自主神经功能对糖尿病患者24小时动态血压和心率的影响

采用２４小时动态心电图和血压同步监测７５例糖尿病患者和３５例正常对照组。结果显示：随ＳＤＮＮ（２４小时内全部正常Ｒ－Ｒ间期的标准差）的降低，糖尿病患者的２４小时平均血压和心率、白昼收缩压和心率，夜间血压和心率均明显递增，昼夜血压差和心率差递减；２４小时血压波动曲线由类似双峰双谷逐渐变为失去正常节律，且夜间血压高于白昼的血压曲线；视网病变和肾病的发生率也随之增高，结论：糖尿病患者高血压的发生、发展和     

Impaired short-term blood pressure regulation and autonomic dysbalance in children with type 1 diabetes mellitus

Aims Because reduction in baroreceptor sensitivity (BRS) has been associated with hypertension in the normal population and with increased cardiovascular morbidity and mortality in patients with diabetes mellitus, we measured BRS in a patient cohort of children with type 1 diabetes mellitus. Methods Two hundred and eight children (150 patients with type 1 diabetes mellitus, mean age 13.9 ± 2.8 years, 70 boys, mean HbA_1c 7.8 ± 1.4%; and 58 healthy controls, mean age 14.1 ± 3.1 years, 32 boys) were studied. BRS and heart rate variability (HRV) were analysed from a short-time ECG and BP recording using the sequence method (BRS) and the frequency domain method (HRV). Results There were 111 of 150 patients (74%) and 5 of 58 controls (8.6%) that showed impaired BRS. Mean BRS differed significantly between patients and controls (18.4 ± 7.2 vs 25.8 ± 8.2 ms/mm, p < 0.001). BRS correlated inversely with systolic BP (r = −0.23, p = 0.009) and was related to diabetes duration (r = −0.194, p = 0.027). Analysis of HRV showed greater sympathetic and less parasympathetic influence in patients than in controls (low frequency/high frequency ratio 1.3 ± 0.8 vs 0.9 ± 0.6, p < 0.05); the low frequency/high frequency ratio was inversely correlated with BRS (r = −0.28, p = 0.001). Conclusions/interpretation Diabetic children show reduced BRS. In our patient group, the single risk factor for this finding was found to be the disease duration. The degree of BRS impairment was related to the degree of autonomic dysbalance. R. Dalla Pozza and S. Bechtold contributed equally to this study.     

Relationship of progressively increasing albuminuria to apoprotein(a) and blood pressure in Type 2 (non-insulin-dependent) and Type 1 (insulin-dependent) diabetic patients

Summary This study has explored the temporal relationship between apoprotein(a), blood pressure and albuminuria over a mean interval of 11 years in a cohort of 107 diabetic patients of whom 26 (14 Type 2 (non-insulin-dependent), 12 Type 1 (insulin-dependent) had progressively increasing albuminuria (‘progressors’). In Type 2 diabetic patients, no significant differences were noted for HbA₁, blood pressure, creatinine clearance or serum lipids between progressors and non-progressors. In Type 1 diabetic patients, final systolic and diastolic blood pressures were higher in progressors compared with non-progressors and progressors showed impairment of renal function in association with a rise in blood pressure at the macroalbuminuric stage. Initial apoprotein(a) levels were similar in progressors and non-progressors of either diabetes type. Apoprotein(a) levels increased exponentially with time in 12 of 14 Type 2 progressors but only in 5 of 12 Type 1 progressors (p<0.01). In Type 2 diabetic patients, the annual increase in apoprotein(a) levels was 9.1±2.4%, which was significantly greater than in non-progressors, 2.0±1.2% (p<0.01) and also exceeded the rates of increase of apoprotein(a) in progressors with Type 1 diabetes, 4.0±1.4%, (p<0.05). Apoprotein(a) levels correlated significantly with albuminuria in 8 of 14 Type 2 progressors but only in 3 of 12 Type 1 progressors (p<0.05). The rate of increase of apoprotein(a) levels was not related to mean HbA₁, creatinine or creatinine clearance levels, or to albuminuria. The rate of rise of apoprotein(a) was not influenced by initial apoprotein(a) levels, suggesting that specific apoprotein(a) isoforms do not influence albuminuria-related increases in apoprotein(a). The data are consistent with the hypothesis that apoprotein(a) levels increase in response to albuminuria and may be part of a self-perpetuating process. This study also suggests that increases in apoprotein(a) levels commence during the microalbuminuria stage in diabetic patients, which is earlier than has been documented in non-diabetic proteinuria.     

