Albuminuria in type 2 diabetes mellitus: from remission to progression

Objective Albuminuria is an early marker of renal impairment and a powerful factor of progression of renal disease in type 2 diabetes (T2D). Approximately, one-third of patients with T2D have micro- or macroalbuminuria and these patients have a high risk of progression toward End Stage Renal Disease (ESRD) as well as increased cardiovascular disease. The aim of this study was to determine the prevalence of remission, regression, persistence, and progression of albuminuria, and to evaluate the impact of change in albuminuria on kidney disease and cardiovascular disease in a prospective cohort of patients with T2D. Methods This is a prospective study. The Ethics Committee of Morocco’s Mohammed V University in Rabat approved the study protocol. Inclusion criteria targeted patients who were type 2 diabetics with albuminuria?>30?mg/day, and who had been regularly followed-up in nephrology consultation for at least 36 months. Results Five-hundred twenty-four patients were included. 75.8 and 24.6% of all patients had micro- and macroalbuminuria at enrollment in the study. At the end of the study, 91, 141, 199, and 93 patients had remission, regression, persistence, and progression of albuminuria, respectively. Remission of microalbuminuria to normoalbuminuria was observed in 23.6% of cases. Regression of macroalbuminuria to micro- was observed in 29.9% of cases. Conclusion In our study, the incidence of remission and/or regression of micro- and macroalbuminuria was higher. The incidence of ESRD and the occurrence of cardiac events were greater in the regression, persistence, and progression groups than in the remission of albuminuria group.     

Hyperglycemia as a predictor of in-hospital mortality in elderly patients without diabetes mellitus admitted to a sub-intensive care unit

OBJECTIVES: To investigate the association between hyperglycemia and in‐hospital and 45‐day mortality in acutely ill elderly patients. DESIGN: Retrospective cohort. SETTING: Hospital medical patients admitted to a sub‐intensive care unit (sub‐ICU) for elderly patients, which is a level of care between ordinary wards and intensive care. PARTICIPANTS: One thousand two hundred twenty‐nine patients (mean age 79.6±8.4) admitted to the sub‐ICU from January 2003 to January 2006. Forty patients with acute myocardial infarction and 34 patients with extreme fasting glucose values (<60 or >500 mg/dL) were excluded. Eight hundred twenty‐two patients without a history of diabetes mellitus (DM) and 333 patients with a diagnosis of DM were selected and subdivided into three categories according to serum fasting blood glucose: 60 to 126 mg/dL (Group A), 127 to 180 mg/dL (Group B), and 181 to 500 mg/dL (Group C). MEASUREMENTS: Age, sex, mental and functional status, Acute Physiology Score, comorbid conditions, serum albumin, serum cholesterol, fasting serum glucose, and length of stay. In‐hospital mortality was the primary outcome, and 45‐day mortality was the secondary outcome. RESULTS: Total in‐hospital mortality was 14.5%. In patients with and without DM, mortality was 8.8% and 11.3%, respectively, in Group A; 13.6% and 17.3% in Group B, and 12.6% and 34.3% in Group C. After controlling for confounders, newly recognized hyperglycemia (>181 mg/dL) was independently associated with in‐hospital mortality (adjusted odds ratio=2.7, 95% confidence interval=1.6–4.8). Forty‐five‐day mortality in newly recognized hyperglycemic patients was 17.5%, 25.7%, and 42% in Groups A, B, and C, respectively, whereas it was 21.2% in patients with DM. CONCLUSION: In elderly patients, newly recognized hyperglycemia was associated with a higher mortality rate than in those with a prior history of DM. These data suggest that further randomized clinical trials are needed to assess the efficacy and the risk of a target glucose of greater than 180 mg/dL.     

Adrenergic mechanisms and remodeling of subcutaneous small resistance arteries in humans

BACKGROUND: Vascular structural alterations in small resistance arteries of patients with essential hypertension (EH) are mostly characterized by inward eutrophic remodeling. In fact, no difference in the smooth muscle cell volume (CV) between normotensive subjects (NT) and essential hypertensive patients was observed. However, experimental models of hypertension with chronic infusion of agonists of adrenergic receptors were characterized by the presence of smooth muscle cell hypertrophy or hyperplasia. Recently, we have observed the presence of vascular smooth muscle cell hypertrophy in patients with renovascular hypertension. OBJECTIVE: The aim of the study to investigate the structural characteristics of subcutaneous small resistance arteries of NT, of EH, and of patients with phaeochromocytoma (Phaeo). PATIENTS AND METHODS: Thirty Phaeo, 30 NT and 30 EH were included in the study. A biopsy of subcutaneous fat was taken from all subjects. Small resistance arteries (relaxed diameter 160-280 microm) were dissected and mounted on a micromyograph and the media : lumen ratio was calculated. In nine Phaeo, nine NT and 13 EH the cell volume was measured by an unbiased stereological principle, the 'disector' method.RESULTS No difference in smooth muscle cell volume was observed between groups. However, inward remodeling in Phaeo was less marked than in EH, although the increase in media : lumen ratio was similar compared with NT. However, the lack of changes in media cross-sectional area, compared with NT, suggest that there has been little hypertrophy, the changes observed thus being eutrophic. CONCLUSIONS: Our data show, based on a reasonably large sample, that a pronounced activation of the adrenergic system is not associated with vascular smooth muscle cell hypertrophy or hyperplasia in humans. It is therefore possible that adrenergic mechanisms may have a relevant role in the development of eutrophic remodeling in small vessels.