Nephropathic Diabetic Patients Research Articles

Screening for Chronic Kidney Disease in Type 2 Diabetic Patients: Single Centre Study

Abstract Background Diabetes mellitus is the most common cause of chronic kidney disease in the world, leading to multiple complications including end-stage renal disease, cardiovascular disease and even death so, Screening is an important strategy to address the burden of CKD in diabetic population. International clinical guidelines recommend CKD screening for individuals with risk factors such as diabetes, using laboratory assessments of glomerular filtration rate (GFR) and urine albumin excretion. Objective This study describes the implementation and outcomes of screening programme for chronic kidney disease in type 2 diabetic patients to assess the burden of renal disease in diabetic population. Patients and Methods The present study included two hundred type 2 diabetic patients complicated with diabetic nephropathy. Fifty five percent of the studied patients were males. Age ranged from 42 to 82 years with mean ± SD of 60.09 ± 8.55 years. They were screened in Alagouza Hospital for CKD by using urinary ACR and average eGFR. Patients with CKD were further investigated for extrarenal diabetic complications as PVD, amputation and cardiovascular complications by using LL arterial duplex and echocardiography. Results As regard diabetic complications, nephropathy came in the 1st rank with 106 patients (53%) presented with either average eGFR<60 ml/min/1.73 m2(10.5%), ACR >30 mg albumin/gm creatinine (30%) or both(12.5%). That was followed by history of neuropathy which represented 44.5% of the studied patients. Retinopathy evidenced in fundus examination compromised about 34.516% out of our studied population. Patients with past history of stroke represented 17.5% of the studied population Peripheral neuropathy was more common in patients with nephropathy 69.7 % (n = 62) (4 patients with decline eGFR, 36 patients with albuminuria and 22 patients with both), compared to only 30.3 % (n = 27) non- nephropathic diabetic patients gave positive history of neuropathy. retinopathy was more common in patients with nephropathy (11 patients with declined GFR, 25 patients with albuminuria and 25 patients with albuminuria and declined GFR), versus only 8 patients in among the non-nephropathic diabetic patients had retinopathy evidenced in fundus examination. Stroke was more common among patients with nephropathy (4 patients with decline eGFR, 6 patients with albuminuria and 12 patients with albuminuria and declined eGFR), versus 13 patients with positive stroke history in non- nephropathic diabetic patients. Patients with nephropathy were further investigated for the presence of extra renal diabetic complications as PVD and cardiovascular complications. Arterial LL duplex revealed PVD in 32.1% (34 patients) with 3 patients underwent amputation. As regard cardiovascular complications, 17.9 % (19 patients) were found to have abnormal findings in echocardiography examination including heart failure and ischemic changes. Conclusion From our study, we showed the high burden of diabetic complications among the patients with type 2 diabetes especially renal diabetic complications. Therefore, screening of diabetic nephropathy in patients with type 2 diabetes mellitus can help in early treatment and avoid its more serious complications not only the progression to ESRD but also development of other extra-renal diabetic complications.

Biophysical and Immunological Characterization of Carbamylated-DNA: Serum Autoantibodies of Diabetic Nephropathy Patients Exhibit Strong Binding with Carbamylated-DNA

Isocyanates (ICN) have drawn considerable attention in recent past as they can react with a variety of nucleophiles including DNA, proteins and cause damage(s). However, pathophysiological implications resulting from the occupational and accidental exposures of ICN are yet too elusive. It may be produced in high concentrations in the conditions of chronic renal failure and chronic inflammatory diseases (diabetes mellitus, rheumatoid arthritis, etc.). In this study, mammalian dsDNA was modified with ICN and characterized by UV, fluorescence, FT-IR and thermal melting methods. ICN mainly reacts with exocyclic nitrogen of DNA bases. Antibodies against carbamylated-DNA were raised in rabbits and characterized by direct binding and inhibition ELISA. The presence of anti-carbamylated-DNA autoantibodies in the sera of diabetic nephropathy patients was evaluated by ELISA. Carbamylated-DNA exhibited hyperchromicity at 260 nm and depicted increase in ethidium bromide-assisted fluorescence as compared to the native DNA. Furthermore, the appearance of prominent new peaks in FT-IR profile at different wave numbers suggested carbamoylation-induced changes in the vibration of sugar-phosphate backbone, base(s) etc. Carbamylated-DNA was highly immunogenic as compared to the native DNA. Experimental induction of antibodies against carbamylated-DNA and presence of autoantibodies against carbamylated-DNA in the sera of diabetic nephropathic patients point towards the significance of carbamylated-DNA in diabetic nephropathy.