Assessment of blood pressure in patients with Type 2 diabetes: comparison between home blood pressure monitoring, clinic blood pressure measurement and 24-h ambulatory blood pressure monitoring.

AIMS: To compare a home blood pressure (BP) monitoring device and clinic BP measurement with 24-h ambulatory BP monitoring in patients with Type 2 diabetes mellitus (DM). METHODS: Fifty-five patients with type 2 DM had BP measured at three consecutive visits to the DM clinic by nurses using a stethoscope and mercury sphygmomanometer (CBP). Twenty-four-hour ambulatory BP was measured using a Spacelabs 90207 automatic cuff-oscillometric device (ABPM). Subjects were then instructed in how to use a Boots HEM 732B semiautomatic cuff-oscillometric home BP monitoring device and measured BP at home on three specified occasions on each of 4 consecutive days at varying times (HBPM). RESULTS: Correlations between HBPM and ABPM were r = 0.88, P < 0.001 for systolic BP and r = 0.76, P < 0.001 for diastolic BP, with correlations between CBP and ABPM being systolic r = 0.59, P < 0.001, diastolic r = 0.47, P < 0.001. HBPM agreed with ABPM more closely compared with CBP (CBP +10.9/+3.8 (95% confidence intervals (CI) 6.9, 14.8/1.6, 6.1) vs. HBPM +8.2/+3.7 (95% CI 6.0, 10.3/2.0, 5.4)). The sensitivity, specificity and positive predictive value of HBPM in detecting hypertension were 100%, 79% and 90%, respectively, compared with CBP (85%, 46% and 58%, respectively). CONCLUSIONS: In patients with Type 2 DM, home BP monitoring is superior to clinic BP measurement, when compared with 24-h ambulatory BP, and allows better detection of hypertension. It would be a rational addition to the annual review process. Diabet. Med. 18, 431-437 (2001)     

糖尿病患者心自主神经系统功能与24 小时动态血压变化关系的探讨

目的 探讨偶测血压正常的糖尿病（ＤＭ）患者心自主神经系统功能（ＡＮＳＦ）状况与２４小时动态血压（２４小时ＡＭＢＰ）的变化关系。方法 对例偶测血压正常的ＤＭ患者进行心率功率谱分析及２４小时ＡＭＢＰ检测。结果 无压力负荷发生率明显高于正常对照组,而昼夜改变百分率明显低于正常对照组,伴工ＡＮ的ＤＭ患者,其２４小时动态收缩压及２４小时ＡＭＢＰ负荷发生率高一伴轻度ＡＮ的ＤＭ患者,昼夜改变百分率低于伴轻度ＡＮ     

Autonomic nerve function in adolescents with Type 1 diabetes mellitus: relationship to microalbuminuria.

AIMS: Thirty adolescent patients with Type 1 diabetes mellitus and microalbuminuria were studied for evidence of early autonomic neuropathy. METHODS: Using tests involving cardiovascular and pupillary reflexes, the adolescents were compared with a normoalbuminuric group of patients with diabetes, who were matched for age, sex, puberty and duration of diabetes. RESULTS: There was an increased prevalence of autonomic nerve dysfunction in the patients with microalbuminuria. These patients had higher resting heart rates (86 beats/min in the microalbuminuric group vs. 77 beats/min in normoalbuminuric controls, P = 0.002), and impaired pupillary dilatation in darkness (pupillary diameter % 56.5% vs. 62.5%, P = 0.003). Patients with microalbuminuria also had poorer long term glycaemic control (mean HbA1C 8.7% vs. 7.8%, P = 0.002) and higher blood pressures (systolic 125 vs. 116 mmHg, P = 0.001; diastolic 69 vs. 62 mmHg, P = 0.0001; mean arterial pressure 90 vs. 83 mmHg, P = 0.002) than those with normal urinary albumin excretion. CONCLUSIONS: Microalbuminuria and autonomic nerve dysfunction co-exist in patients with Type 1 DM. Longitudinal studies will determine whether these findings have implications for the identification of patients at higher risk of progression of early renal complications.     

