Severe Epidermal Nerve Fiber Loss in Diabetic Neuropathy Is Not Reversed by Long-Term Normoglycemia After Simultaneous Pancreas and Kidney Transplantation.

Whether nerve fiber loss, a prominent feature of advanced diabetic neuropathy, can be reversed by reestablishment of normal glucose control remains questionable. We present 8-year follow-up data on epidermal nerve fiber (ENF) density and neurological function in patients with type 1 diabetes after simultaneous pancreas and kidney transplantation (SPK) with long-term normoglycemia. Distal thigh skin biopsies with ENF counts, vibration perception thresholds (VPTs), autonomic function testing (AFT) and electrophysiological examinations were performed at time of SPK and 2.5 and 8 years after SPK in 12 patients with type 1 diabetes. In comparison to controls, baseline ENF density, VPT and AFT results of patients indicated severe neuropathy. At follow-up, all SPK recipients were insulin independent with excellent glycemic control and kidney graft function; however, the severe ENF depletion present at baseline had not improved, with total ENF absence in 11 patients at 8-year follow-up. Similarly, no amelioration occurred in the VPT and AFT results. Numerical improvement was seen in some electrophysiological parameters; however, statistical significance was achieved only in median motor nerve conduction velocity. ENF loss and functional deficits in advanced diabetic peripheral neuropathy are rarely reversible, even by long-term normoglycemia, which underscores the importance of neuropathy prevention by early optimal glycemic control.

[Diabetic nephropathy/diabetic kidney disease]. / Diabetická nefropatie/diabetické onemocnení ledvin.

Diabetic kidney disease (DKD), which belongs to the triad of diabetic microvascular complications, is currently the main cause of end-stage renal disease in developed countries. DKD usually simultaneously leads to a deteriorated long-term control of glucose metabolism and blood pressure, and to the development of diabetic retinopathy, neuropathy and atherosclerotic complications, which are the main causes of patients' mortality. Screening of the initial stages of DKD is to be based on the detection of increased albumin leak into the urine, microalbuminuria, and the reduction of renal function by means of estimates of glomerular filtration rate based on the serum creatinine level. The main objective of the prophylactic and treatment measures is to prevent the onset of DKD, or at least to stop its transition into an irreversible, progressive stage characterised by a permanent, often nephrotic proteinuria. The basic procedures in the prevention and treatment of DKD are maintaining the optimal metabolic control of diabetes and intensive hypertension treatment based on the inhibition of the renin-angiotensin system. Reaching the stage of progressive renal insufficiency (serum creatinine level approximately > or = 200 micromol/l) is an indication for further follow-up in the nephrology department, which will then take the necessary preparatory measures for dialysis treatment. The optimal method of kidney function replacement for patients with DKD is kidney transplantation, or combined kidney-pancreas transplantation in patients with type 1 diabetes.

Immunosuppression in pancreas transplantation: the Euro SPK trials and beyond.

The Immunosuppression in Pancreas Transplantation was historically based on the fact that the pancreas is an extremely immunogenic organ. Quadruple drug therapy with polyclonal or monoclonal antibodies induction was the mainstay therapy since the introduction of Cyclosporine A. In the modern era of Immunosuppression, Mycophenolate Mofetil replaced Azathioprine while Tacrolimus-another potent calcineurin inhibitor-had-and still has-a difficult challenge to replaced Cyclosporine A, due to its potential diabetogenic effect. Thanks to the first two EuroSPK studies which prospectively tried to answer several questions in that field. But, the future challenge will be in understanding the impact of innate immunity and ischemic reperfusion injuries on the long-term graft function. Hopefully, new drugs will be available and tested to block unspecific deleterious reactions to attenuate the proinflammatory response. It will be the aim of the third Euro SPK Study.

[Examination of tactile disorders in diabetic patients and cooperation with a neurologist]. / Vyletfení taktilních poruch u diabetiku a spolupráce s neurologem.