A comparitive study on levels of sirt 1 and antioxidant status in type 2 diabetic and diabetic nephropathic patients - A case control study

A comparitive study on levels of sirt 1 and antioxidant status in type 2 diabetic and diabetic nephropathic patients - A case control study

Relationship of cutaneous manifestations with inflammatory markers in diabetic nephropathic patients on haemodialysis

<p class="abstract"><strong>Background:</strong> Diabetic nephropathy is a serious life threatening complication of type-2 diabetes mellitus. Apart from severe kidney dysfunction these patients are prone to various cutaneous complications including psoriasis and eczema due to accumulated nitrogenous waste products. Inflammation is the basic cause of cutaneous complications and many inflammatory markers have been shown elevated in chronic kidney dysfunction. Hence a study has been planned to assess the levels of inflammatory markers such has C-reactive protein (CRP) and interlukin-6 (IL-6) as well as to correlate these markers with creatinine levels along with existing cutaneus complications.</p><p class="abstract"><strong>Methods:</strong> The study included 50 diabetic nephropathic patients undergoing regular heamodialysis. A heparanised blood sample was collected and plasma was employed for estimation of glucose, creatinine, CRP and IL-6. A detailed dermatological examination was done to record the cutaneous complications like pruritis, xerosis, hyper pigmentation and half & half nails.<strong></strong></p><p class="abstract"><strong>Results:</strong> The results show a significant raise in CRP and IL-6 levels in proportion to the severity of kidney dysfunction as reflected by creatinine levels. Also a positive relationship was observed between the inflammatory markers and multiplicity of cutaneous complications.</p><p class="abstract"><strong>Conclusions:</strong> It can be concluded from the present study that evaluation of inflammatory markers, CRP and IL-6 along with creatinine is beneficial in controlling cutanious complications in DN patients undergoing regular heamodialysis.</p>

Evaluation of procalcitonin levels in nephropathic and non- nephropathic diabetic patients

Amac : Nefropatisi olan ve olmayan diyabetli hastalarda serum prokalsitonin (PCT) duzeylerinin nasil etkilendigini arastirarak bu hastalarda PCT’nin bir enflamasyon gostergesi olup olamayacagini belirlemektir. Gerec ve Yontem : Calismaya 175 hasta [75 diyabetik nefropati (grup 1), 75 nefropatisi olmayan diyabetik (grup 2) ve 25 non-diyabetik nefropati (grup 3)] ve 75 saglikli gonullu dahil edildi. Hasta ve kontrol gruplarinin serum ve uriner kreatinin, serum high sensitive C-reaktif protein (hsCRP), PCT, beyaz kure, notrofil, HbA1c ve uriner protein degerleri elde edildi. Uriner protein/kreatinin orani ve eGFR hesaplandi. Bulgular : Grup 1, 2 ve 3 ile kontrol grubunun PCT degerleri (sirasiyla 0,20-0,19-0,23 ve 0,19) arasinda anlamli bir fark yoktu (p>0,05). Her 3 hasta grubunun hsCRP duzeyleri ise kontrol grubundan yuksekti (p 0,05). Sonuc : Diyabetli ve diyabetik nefropatili hastalarin PCT degerlerinde anlamli bir artis yoktu. Ancak PCT duzeyi ile GFR arasinda negatif korelasyon mevcuttu. Bu durum ozellikle ileri evre kronik bobrek hastaliginda, etiyolojik nedenden bagimsiz olarak PCT degerlerinde artis olabilecegini gostermektedir.