Effects of smoking on 24-h ambulatory blood pressure and autonomic function in normoalbuminuric insulin-dependent diabetes mellitus patients

Smoking is an important risk factor for the development and progression of diabetic nephropathy. The mechanisms by which smoking increases albuminuria and promotes nephropathy are unknown. Considering the acute pressor effect of smoking and the close association between blood pressure elevation and development of diabetic nephropathy, blood pressure increase might be implicated in the association between smoking and diabetic nephropathy. However, among nondiabetics, smokers have repeatedly been found to have lower blood pressure than nonsmokers. This is possibly mediated by an autonomic adjustment to sustained sympathetic stimulation by nicotine. Impaired modulation of the sympathovagal activity has been described in diabetes. In diabetic patients, the effect of smoking on blood pressure and autonomic function remains unclarified. We examined 24-h ambulatory blood pressure (oscillometric technique) and autonomic function (short-term power spectral analysis as well as conventional tests) in 24 smokers and 24 nonsmokers matched for sex, age, and diabetes duration. All patients were normoalbuminuric insulin-dependent diabetes mellitus patients. Smoking status was assessed by questionnaire with confirmatory determinations of urinary cotinine. Diabetic smokers had significantly higher 24-h mean arterial blood pressure (94 ± 6.7 mm Hg compared to diabetic nonsmokers 90 ± 5.8 mm Hg, P = .04) including higher diastolic nighttime blood pressure (68 ± 7.3 mm Hg v 64 ± 5.2 mm Hg, P = .03). Smokers also had significantly higher 24-h heart rate (80 ± 7.2 compared to 72 ± 9.2 beats/min, P < .001). In addition, smoking was associated with significantly reduced short-term RR interval variability (supine low frequency component) (5.45 ± 1.29 ln ms² in smokers compared to 6.31 ± 1.11 ln ms² in nonsmokers, P < .02), as well as reduced brake index (33.5 ± 14.5 in smokers v 42.1 ± 16.0 in nonsmokers, P < .05). Diabetic smokers have significantly higher 24-h blood pressure compared to diabetic nonsmokers. This finding, contrasting the effect of smoking among nondiabetics, is possibly mediated by coexisting abnormal postural responses in autonomic cardiac regulation in diabetic smokers. Blood pressure elevation, persisting throughout 24 h, might be operative in the association between smoking and development of diabetic nephropathy.     

Enhanced albuminuric response to atrial natriuretic peptide in normoalbuminuric patients with Type 1 diabetes mellitus--a pilot study.

AIMS: To ascertain whether intravenous infusion of atrial natriuretic peptide (ANP) can induce microalbuminuria in patients with Type 1 diabetes mellitus (DM), as already demonstrated in patients with microalbuminuria, and to compare the albuminuric response to ANP infusion in Type 1 DM and a matched group of healthy non-diabetic controls. METHODS: Eight normoalbuminuric DM patients participated in a three limb, randomized, double-blind, placebo-controlled study. Subjects were kept euglycaemic by insulin infusion, and subsequently water-loaded (20 ml/kg orally plus urinary losses). When in steady state, a 30-min infusion of either placebo, ANP 0.025 mg x kg(-1).min(-1) or ANP 0.05 mg x kg(-1) x min(-1) was administered intravenously. Urine was collected every 15 min for 90 min for the estimation of albumin-creatinine ratio (ACR). In addition, eight nondiabetic volunteers received a single infusion of ANP 0.025 mg x kg(-1) x min(-1). RESULTS: ACR was unaltered by placebo in DM subjects (1.4 +/- 0.7-1.7 +/- 1.1 mg/mmol, mean +/- SD, ANOVA, P > 0.9), and by low dose ANP in controls (1.4 +/- 0.9-2.6 +/- 1.9 mg/mmol, P = 0.4). ACR increased with low dose ANP (1.3 +/- 0.5-14.6 +/- 13.6 mg/mmol, P = 0.02), and high dose ANP (1.3 +/- 0.7-26.4 +/- 31 mg/mmol, P = 0.01) in DM subjects. The ACR response to low dose ANP was greater in the DM than control subjects (P = 0.02). CONCLUSIONS: ANP increases urine albumin excretion rate in normoalbuminuric Type 1 DM patients, and this effect is more pronounced than in healthy volunteers.     

