortality and morbidity both among patients with non-insulin-dependent diabetes mellitus and those with insulin-dependent diabetes mellitus. Furthermore, non-insulin-dependent and insulin-dependent diabetes mellitus overlap in their pathogenesis as well as short- and long-term complications. In the diabetic patient, genetic susceptibility as well as other factors, ie, microalbuminuria, hypertension, high protein intake, blood glucose control, etc, ultimately culminate in a diffuse disease process, eg, diabetic vascular and/or renal disease. Early predictors of susceptibility for development of renal disease in diabetic subjects would help focus our treatment strategies. The role of microalbuminuria as a prognostic marker for the major complications of insulin-dependent diabetes mellitus has been previously reviewed. We reviewed the role of microalbuminuria as prognostic marker for progression of diabetic renal disease in subjects with non-insulin-dependent diabetes mellitus. We examined treatment strategies to lower microalbuminuria and its associated impact on disease progression.