Evaluation of procalcitonin levels in diabetic and diabetic nephropathic patients

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Frequency of Type-2 diabetes mellitus in Nephropathic patients and comparison of mean magnesium levels in Nephropathic patients with and without Type-2 diabetes mellitus.

Objective:The objective of this study was to determine the frequency of Type 2 diabetes mellitus (T2DM) in patients with nephropathy (i.e. Chronic Kidney Disease Stage 1 to 3) and to compare the mean magnesium levels in diabetic nephropathic patients and non-diabetic nephropathic patientsMethods:This cross-sectional study was conducted in department of Medicine, Mayo Hospital Lahore from August 2014 to February 2015. Using non-probability purposive sampling 200 nephropathic (Chronic Kidney Disease Stage 1 to 3) patients were selected. Patients were assessed for T2DM and divided in two groups on the basis of presence or absence of DM. Magnesium levels were recorded in both groups. Percentages, mean, standard deviation and unpaired t-test was used to assess the data. SPSS was used for analysis of information.Results:Total number of cases were 200, 43.5% (n=87) out of them were between 25-50 years of age while 56.5% (n=113) patients were between 51-70 years. The Mean+SD was calculated to be 51.38+11.51 years. The male patients were 48.5 %(n=109) while 51.5 %(n=91) were females. The frequency of DM in patients with nephropathy was 25.5% (n=51). Comparison of mean magnesium levels in nephropathic patients with and without diabetes was done. The results showed nephropathic patients having diabetes had 1.54+0.301 mg/dL magnesium levels while cases without diabetes had 1.92+0.313 mg/dL levels of magnesium, p value was calculated as 0.001 showing a significant difference between the two groups.Conclusion:The frequency of diabetes mellitus is higher among patients with nephropathy while on comparison of mean magnesium levels, nephropathic patients with diabetes had significant lower levels of magnesium as compared to without diabetes.

Pharmacoeconomic evaluation of diabetic nephropathic patients attending nephrology department in a tertiary care hospital.

Aims:To evaluate the cost of pharmacotherapy and its determinants in diabetic nephropathy (DN) in the nephrology department of a tertiary care hospital.Materials and Methods:A prospective observational study was conducted among adult patients visiting nephrology outpatient department (February–July 2015). Data on demography, investigations, and medications prescribed, direct cost and indirect costs were analyzed. We used Chi-squared test for categorical variables and multivariate linear regression analysis to identify determinants of cost of pharmacotherapy and total cost.Results:Of 100 patients, 50 were above 60 years and 75 were male. Ninety-seven patients had hypertension, which was the most common comorbidity. The majority (60 patients) belonged to Stage 5 DN and 59 patients were on dialysis. The mean number of drugs per patient was 7.60 ± 2.44. The total monthly cost per patient amounted to INR 24,203.27 with total direct cost of INR 21,013.90 (87%) and indirect cost of INR 3189.30 (13%). The monthly cost of dialysis and pharmacotherapy per patient were INR 9060.00 (37%) and INR 2535.98 (11%), respectively. Stage of DN (unstandardized coefficient, B = 7553.96, 95% confidence interval [CI] [6175.09–8932.82], P < 0.001) was a significant determinant of total cost. Number of drugs (B = 636.694, 95% CI [335.670–937.718], P < 0.001) and stage of DN (B = 852.986, 95% CI [297.043–1408.928], P = 0.003) were predictors of cost of pharmacotherapy.Conclusion:Stage of DN and number of drugs prescribed were major determinants of cost of pharmacotherapy.