24-h blood pressure and autonomic function is related to albumin excretion within the normoalbuminuric range in IDDM patients

Summary Significant changes in both blood pressure, autonomic function and kidney ultrastructure are observed in insulin-dependent diabetic (IDDM) patients with microalbuminuria. Intervention strategies are evaluated at even earlier stages of disease. Identification of patients at risk of developing microalbuminuria must be based on a thorough knowledge of the relations between key pathophysiological parameters in patients with normoalbuminuria. The aim of the present study was to characterize the interactions of urinary albumin excretion (UAE), 24-h ambulatory blood pressure (AMBP), and sympathovagal balance in a large group of normoalbuminuric IDDM patients. In 117 normoalbuminuric (UAE < 20 μg/min) patients we performed 24-h AMBP (Spacelabs 90 207), with assessment of diurnal blood pressure and heart rate (HR) variation, and short-term (three times 5 min) power spectral analysis of RR interval oscillations, as well as cardiovascular reflex tests (HR variation to deep breathing, postural HR and blood pressure response). Patients with UAE above the median (4.2 μg/min) had significantly higher 24-h systolic and diastolic AMBP (125 ± 10.1/76 ± 7.2 mmHg) compared to the low normoalbuminuric group (120 ± 8.4/74 ± 5.1 mmHg), p < 0.01 and 0.02, respectively. Patients with UAE above the median had significantly reduced short-term RR interval variability including both the high frequency component (5.47 ± 1.36 vs 6.10 ± 1.43 ln ms²), and low frequency component (5.48 ± 1.18 ln ms² compared to 5.80 ± 1.41 ln ms²), p < 0.02 and p = 0.04 (ANOVA). In addition, patients with high-normal UAE had reduced mean RR level (faster heart rates) 916 ± 108 compared to 963 ± 140 ms, p < 0.04. These differences were not explained by age, duration of diabetes, gender, level of physical activity, or cigarette smoking. HbA_{1 c} was significantly higher (8.6 ± 1.2 vs 8.2 ± 1.0 %, p = 0.03) in the group with high normal UAE. Comparing normoalbuminuric IDDM patients with UAE above and below the median value, we found significantly higher AMBP in combination with significant differences in sympathovagal balance and significantly poorer glycaemic control in the group with high-normal albumin excretion. Our data demonstrate interactions between albumin excretion, blood pressure, autonomic function, and glycaemic status, already present in the normoalbuminuric range and may describe a syndrome indicative of later complications. [Diabetologia (1997) 40: 718–725] Received: 9 January 1997 and in revised form: 12 March 1997     

NIDDM患者自主神经病变,动态血压与尿白蛋白排泄率的关系

目的 探讨ＮＩＤＤＭ患者自主神经病变与糖尿病肾病的关系。方法 测定了６８例ＮＩＤＤＭ患者的ＨｂＡｌｃ,血脂,２４小时动态血压,尿白蛋白排泄率及自主神经功能。以健康对照心率功能谱变量９５％可信区间作为ＡＮＦ正常参考值,将ＮＩＤＤＭ患者分成伴ＡＮ和无ＡＮ组。结果 伴ＡＮ患者血压,心率,ＵＡＥＲ２４小时均值显著高于无ＡＮ组,其昼夜变异率显著低于ＡＮ组,且伴ＡＮ患者血压和相应ＵＡＥＲ相关性更好。     