Examining sensorial dysfunction may be difficult for both the doctor and the patient because subjective feelings are misleading and do not reflect the actual severity of a neurological disorder. Sensorial tests provide objective results of measurements, which can be checked against normal values and which allow for determining the severity of neuropathy. Examining sensorial function on feet is necessary in diabetic patients because its loss is the principal risk factor for ulceration. The examination comprises vibration perception tests using a tuner or a biothesiometer, and evaluating surface sensation with the use of monofilaments. A more detailed type of examination is the testing of the electric current perception threshold with the use of different models of neurometer which allows for examining all three main groups of sensorial nerve fibres, i.e. Abeta (large myelinated), Agamma (small myelinated) and C (non-myelinated). The study evaluated the differences between routine diagnosing of polyneuropathy on outpatient basis and biothesiometer and monofilament examination. We discovered that patients with severe neuropathy diagnosed by non-invasive semi-quantitative examination were diagnosed for neuropathy on outpatient basis only in 54% of cases, which points to the need to extend the use of non-invasive examination to outpatient practice. The Neuropathy Disability Score (NDS) assesses neurological functions as a whole, but is more time consuming than simple sensorial tests. Neuropathy self-monitoring by the patient in risk of diabetic foot using the diagnostic test (Neuropad) looks promising. The diabetologist cooperates with a neurologist especially in differential diagnosis of neuropathy, in the treatment of its painful forms and in the classification of its severity.

[Prevention of type 2 diabetes mellitus due to antihypertensive treatment affecting renin-angiotensin system]. / Prevence vzniku diabetu 2. typu pri lécbe antihypertenzivy ovlivnujícími systém renin-angiotenzin.

Hypertension is often associated with an impairment of glucose tolerance and is a risk factor for the development of type 2 diabetes mellitus. The occurrence of diabetes may be also influenced by the selection of the type of antihypertensive treatment. While it has been shown that the use of older type antihypertensives - diuretics and beta-blockers - may precipitate diabetes, newer drugs which inhibit the renin-angiotensin system have a positive effect on glucose tolerance. Several recent clinical trials of ACE-inhibitors and AT1-blockers have demonstrated a decreased risk of the occurrence of diabetes in comparison with placebo or conventional antihypertensive drugs. The mechanisms responsible for the antidiabetic effect of these newer antihypertensive agents remain largely speculative. Insulin resistance may be improved in several ways, e.g. by changes in microcirculation or direct effects on insulin response and glucose transport in target organ cells. However, as shown in experimental studies, improved islet function and insulin secretion may also have role due to an inhibitory effect on the local renin-angiotensin system in the pancreas. Ongoing prospective clinical trials having the occurrence of diabetes as a primary specified endpoint should confirm the preventive potential of the inhibitors of the renin-angiotensin system. Since direct comparisons are lacking, current data are inconclusive as to the superiority of one of the two classes of these inhibitors or of any single drug. Nevertheless, inhibitors of the renin-angiotensin system should definitely represent first choice antihypertensive agents for persons with additional risk factors such as family history of diabetes, obesity or impaired glucose tolerance.

Metabolic effect of sirolimus versus mycophenolate mofetil on pancreatic graft function in the early posttransplant period.

Metabolic effects of immunosuppressive agents are of great importance in pancreas or islet transplantation. The aim of our study was to compare effects of tacrolimus-based immunosuppression in conjunction with sirolimus (RAPA) versus mycophenolate mofetil (MMF) on glucose metabolism in type 1 diabetic recipients following a simultaneous pancreas and kidney transplantation (SPK). We examined 30 insulin-independent patients after SPK with venous systemic drainage of the pancreatic graft. All recipients had good kidney graft function. Fasting glycemia, insulin levels, glycosylated hemoglobin (HbA(lc)), standard intravenous glucose tolerance test (IVGTT), and trough RAPA levels were assessed in pancreas recipients before elective steroid withdrawal. Insulin sensitivity was evaluated using the homeostasis model assessment (HOMA-IR). The groups did not differ in age, BMI, posttransplant period, steroid daily dose, HbA(lc), and fasting glycemia. We did not find any significant difference in the IVGTT response. Area under the curve of insulin levels during IVGTT and HOMA-IR were significantly lower in the RAPA group. Trough levels of RAPA had no significant impact on any of the examined parameters. Glucose tolerance measured with the use of IVGTT was similar in patients treated with RAPA and MMF. However, recipients on sirolimus treatment had significantly lower insulinemia during the test and consequently more favorable indices of insulin action as assessed by HOMA-IR.