HYPOGLYCAEMIA

Objectives: Find out the hypoglycaemia in patients with diabetic nephropathicpatients. Study Design: Cross sectional study. Setting: National Institute of Diabetes &amp;Endocrinology at Dow University Hospital, Ojha Campus, Karachi. Duration of Study: For theperiod of one year, from October 2014 to November 2015. Methodology: Known “diabeticpatients” with nephropathy which were present at National Institute of Diabetes &amp; Endocrinology,Dow University Hospital, Ojha Campus, Karachi Patients presenting with signs and symptomsof hypoglycemia are diagnosed cases of “diabetes mellitus with nephropathy”, age 30 andabove, Type-I and type-Il diabetes mellitus, on oral hypoglycemic agents I insulin were includedin this study. Questions regarding the time period for which patient has been using these drugsand if the patient is suffering from illness which may be acute or chronic, should be askedregarding the relevant disease &amp; its association with hypoglycaemia be mentioned, &amp; patientsurine D/R &amp; Serum Creatinine &amp; Urea are measured by sending to the appropriate laboratory.Patients with severe malnutrition and starvation, chronic liver disease, alcoholics, chronicdisease as tuberculosis, patients with renal diseases without diabetes, any other malignancypatients were excluded from this study. Results: Depending upon the selection of 200 patients,the result concluded in our study consisted of 54% male patients and 46% were females, out ofwhich 11% had type I and diabetes and type II diabetics constituted 89%. Most of the patientsage between 60 to 75 years of age. The average duration of diabetes was 12.20 + 6.14 years.Out of 24 hypoglycaemic patients, 6 (25%) had type-I diabetes in which 4 were male and 2 wasfemale while 18 (75%) had type-II diabetes in which 10 were male and 8 were female patients.Conclusion: Observed that hypoglycaemia was common in diabetic patients, who developedrenal failure due to diabetic nephropathy.

Urinary Peptides as a Diagnostic Tool for Renal Failure Detected by Matrix-Assisted Laser Desorption/Ionisation Mass Spectrometry: An Evaluation of Their Clinical Significance

The development of new analytical methodologies related to the proteome for the evaluation of renal physiology and pathology is surely of wide interest for physicians, giving them new tools for monitoring complications associated with diabetes, such as end-stage renal disease. In the present study, the clinical significance of the urinary abundance of two peptides, SGSVIDQSRVLNLGPITR (the uromodulin precursor, m/z 1912) and IGPHypGPHypGLMGPP [present in the collagen-α-5(IV) chain precursor, m/z 1219], detected by matrix- assisted laser desorption/ionisation mass spectrometry (MALDI/MS) in microalbuminuric or nephropathic diabetic patients and in non-diabetic nephropathic patients was evaluated. A progressive increase in the abundance of the ion at m/z 1219 and a decrease in the abundance of the ion at m/z 1912 have been found in diabetic microalbuminuric, diabetic-nephropathic and nephropathic patients. Linear correlations are present between serum creatinine values and the abundances of the ions at m/z 1219 (positive correlation, r=0.3645, P<0.0001) and at m/z 1912 (negative correlation, r=-0.3053, P<0.0005). Correlations between the MALDI data and the estimated glomerular filtration rate were also found, while relationships with urinary albumin excretion were found only in sub-sets of patients. Analysis of receiver operating characteristic curves showed a sensitivity up to 96% and a specificity of up to 84% for the two ionic species, or their ratio, for distinguishing diabetic patients with different degrees of nephropathy from healthy subjects, proving that the urinary abundance of the two peptides at m/z 1219 and m/z 1912, determined with MALDI/MS, may be considered as a possible diagnostic tool for the determination of progression toward renal failure, also with the aim of monitoring kidney function, in diabetic patients.