24-h ambulatory blood pressure and retinopathy in normoalbuminuric IDDM patients

Summary The role of blood pressure elevation in the incidence and progression of diabetic retinopathy is not clearly established and results have been conflicting. Blood pressure and urinary albumin excretion (UAE) are closely related. In order to evaluate the independent relationship between retinopathy and blood pressure elevation, precise information on UAE is essential, as confounding by renal disease (incipient or overt), cannot otherwise be excluded.The aim of the present study was to evaluate the association between diabetic retinopathy and 24-h ambulatory blood pressure (AMBP) in a group of well-characterized normoalbuminuric IDDM patients. In 65 normoalbuminuric (UAE < 20 μg/min) IDDM patients we performed 24-h AMBP (Spacelabs 90 207) with readings at 20-min intervals. Fundus photographs were graded independently by two experienced ophthalmologists. UAE was measured by RIA and expressed as geometric mean of three overnight collections made within 1 week. HbA_{1 c} was determined by HPLC. Tobacco use and level of physical activity were assessed by questionnaire. Fifteen patients had no detectable retinal changes [grade 1], 35 had grade 2 retinopathy; and 15 had more advanced retinopathy [grade 3–6]. Diastolic night blood pressure was significantly higher in patients with diabetic retinopathy compared to patients without retinopathy (68 ± 8 mmHg [grade 3–6] and 65 ± 6 mmHg [grade 2], compared to 61 ± 4 mmHg [grade 1], p = 0.02). Diurnal blood pressure variation was significantly blunted in the patients with retinopathy as indicated by a higher night/day ratio of diastolic blood pressure (84.6 % ± 4 [grade 3–6], and 81.2 % ± 6 [grade 2] compared to 79.1 % ± 4 [grade 1], p = 0.01). Heart rate tended to be higher in patients in group 2 and 3–6 compared to patients without retinopathy with p values of 0.07 and 0.11 for day-time and 24 h values, respectively. Mean HbA_{1 c} increased significantly with increasing levels of retinopathy (p < 0.01). Patients were similar regarding sex, age, tobacco use, and level of physical activity. Notably, UAE was almost identical in the three groups (5.0 × /÷1.7 [grade 1], 3.9 × /÷1.8 [grade 2], and 5.1 × /÷1.6 μg/min [grade 3–6]). In conclusion, night blood pressure is higher and circadian blood pressure variation blunted in patients with retinopathy compared to patients without retinopathy despite strict normoalbuminuria and similar UAE levels in the groups compared. Our data suggest that the association between blood pressure and diabetic retinopathy is present also when coexisting renal disease is excluded. Disturbed diurnal variation of blood pressure is a pathophysiological feature related to the development of both retinopathy and nephropathy in IDDM patients. [Diabetologia (1998) 41: 105–110] Received: 27 May 1997 and in revised form: 5 September 1997     

Ambulatory blood pressure and heart rate in diabetic patients: an assessment of autonomic function

In order to examine the physiological variation in blood pressure and heart rate that occurs during normal activities in patients with diabetes, 24-h profiles were constructed from continuous ambulatory recordings. Isometric and dynamic tests were also performed. The patients were subdivided into 25 uncomplicated cases, 11 with peripheral neuropathy and 6 with autonomic neuropathy. These were compared with a 'control' group of 22 normal subjects. Abnormal 24-h blood pressure profiles were found particularly in the patients with autonomic neuropathy. This group had attenuation or reversal of the usual diurnal rhythm, blood pressure often rising during the night and falling in the early morning. Diurnal heart rate variation was reduced in all three groups of patients. Blood pressure responses to both forms of exercise were also significantly reduced in the autonomic neuropathy group (maximum change in systolic blood pressure during isometric exercise was 10 +/- 4 mmHg vs 36 +/- 3 mmHg in the control group, p less than 0.003). Patients with peripheral neuropathy also had some impairment of exercise-induced blood pressure changes, but to a lesser degree.     