Tacrolimus compared with cyclosporine microemulsion in primary simultaneous pancreas-kidney transplantation: the EURO-SPK 3-year results.

UNLABELLED: This 3-year study compared tacrolimus versus cyclosporine (CsA) microemulsion (ME) in conjunction with rATG induction, mycophenolate mofetil (MMF) and short-term corticosteroids in primary simultaneous pancreas-kidney (SPK) transplantation. PATIENTS AND METHODS: This large, prospective, multicenter study was conducted in 10 European centers and one center in Israel. Of the 205 SPK transplants performed from 1998 to 2000, 103 patients were randomly assigned to tacrolimus and 102 to CsA ME. All patients received concomitant rATG induction therapy, MMF, and short-term corticosteroids. RESULTS: In total, 36.9% patients receiving tacrolimus and 57.8% receiving CsA ME discontinued treatment (P = .003). Although 3-year patient and kidney graft survival rates were similar in both groups, pancreas survival was superior with tacrolimus (89.2% versus 72.4%; P = .002). Thrombosis resulted in pancreatic allograft loss in 10 patients receiving CsA ME and in 2 treated with tacrolimus (P = .02). The first episode of biopsy-proven rejection was moderate or severe in 1 of 31 tacrolimus-treated patients and 11 of 39 patients receiving CsA ME (P = .009). Overall adverse event frequency was similar in both groups, but surgical events were lower in the tacrolimus treated group. CONCLUSION: Tacrolimus was more effective than CsA-ME to prevent moderate or severe kidney or pancreas rejection after SPK transplantation. It also provided superior pancreatic graft survival and reduced the risk of pancreas thrombosis.

Severe depletion of intraepidermal nerve fibers in skin biopsies of pancreas transplant recipients.

BACKGROUND: The minimally invasive method of skin biopsy with intraepidermal nerve fiber (IENF) counts may be used to analyze nerve regeneration in pancreas transplant (PTx) recipients. We assessed IENF counts as a database for long-term follow-up of diabetic neuropathy. METHODS: Skin biopsies were performed using a 3-mm punch from lower thigh and upper calf areas of 16 (13 pancreas/kidney, 3 pancreas alone) PTx patients (mean +/- SD: age, 45+/-8 years; type 1 diabetes duration, 27 +/- 8 years) at 1 month posttransplant. Ten healthy gender- and age-matched controls (C) were also examined. After fixation and freezing, 40-microm sections were stained using rabbit polyclonal antibody to the panaxonal marker PGP 9.5 followed by mouse antirabbit IgG antibody conjugated with rhodamine. Samples were imaged with a digital camera, mounted on a microscope, and equipped for fluorescence. The average number of IENF per millimeter length of epidermis was derived. Clinical neuropathy was assessed by foot vibration perception thresholds (VPT) with a biothesiometer (normal values < mean + 2 SD of C). RESULTS: Significantly lower IENF densities were found in skin biopsies from PTx (PTx vs C: thigh, 0.74 +/- 0.88 vs 9.74 +/- 2.41 IENF/mm; calf, 0.34 +/- 0.91 vs 7.66 +/- 3.16 IENF/mm; P < .001). IENF were totally absent from the thigh and calf samples of 7 and 12 PTxs, respectively. Clinical neuropathy (VPT > 21 V) was present in all but one PTx. CONCLUSIONS: Severe intraepidermal nerve fiber depletion is present in the lower limb area of pancreas transplant recipients with neuropathy. Long-term follow-up would probably be necessary to assess the possibility of posttransplant nerve fiber regeneration.