Sieve‐based device for MALDI sample preparation. III. Its power for quantitative measurements

The solid sample inhomogeneity is a weak point of traditional MALDI deposition techniques that reflects negatively on quantitative analysis. The recently developed sieve-based device (SBD) sample deposition method, based on the electrospraying of matrix/analyte solutions through a grounded sieve, allows the homogeneous deposition of microcrystals with dimensions smaller than that of the laser spot. In each microcrystal the matrix/analyte molar ratio can be considered constant. Then, by irradiating different portions of the microcrystal distribution an identical response is obtained. This result suggests the employment of SBD in the development of quantitative procedures. For this aim, mixtures of different proteins of known molarity were analyzed, showing a good relationship between molarity and intensity ratios. This behaviour was also observed in the case of proteins with quite different ionic yields. The power of the developed method for quantitative evaluation was also tested by the measurement of the abundance of IGPP[Oxi]GPP[Oxi]GLMGPP (m/z 1219) present in the collagen-α-5(IV) chain precursor, differently expressed in urines from healthy subjects and diabetic-nephropathic patients, confirming its overexpression in the presence of nephropathy. The data obtained indicate that SBD is a particularly effective method for quantitative analysis also in biological fluids of interest.

The role of vascular endothelial growth factor in the progression of diabetic vascular complications

This study was planned to study the relationship between vascular endothelial growth factor (VEGF) as an angiogenic factor and different micro- and macrovascular complications in type II diabetic patients and look for a possible role of control on the serum level of VEGF. The study included 55 type II diabetic patients, 10 of them were not complicated with any of the vascular complications of type II diabetes mellitus (DM) (group 1), 21 patients had microvascular complication either retinopathy, nephropathy, or neuropathy (group 2), 14 patients had macrovascular complications either coronary artery disease or peripheral vascular disease (group 3), and 10 patients with mixed micro- and microvascular complications (group 4), as well as 15 healthy subjects served as control group. All subjects were subjected to complete clinical examination, including fundus examination, proper investigations with stress on electrocardiography, electromyography, nerve conduction velocity, Doppler study of the peripheral arteries, and laboratory investigations such as complete blood count, liver function test, serum creatinine, 24-h urinary albumin excretion, lipid profile, fasting and 2-h postprandial blood glucose, glycosylated haemoglobin (HbA(1c)), and serum VEGF. The study revealed that there was a highly significant increase in the serum VEGF in the diabetic patients compared with the control group. The P-value (P<0.001) was detected and there was also a highly significant increase in the serum VEGF in the patients with different micro- and macrovascular diabetic complications compared with uncomplicated diabetic group (P<0.001). A highly significant increase in the serum VEGF in diabetic patients with proliferative diabetic retinopathy was detected compared with non-proliferative diabetic retinopathy (40.55±8.28 vs20.3±2.45, P<0.001) and in diabetic nephropathic patients with macroalbuminuria compared with those with microalbuminuria (36.14±6.99 vs19.42±2.44, P<0.001). The reduction of the serum VEGF in a group of diabetic patients with poor control when their diabetic state was corrected through 4 months follow-up was highly significant (17.29±1.61 before vs9.39±0.82 after control P<0.001), as well as the reduction of the serum VEGF, which was observed in a group of patients with proliferative diabetic retinopathy (PDR) when proper pan retinal photocoagulation (PRP) was applied to their retinae with 4 months follow-up (40.55±8.28 before vs21.15±1.76 after PRP, P<0.001). On the other hand, the impact of some clinical and laboratory parameters of our diabetic patients on the serum VEGF revealed significant positive correlations between serum VEGF and age of the patients, duration of diabetes, systolic and diastolic blood pressure, body mass index, fasting and 2-h postprandial blood glucose, HbA(1c), serum creatinine, degree of albuminuria and total cholesterol, LDL, and platelet count. Serum VEGF was significantly increased in diabetic patients especially with micro- and macrovascular complications and the proper control of diabetes reduced the elevation of serum VEGF in uncontrolled diabetic patients, and in patients with PDR with proper PRP, indicating that VEGF is an angiogenic factor that reflects the degree of neovascularization in diabetic complications.