Day and night variation in ambulatory blood pressure in type 1 diabetes mellitus with nephropathy and autonomic neuropathy

Abstract. The objective was to study ambulatory blood pressure and heart rate variability between day and night in patients with type 1 (insulin-dependent) diabetes mellitus with different degrees of diabetic nephropathy, and to evaluate the influence of autonomic neuropathy and type of antihypertensive treatment. Twenty type 1 diabetic patients with diabetic nephropathy and antihypertensive treatment were studied with 24-h ambulatory blood pressure monitoring using an oscillometric method. They were compared with eight insulin-treated diabetic patients with short duration of diabetes (1–5 years) and with 10 apparently healthy subjects. The degree of autonomic neuropathy was evaluated by measuring the RR-interval during deep breathing and uprising. The 24-h blood pressure was generally higher in patients with diabetic nephropathy compared to those other two groups. These patients also had a lower ratio between day and night in diastolic blood pressure compared to the control subjects (1.15 ± 0.12 vs. 1.25 ± 0.76, P < 0.05) and heart rate compared to the diabetic patients without nephropathy, as well as the control subjects (1.15 ± 0.08 vs. 1.26 ± 0.09 vs. 1.27 ± 0.08, P < 0.01, respectively). All patients with diabetic nephropathy had clinical signs of autonomic neuropathy as judged by RR-interval measurements during deep breathing and uprising.     

1型糖尿病患儿生长障碍与甲状腺功能及皮质醇变化的关系研究

目的　探讨 1型糖尿病 (T1DM)患儿生长障碍与甲状腺功能及皮质醇变化的关系。方法　 1用化学发光免疫法检测 30例 T1DM患儿 (T1DM组 )及 4 1例正常儿童 (对照组 )的 T3、T4 、TSH、FT3、FT4 及皮质醇 ;用放射免疫法检测两组抗甲状腺球蛋白抗体 (TG- Ab)及抗甲状腺微粒体抗体 (TM- Ab) ,并进行比较。2比较两组间各指标的差异。3分析 T1DM患儿 TSH与生长速度 (GV)、皮质醇与空腹血糖的相关性。结果　 1T1DM组 T3、 T4 、 FT3均较对照组显著降低 ,TSH、皮质醇、 TG- Ab及 TM- Ab均较对照组显著升高。2 T1DM组 TSH、 TG- Ab及 TM- Ab异常率最高 ,但与其他指标异常率无显著性差异。3T1DM组 TSH与 GV呈负相关(r=- 0 .4 14 ,P>0 .0 5 )。4 T1DM组皮质醇与空腹血糖呈正相关 (r=0 .73,P<0 .0 5 )。结论　 1T1DM患儿可并发桥本病。2 T1DM患儿生长障碍的部分原因与甲状腺功能低下及皮质醇升高有关。     

Altered hand skin blood flow in type 1 (insulin-dependent) diabetes mellitus

Disturbed upper limb skin blood flow has been described in insulin-dependent (Type 1) diabetes mellitus, but the pathophysiological mechanism remains unclear. Hand skin blood flow was therefore measured at room temperature and following immersion of hands in cold and warm water in 13 healthy control subjects, in 10 patients with Type 1 diabetes mellitus and cardiovascular autonomic neuropathy, and a further 10 Type 1 diabetic patients with normal cardiovascular autonomic tone. Following cold challenge there was failure of digital artery clampdown in all diabetic patients in comparison with healthy control subjects (p less than 0.005), and the index finger temperature fell less (p less than 0.05). Laser Doppler flow was reduced at the palms at room temperature or following the warm challenge (p less than 0.008), as well as on the dorsum at room temperature (p less than 0.05), in all diabetic patients. In addition laser Doppler flow in the diabetic patients was reduced at the palms and dorsum immediately following cold water challenge (p less than 0.004) and this reduction persisted 15 min (p less than 0.05) and 30 min (p less than 0.01) into the recovery phase. In comparison to those diabetic patients with normal cardiovascular tone, those with cardiovascular autonomic neuropathy had reduced laser Doppler flow at the pulp 15 min after cold water immersion (p less than 0.05), at the nailbed immediately after cold water immersion (p less than 0.01), and at the palms immediately after warm water challenge (p less than 0.01).     