BK-virus nephropathy and simultaneous C4d positive staining in renal allografts.

The role of antibodies in rejection of transplanted kidneys was the subject of debate at the last two Banff meetings and in medical journals. Diffuse C4d positive staining of peritubular capillaries (PTCs) was recognized as a marker of antibody-mediated rejection and this morphological feature was included in the updated Banff schema. At the same time polyomavirus infection of the renal allografts has been reported more frequently and is emerging as an important cause of renal allograft dysfunction and graft loss. At the present time, BK-virus nephropathy (BKN) represents the most common viral disease affecting renal allografts. BKN was identified in 6 patients in 12 biopsies and 2 graft nephrectomy specimens of 1115 biopsies between September 2000 and December 2003. Definite virus identification was done by immunohistochemistry. The reason for graft nephrectomies was graft failure due to BKN in a recipient after kidney-pancreas transplantation with good function of his pancreas graft and the necessity of continuing immunosuppression. Detection of C4d deposits was performed by immunofluorescence or by immunohistochemistry. In graftectomy samples C4d detection was performed by immunohistochemistry and retrospectively in all cases of BKN. Focal C4d positive PTCs and BKN were found simultaneously in 9 of 12 needle biopsies and in both graft nephrectomy samples. Detection of C4d by immunohistochemistry disclosed focal C4d positive staining in kidney tissue but diffuse in the sites where BK-virus inclusions in tubular epithelial cells were found. The complement system is part of the host defense response and is crucial to our natural ability to ward off infection. In cases of BKN, virus likely gains access to the bloodstream through injured tubular walls and via PTCs. Vascular endothelium in the PTCs represents a potential target antigen for alloresponse, and simultaneously possibly represents an imprint of complement activation or complement production in the places with BK-virus infection.

Beneficial effect of pancreas and kidney transplantation on advanced diabetic retinopathy.

In pancreas recipients with advanced diabetic eye disease, conflicting ophthalmologic results over different follow-up periods have been reported. In the present prospective study we performed ophthalmologic evaluation groups of type I diabetic patients: 1) normoglycemic recipients of pancreas and kidney grafts (group SPK, n = 43, follow-up 44.9 +/- 35.1 months), 2) pancreas and kidney graft recipients with nonfunctioning pancreatic graft, and recipients of isolated kidney graft (group K, n = 45, follow-up 60.3 +/- 34.2 months). The examinations were performed before transplantation, at the end of follow-up (at least 1 year), and in 63 recipients also at 3 years posttransplant. Visual acuity results at baseline and at the end of follow-up were 0.48 +/- 0.39 vs. 0.50 +/- 0.39 in the SPK group, and 0.46 +/- 0.38 vs. 0.40 +/- 0.39 in the K group. While intragroup changes were not significant, the changes were significantly different between the groups (p < 0.05). Fundoscopic findings at the end of follow-up were improved, stabilized, or deteriorated in the SPK group in 21.3%, 61.7%, and 17.0%, respectively. The respective figures for the K group were 6.1%, 48.8%, and 45.1% (p < 0.001). Similar results were obtained when evaluating findings at 3 years posttransplant. Before transplantation, 78% of the SPK group and 81% of the K group had been treated by laser. The need for additional posttransplant laser therapy was significantly lower in the SPK (31%) than in the K group (58%; p < 0.001). In conclusion, pancreas transplant exerts a beneficial effect on the course of diabetic retinopathy even in its late stage.

Identification of patients at risk for diabetic foot: a comparison of standardized noninvasive testing with routine practice at community diabetes clinics.