A further investigation on a MALDI‐based method for evaluation of markers of renal damage

The validity of the urinary protein profile to characterize the pathological states of diabetic, nephropathic and diabetic-nephropathic patients was considered on the basis of previously obtained results by MALDI/MS, showing a different abundance ratio of the collagen alpha1 and alpha5 chain precursor fragments at m/z 1219 and 2049 and of the uromodulin precursor fragment at m/z 1912 observed in healthy subjects and patients; a larger number of subjects was examined and the obtained results were statistically evaluated. The p values related to the observed differences indicate that they are statistically significant when comparing all patients versus healthy controls, diabetic with normo or microalbuminuria versus nephropathic with advanced renal disease patients and diabetic with normo or microalbuminuria versus diabetic with advanced nephropathy patients. The scatter plot matrix gives evidence of the strict inverse relationship between the abundances of ions at m/z 1912 and 1219, the correlation coefficient being particularly high (r = 0.921, p < 0.001). The relationship between the true positive rate (sensitivity) and false positive rate (1-specificity) for every possible cutoff value in abundance of the considered ionic species was investigated through the receiver-operating characteristic (ROC) curve. The obtained data indicate that a good differentiation of nephropathic patients with advanced renal disease and diabetic patients with advanced nephropathy versus healthy subjects can be easily obtained by this approach.

Low molecular weight proteins in urines from healthy subjects as well as diabetic, nephropathic and diabetic‐nephropathic patients: a MALDI study

Urine samples from healthy subjects as well as diabetic, nephropathic and diabetic-nephropathic patients were analyzed by matrix assisted laser desorption/ionization (MALDI) mass spectrometry in order to establish evidence of some possible differences in the peptide profile related to the pathological states. Multivariate analysis suggested the possibility of a distinction among the considered groups of patients. Some differences have been found, in particular, in the relative abundances of three ions at m/z 1912, 1219 and 2049. For these reasons, further investigation was carried out by MALDI/TOF/TOF to determine the sequence of these peptides and, consequently, to individuate their possible origin. By this approach, the peptide at m/z 1912 was found to originate from uromodulin, and its lower expression in the case of nephropathy can be well related to the pathological condition. Ions at m/z 2049 and 1219 originate from the collagen alpha-1(I) chain precursor and from the collagen alpha-5 (IV) chain precursor, respectively, and, also in this case, their different expressions can be related to the pathologies under investigation. The obtained data seem to indicate that urine is an interesting biological fluid to investigate on the peptide profile and to obtain, consequently, information on the dismetabolism activated by specific pathologies.

Diabetes, vascular complications and antiplatelet therapy: open problems

Diabetes mellitus is commonly associated with both microvascular and macrovascular complications (coronary artery disease, cerebrovascular events, severe peripheral vascular disease, nephropathy and retinopathy). There is wide evidence demonstrating that platelet degranulation and synthesis of TxA2 are increased in diabetic patients. For this reason, many studies on anti-platelet therapy have been made to reduce thrombotic complication of diabetes mellitus. Some diabetic patients, although treated with ASA, have a high prevalence of recurrent thrombotic events, which may presumably be due to an "ASA resistance". Nevertheless, this drug remains the one with the greatest benefit. To optimize its function, we should try to understand the causes of "aspirin resistance", try to find the most suitable dosage, recommending patients to comply constantly with the prescription given and to avoid interactions with other drugs. "Clopidogrel resistance" is a term not clearly defined. The clinical implications of "clopidogrel resistance" are unknown. An important consideration affecting the use of aspirin in diabetic patients is its interaction with ACE-inhibitors. Another question is antiplatelet therapy in nephropathic diabetic patients. Although these patients are at high thrombotic and haemorrhagic risk, they should nevertheless be considered eligible to undergo antithrombotic therapy, taking into account the individual's haemorrhagic risk.