Relation between homocysteinaemia and diabetic neuropathy in patients with Type 2 diabetes mellitus.

AIMS: Limited data are available on determinants of diabetic neuropathy as its pathogenesis is multifactorial. Since homocysteine exhibits toxic effects on vascular endothelial cells, the association between homocysteine and the prevalence of neuropathy in Type 2 diabetes mellitus was investigated. METHODS: A total of 65 Type 2 diabetic patients were consecutively enrolled into the study. Neuropathy was diagnosed according to clinical symptoms, clinical examination, electrophysiological sensory testing and autonomic function testing. With regard to homocysteine-related parameters, plasma homocysteine, folate, vitamin B12, vitamin B6 and renal function (creatinine, ceratinine clearance, cystatin C) were measured, and the C677T polymorphism of the methylenetetrahydrofolate reductase gene was determined. RESULTS: Forty-three of the Type 2 diabetic patients were classified as suffering from neuropathy. Both patient groups were comparable with regard to demographic data, blood pressure, glucose metabolism, renal function and homocysteine-related vitamins. In contrast, homocysteine levels (P = 0.04) and the frequency of hyperhomocysteinemia (>or= 15 micromol/l) (P = 0.01) were significantly increased in neuropathic patients. In a logistic regression model with neuropathy as dependent variable, homocysteine (adjusted for creatinine, homocysteine-related vitamins, HbA1c and duration of diabetes) was the only significant variable associated with the prevalence of neuropathy (odds ratio for homocysteine per 5 micromol/l increase: 2.60 (95% confidence interval 1.07-6.33)). CONCLUSION: The data indicate that homocysteine is independently associated with the prevalence of diabetic neuropathy in a collective of Type 2 diabetic patients. A larger, prospective study would be desirable to clarify the role of homocysteine in the pathogenesis of diabetic neuropathy.     

Subclinical diabetic neuropathy: similarities between electrophysiological results of patients with Type 1 (insulin-dependent) and Type 2 (non-insulin-dependent) diabetes mellitus

Summary Type 1 (insulin-dependent) and Type 2 (non-insulin-dependent) diabetic patients share many clinical and biochemical characteristics. However, sural nerve biopsies from patients with advanced and chronic neuropathy show ultrastructural differences between these two groups. We investigated whether at a subclinical stage of the illness, when Type 1 and Type 2 diabetic patients are clinically uniform and the histopathological nerve alterations are not advanced, comparison between the two diabetes groups might show differences in nerve fibre involvement related to the different pathogeneses of the neuropathies. A total of 88 diabetic patients (52 Type 1 and 36 Type 2), with a subclinical form of polyneuropathy were selected. The clinical neurophysiological examination consisted of motor and sensory nerve conduction studies, Hoffmann (H)-reflex, single fibre electromyography and static as well as dynamic pupillometry. With regard to clinical neurophysiological abnormalities, the severity of the polyneuropathy appeared to be equal in both groups. Despite the absence of clinical symptoms the neurophysiological abnormalities were pronounced and it was impossible to differentiate Type 1 diabetic patients from Type 2 diabetic patients on a clinical neurophysiology basis when correcting for differences in age, height, and duration of illness. In the Type 1 diabetic group as well as in the Type 2 diabetic group the autonomic nerve fibres and nerves in the legs were more frequently affected than the thick myelinated nerves in the arms. These findings do not support the assumption that there is a difference in the manifestation of polyneuropathy between Type 1 and Type 2 diabetic patients.     