The aim of the study was the comparison of a simple standardized noninvasive examination of neuropathy and angiopathy with routine diagnostic practice in community diabetes clinics for the identification of patients at risk of foot ulceration. Consecutive patients (n=322), aged 30 years and more, with a diabetes duration of more than 5 years, were examined by trained podiatric nurses in six diabetes clinics over a 1-year period; 44 of these patients had active or previous foot ulcerations. We evaluated the differences between the routine diagnostic practice (based on the patient's medical history and a physical examination) and noninvasive testing of peripheral neuropathy [vibration perception threshold (VPT) and the Semmes-Weinstein 10-g monofilament wire system] and angiopathy [Doppler ankle/brachial index (ABI)]. Using receiver operating characteristic (ROC) analysis, we evaluated the sensitivity and specificity of noninvasive testing methods for identifying patients at risk and selecting the optimal diagnostic cutoff points. Patients with severe neuropathy, as determined by noninvasive testing (VPT > or =30 V and/or insensitivity to 10 g monofilament), had been diagnosed to have neuropathy in diabetes clinics in 54% of cases. Patients with angiopathy at risk of developing diabetic foot ulcers (ABI < or =0.8) had been diagnosed, in diabetes clinics, to have peripheral arterial disease in 50% (they reported claudications in 41%, had femoral artery bruits detected in 29% and nonpalpable peripheral pulsations in 12%). Our findings stress the importance of using standardized simple noninvasive testing methods to increase the accuracy of identifying patients at risk for the diabetic foot at the community level.

A prospective comparison of bladder versus enteric drainage in vascularized pancreas transplantation.

Although the number of pancreas transplants has increased significantly in previous years, debate continues concerning the optimum technique for exocrine pancreas drainage. Enteric drainage (ED) has recently been increasingly popular due to the long-term complications with bladder drainage (BD). We prospectively assigned 40 consecutive pancreas transplant recipients to either bladder (n = 20) or enteric (n = 20) drainage. Patient, kidney, and pancreas graft survival rates at 1 year after simultaneous kidney-pancreas transplantation were 95%, 95%, 85%, for BD group and 90%, 85%, 85% for ED group, respectively. Surgical complications were not significantly different between the two groups. The incidence of acute rejection, major infections, and CMV disease were similar between groups. The length of the initial hospital stay was likewise comparable. However, the BD group showed a slight increase in the number of urologic complications, metabolic acidosis, and dehydration. Based on the results of our study, patient and graft survivals were excellent irrespective of technique.

Modulating amylase and lipase secretion in the pancreatic graft by somatostatin administration: preliminary results of a prospective, randomized trial.

Pancreas transplantation is a routine method for the treatment of diabetes mellitus. One of the main challenges of a transplant with extraperitoneal placement of the pancreatic graft is impaired wound healing due to massive amylase and lipase secretion by the pancreatic graft, evoking edemtous fluid. From February 2002 through January 2003, we performed pancreatic transplant procedures in 21 patients who were prospectively and randomly assigned to two groups: 8 organ donors and the recipients were administered somatostatin by continuous infusion. Thirteen grafts were harvested and transplanted without somatostatin infusion. The two groups did not show significantly differences in mean donor or recipient ages, weights, of serum amylase and lipase content values or drain output until day 6. There was a significantly lower lipase in the drain output of transplant recipients given somatostatin (12.5 and 54.2 micromol/L, respectively; P <.05). Neither the post-pancreatic transplant wound healing nor the number of rejection episodes were affected by somatostatin administration.

Spectral analysis of heart rate variation following simultaneous pancreas and kidney transplantation.