Increased methionine sulfoxide content of apoA-I in type 1 diabetes

Cardiovascular disease is a major cause of morbidity and premature mortality in diabetes. HDL plays an important role in limiting vascular damage by removing cholesterol and cholesteryl ester hydroperoxides from oxidized low density lipoprotein and foam cells. Methionine (Met) residues in apolipoprotein A-I (apoA-I), the major apolipoprotein of HDL, reduce peroxides in HDL lipids, forming methionine sulfoxide [Met(O)]. We examined the extent and sites of Met(O) formation in apoA-I of HDL isolated from plasma of healthy control and type 1 diabetic subjects to assess apoA-I exposure to lipid peroxides and the status of oxidative stress in the vascular compartment in diabetes. Three tryptic peptides of apoA-I contain Met residues: Q(84)-M(86)-K(88), W(108)-M(112)-R(116), and L(144)-M(148)-R(149). These peptides and their Met(O) analogs were identified and quantified by mass spectrometry. Relative to controls, Met(O) formation was significantly increased at all three locations (Met(86), Met(112), and Met(148)) in diabetic patients. The increase in Met(O) in the diabetic group did not correlate with other biomarkers of oxidative stress, such as N(epsilon)-malondialdehyde-lysine or N(epsilon)-(carboxymethyl)lysine, in plasma or lipoproteins. The higher Met(O) content in apoA-I from diabetic patients is consistent with increased levels of lipid peroxidation products in plasma in diabetes. Using the methods developed here, future studies can address the relationship between Met(O) in apoA-I and the risk, development, or progression of the vascular complications of diabetes.

Natural history and prognostic factors of diabetic nephropathy in type 2 diabetes.

The causes and mechanisms of increased mortality of patients with diabetic nephropathy are unclear, and its natural history is poorly understood. To evaluate risk factors for mortality in type 2 diabetic patients with nephropathy. Retrospective study of clinical and biochemical parameters in diabetic nephropathic patients and controls sampled from a secondary care register. We studied 170 type 2 diabetic patients (from 1987 to 1995) with nephropathy (proteinuria >0.5 g/24 h) and 170 non-nephropathic patients. Follow-up was until death or December 1997. Details of demographics, clinical and treatment history were obtained from medical records. Mean follow-up was 5.3 years. Of the patients with nephropathy at baseline, 63 (37%) died compared with 14 (8%) non-nephropathic patients (chi(2)=53.8, p<0.0001). Age- and sex-adjusted all-cause mortality rates were 8.1 (6.4, 9.8) and 1.4 (0.5, 2.2) deaths per 100 person-years, respectively (rate ratio 5.8). Forty-four patients (57%) died from cardiovascular causes (rate ratio 5.4). Mortality was directly proportional to degree of proteinuria: 0.5-2 g/24 h, 4.6 (2.9-7.1); >2 g/24 h, 9.9 (7.3-13.5) per 100 patient-years. A 36% (5-78%) excess risk of mortality was observed for each log unit increase in proteinuria. Multivariate Cox regression analyses confirmed a five-fold excess risk for all-cause and cardiovascular mortality in patients with nephropathy compared with those without. This was independent of other risk factors including baseline age [5% (1-8%)/year], creatinine [2.5 (1.12-5.6)/10 micromol/l] and glycaemic control (HbA(1c)) [15% (1-31%) per 1% rise]. Proteinuria is a potentially preventable and reversible risk factor associated with high mortality in type 2 diabetic patients. Prevention of the development of overt nephropathy and improvement in diabetes control may reduce mortality in these patients.

Enhanced in situ expression of aldose reductase in peripheral nerve and renal glomeruli in diabetic patients