原发性高血压并2型糖尿病患者脉压与蛋白尿的相关性探讨

目的　研究 2型糖尿病及高血压病患者脉压 (PP)与尿微量白蛋白的关系。方法　对 2 4 1例患者 ,高血压 (EH)患者 75例、2型糖尿病 (T2 DM)患者 77例和高血压病合并 2型糖尿病 (EH +T2 DM)患者 89例进行血压检测和尿微量白蛋白测定。结果　T2 DM组微量白蛋白与收缩压 (SBP)相关性不显著 (P >0 .0 5 ) ;而与PP显著正相关 (P <0 .0 5 )。EH组微量白蛋白与SBP和PP呈显著正相关 (P <0 .0 5 ) ;EH +T2 DM组微量白蛋白与SBP和PP呈显著正相关 (P <0 .0 5 ) ,微量白蛋白与PP相关性在EH +T2 DM组最大。反映肾功能的其它指标则与SBP、PP无相关性。结论　在上述 3种患者中只PP与早期肾损害相关 ,故为防止DM和EH患者肾脏损害加重 ,降低PP很重要。     

Value of ambulatory arterial stiffness index and 24-h pulse pressure to predict progression of albuminuria in elderly people with diabetes mellitus

BACKGROUND: Ambulatory 24-h pulse pressure predicts progression of albuminuria in people with diabetes mellitus. It is not known whether the ambulatory arterial stiffness index (AASI) may add to that prediction. METHODS: We compared the multivariate-adjusted association of AASI and 24-h pulse pressure with progression of urine albumin excretion during follow-up in a multiethnic cohort of older people with type-2 diabetes mellitus. The baseline evaluation included office and 24-h ambulatory blood pressure (BP) measurements, and a spot urine measurement of albumin-to-creatinine ratio (ACR). The ACR measurements were repeated annually during 3 years. RESULTS: The AASI was >or=0.55 units in 47% of those exhibiting progression of albuminuria, and in 37% of those without progression (P = .004), whereas 24-h pulse pressure was >or=65 mm Hg in 50% and 38% of those with and without progression, respectively (P = .001). In repeated measures mixed linear model (n = 1043), after adjustment for several covariates including office pulse pressure, AASI in the fourth quartile was independently associated with higher follow-up ACR (P = .024). However, that association did not persist after adjusting for 24-h pulse pressure, which was an independent predictor (P < .001). Cox proportional hazards models examined progression of albuminuria in 957 participants without macroalbuminuria at baseline. The hazard ratio (95% CI) for AASI >or=0.55 units was 1.37 (1.02-1.83) after multivariable adjustment, including office pulse pressure. But AASI was not an independent predictor after adjustment for ambulatory pulse pressure, which was again an independent predictor (P = .033). CONCLUSIONS: Ambulatory 24-h pulse pressure outperformed AASI in predicting progression of albuminuria in elderly people with type 2 diabetes.     

Autonomic neuropathy--a complication less pronounced in patients with Type 1 diabetes mellitus who have lower blood glucose levels.

AIMS: Autonomic neuropathy is a serious diabetic complication, probably contributing to the death of many young people with Type 1 diabetes mellitus. It is often not diagnosed. METHODS: Patients with Type 1 diabetes from the Stockholm Diabetes Intervention Study were investigated with power spectral analysis (n = 88), heart rate and blood pressure reactions to tilting (n = 66), and heart rate variability during deep breathing (n = 70) a mean of 11.4 years after randomization to intensified conventional treatment (ICT) or standard treatment (ST), the treatment groups similar with regard to age, duration of diabetes and metabolic control at baseline (HbA1c 9.4 (1.3)%, mean (SD)). Blood glucose levels (mean of 29 HbA1c values) during the 10 years were lower in the patients from the ICT group (7.2 (0.6) vs. 8.3 (1.0)%, P = 0.001). RESULTS: Heart rate variability (HRV) in the high frequency range (P = 0.034), the expiration-inspiration ratio (P = 0.020), and the brake index during tilt (P = 0.044) were lower in the ST group, indicating more pronounced parasympathetic insufficiency. Systolic blood pressure fell by 10 (16) mmHg in the ST group, and by 2.5 (15) mmHg in the ICT group 8 min after rising from the supine to a 70 degrees upright position (P = 0.034). A decreased autonomic function was associated with age and higher HbA1c. CONCLUSION: Better autonomic nerve function is associated with lower HbA1c and lower age which were both the same in the intensively and the conventionally treatment groups at baseline. After a mean of 11.4 years autonomic function was better in the intensively treated group.