Only marginally improved results have been observed in standard autonomic function tests (AFT) in follow-up studies after simultaneous pancreas and kidney transplantation (SPK). We therefore used power spectral analysis (PSA) of heart rate variability (HRV) to assess the effect of SPK on autonomic neuropathy in patients with type I diabetes mellitus (DM I). We evaluated 82 patients with DM I who were insulin and dialysis free following SPK. Both pre- and posttransplant (at [mean +/- SD], 25 +/- 15 months post-SPK) examinations were performed in 29 patients. Posttransplant evolution was examined in another 60 patients with two serial examinations at 20 +/- 20 and 43 +/- 27 months after SPK. Comparisons included 32 age-matched healthy controls and 13 patients with kidney transplant alone (KTA) matched for age and duration of DM I at a comparable time point posttransplant. Short-term time (modified Ewing battery) and frequency domain (PSA of HRV: LF-low, HF-high frequency, and TP-total spectral power) analysis was performed with a telemetric, on-line, computer-aided system. Significantly worse results in all standard AFT and PSA indexes were obtained for SPK patients compared with controls at all time points. No significant improvement was seen in SPK patients in the posttransplant period and no differences were found compared with KTA patients. Thus the results of a power spectral analysis of HRV failed to show improvement following SPK. This examination adds little positive information to that obtained from standard autonomic function tests.

A prospective comparison of bladder versus enteric drainage in vascularized pancreas transplantation.

In previous years, the number of pancreas transplants has increased significantly. Debate continues over the optimum technique for exocrine drainage. Enteric drainage (ED) has recently been increasingly popular owing to the long-term complications of bladder drainage (BD). We prospectively evaluated 40 consecutive pancreas transplant recipients undergoing either bladder (n = 20) or enteric (n = 20) drainage. After simultaneous kidney-pancreas transplantation 1-year patient, kidney, and pancreas graft survival rates were 95%, 95%, 85% for the BD group, and 90%, 85%, 85%, for the ED group. Surgical complications were not significantly different between the two groups. The incidence of acute rejection, major infections and cytomegalovirus disease were also similar. The length of the initial hospital stay was likewise comparable. However, the BD group was characterized by a slight increase in the number of urologic complications, metabolic acidosis, and dehydration. Our results suggest excellent patient and graft survival irrespective of the drainage technique.

[Hemodialysis in diabetics]. / Hemodialýza u diabetiku.

In the submitted review the author deals with the problem of haemodialysis in diabetics. He summarizes some basic information on the state of haemodialysis treatment of diabetics in advanced countries with regard to the situation in Czechoslovakia, the survival of patients and causes of mortality, complications, the standard of rehabilitation and quality of life. The author gives a rough outline of the strategy of care of diabetics in the pre-dialysis stage of diabetic nephropathy and in a chronic dialysis programme. The author emphasizes that haemodialysis means a significant prolongation of life in patients with advanced diabetic nephropathy. In an integrated dialysis transplantation programme it is possible to achieve in these patients prolonged satisfactory quality of life after successful transplantation.

[Care of patients with diabetic nephropathy]. / Péce o nemocné s diabetickou nefropatií.

Diabetic nephropathy is one of the main causes of chronic renal failure in developed countries. The genesis and development of diabetic nephropathy is associated in both types of diabetes with a more rapid progression of other secondary complications and an increased mortality, in particular cardiovascular mortality. The main causes of development of diabetic nephropathy are prolonged hyperglycaemia along with a so far not elucidated inborn disposition. The course of diabetic nephropathy is characterized more clearly in type 1 diabetes. The clinically manifest stage is already irreversible and in the course of years it develops into chronic renal failure. Preventive and curative measures include maintenance of optimal metabolic control, systematic control of blood pressure, in particular by ACE-inhibitors, and a reduction of protein intake. Systematic multidisciplinary collaboration in care for patients with diabetic nephropathy helps to prevent the progression of other secondary complications such as diabetic foot and diabetic retinopathy. At present in the Czech Republic dialysis methods substituting renal function are available to practically all patients with diabetic nephropathy. As regards survival time and quality of life the optimal method of renal function replacement for patients in the terminal stage of diabetic nephropathy is transplantation.

[Pancreas transplantation: who and when?]. / Transplantace pankreatu: komu a kdy?