To explore the relationships between polyol pathway‐related enzymes and pathologic features, we examined the immunohistochemical expression of aldose reductase (AR) and sorbitol dehydrogenase (SDH) in the peripheral nerve and kidney tissues collected postmortem from diabetic patients and compared it with those from non‐diabetic patients. Tissue AR protein concentrations were also quantified. In non‐diabetic patients, AR distributed in pericytes, smooth muscle cells of endo‐and epi‐neurial microvessels, Schwann cells in the sciatic nerve, and tubular cells of the renal medulla. By contrast, positive SDH reactions were observed in tubular cells of the renal cortex but were faint in the sciatic nerve. Diabetic patients frequently showed dense AR expressions in the sciatic nerve. In nephropathic diabetic patients, the glomerular mesangial area showed diffuse positive reactions for AR. The severity of structural changes in glomeruli correlated with the intensity of immunoreactive AR (r(2)=0.626. P &lt;0.01). AR contents in the renal cortex and sciatic nerve from diabetic patients were 1.5‐ and 1.8‐fold greater than those from non‐diabetic patients, respectively (P &lt;0.05 for both). These findings are the first to demonstrate enhanced AR expressions in peripheral nerve and renal glomeruli in diabetic patients and its relevance to the characteristic pathology.

Enhanced in situ expression of aldose reductase in peripheral nerve and renal glomeruli in diabetic patients.

To explore the relationships between polyol pathway-related enzymes and pathologic features, we examined the immunohistochemical expression of aldose reductase (AR) and sorbitol dehydrogenase (SDH) in the peripheral nerve and kidney tissues collected postmortem from diabetic patients and compared it with those from non-diabetic patients. Tissue AR protein concentrations were also quantified. In non-diabetic patients, AR distributed in pericytes, smooth muscle cells of endo- and epi-neurial microvessels, Schwann cells in the sciatic nerve, and tubular cells of the renal medulla. By contrast, positive SDH reactions were observed in tubular cells of the renal cortex but were faint in the sciatic nerve. Diabetic patients frequently showed dense AR expressions in the sciatic nerve. In nephropathic diabetic patients, the glomerular mesangial area showed diffuse positive reactions for AR. The severity of structural changes in glomeruli correlated with the intensity of immunoreactive AR (r2=0.626, P<0.01). AR contents in the renal cortex and sciatic nerve from diabetic patients were 1.5- and 1.8-fold greater than those from non-diabetic patients, respectively (P<0.05 for both). These findings are the first to demonstrate enhanced AR expressions in peripheral nerve and renal glomeruli in diabetic patients and its relevance to the characteristic pathology.

Analysis of the HNF4 alpha gene in Caucasian type II diabetic nephropathic patients.

Linkage and association studies in Caucasian patients with Type II (non-insulin-dependent) diabetes mellitus suggest that one or more diabetes susceptibility gene(s) reside within human chromosome 20q12-13.1. This region of chromosome 20 contains the maturity-onset diabetes of the young type 1 gene, HNF4 alpha. The purpose of this study was to assess the possible involvement of HNF4 alpha in Type II diabetes. Mutation analysis was done on the 12 exons and promoter regions of the HNF4 alpha gene in 182 Caucasian diabetic nephropathic patients and 100 Caucasian control subjects. The functional consequences of a novel promoter mutation were examined using a reporter system in the HepG2 liver cell line and electrophoretic mobility shift assays. We identified two novel mutations in the HNF4 alpha, an R323H missense mutation in exon 8, and a 7 bp deletion (delta 7) in the proximal promoter region resulting in deletion of a single putative Sp1 binding site. Using a reporter assay system, the delta 7 sequence was found to exhibit a 51.2% (standard error +/- 4.2%) reduction in promoter activity relative to the normal sequence. In electrophoretic mobility shift assays using specific and non-specific competitors, the delta 7 sequence had a 45.5% (range 40.4-46.6) reduction in binding compared with the normal sequence. The delta 7 allele occurs in a family with multiple cases of Type II diabetes in a pattern consistent with coinheritance of the delta 7 allele and diabetes. Analysis of the HNF4 alpha gene revealed two possible mutations in 182 diabetic patients which suggests that the HNF4 alpha gene does not make a large contribution to diabetes susceptibility in the general population of Caucasian diabetic nephropathic patients. Functional analysis of the delta 7 promoter deletion suggests, however, that promoter mutations in otherwise normal genes could contribute to diabetes susceptibility.