Hyperglycemia is an important factor in the development and progression of the complications of diabetes. Pancreas transplantation is currently the only method able to achieve sustained normoglycemia in type I diabetes. By now, this procedure has become an accepted treatment option combined with kidney transplantation for selected patients with end-stage diabetic nephropathy. The definite benefits of pancreas transplantation comprise relieve from insulin administration, superb glycemic control, improved quality of life and long-term survival of patient with severe autonomic neuropathy. Presumed benefits represent stabilization or slowing of progression of microvascular complications. Definite disadvantages are the risk of the surgical procedure, graft rejection and the necessity of permanent immunosuppression. Isolated pancreas transplantation in nonuremic type-1 diabetic patients is still controversial. Diabetic complications of the potential recipient have to be potentially correctable by the transplantation and their significance must exceed all risks of the operation and life-long immunosuppression. Currently, approx. 25 combined transplants are performed per year in IKEM with the results comparable to those reported by the International Pancreas Transplant Registry. Seven nonuremic type-1 diabetic recipients of 8 operated in IKEM by June 2000 have been insulin-independent for 1-33 months. The main indication for isolated pancreas transplantation is brittle diabetes with hypoglycemia unawareness syndrome and labile diabetes with severe autonomic neuropathy and rapid progression of microangiopathy despite appropriate intensified insulin therapy.

[Autonomic neuropathy in patients with type 2 diabetes and microalbuminuria]. / Autonomní neuropatie u nemocných s diabetem 2. typu a mikroalbuminurií.

BACKGROUND: Microalbuminuria (MAU) represents in patients with type 2 diabetes a risk factor for total and cardiovascular mortality and morbidity, whose principal pathogenic mechanism is the development of atherosclerosis. Other factors may also participate, e.g., cardiovascular vegetative neuropathy, which is supposed to be an independent risk factor. The aim of the study was the analysis of the cardiovascular autonomic regulations in patients with type 2 diabetes and microalbuminuria. METHODS AND RESULTS: 16 patients with type 2 diabetes and microalbuminuria and 23 healthy controls were included in the study. Heart rate variability was tested (during short-term recording at rest, deep breathing, orthostasis and Valsalva manoeuvre) and spectral analysis of telemetric records of heart rate in three positions (lying--standing--lying) was employed. In the group of patients with type 2 diabetes and MAU, in comparison with patients without MAU and controls, significant differences in heart rate variability during deep breathing were found. In comparison to controls, differences were found also during the Valsalve manoeuvre. In parameters of reaction of the heart rate to orthostasis, both groups of diabetic patients differed from controls. When comparing patients with MAU and controls significant differences were also found in spectral analysis of the heart rate variability, namely in total spectral power and the power of the low frequency band in both recumbent positions. In the same parameters, significant differences were found also between patients with and without MAU. The later were not different from the controls. CONCLUSIONS: The presented results indicate the existence of a significant impairment of the autonomic nervous system in patients with type 2 diabetes and microalbuminuria. This fact may contribute to the higher cardiovascular risk in this group of diabetic patients.

[The relation between peripheral and autonomic neuropathies in insulin-dependent diabetics]. / Vztah periferní a autonomní neuropatie u inzulíndependentního diabetu.

Eighty-eight type I diabetics were subjected to neurological and myographic examination and tests were performed assessing the condition of the vegetative nervous system. Forty-four patients (50% of the group) suffered from diabetic nephropathy with different expression in the stage of chronic renal failure. The authors revealed significant positive correlation between the results of tests of vegetative neuropathy and all evaluated parameters of the neurological and electromyographic finding. In patients with a S-creatinine level above 125 mumol/l in both tests of vegetative neuropathy and in all examined parameters of peripheral nerves highly significantly lower values were recorded than in diabetic patients with normal renal function. In diabetics without renal insufficiency, however, the correlations between the findings on the autonomous and peripheral nervous system were also statistically significant.