Retinopathy and microalbuminuria in type 2 diabetes: determinants and time-dependency of the association.

Background: The aim of this study was to identify the independent determinants of diabetic retinopathy (RET) and microalbuminuria (MA) and to assess the time-dependency of the association of RET with MA. Methods: In 668 out-patients with type 2 diabetes, RET was assessed by stereoscopic fundoscopy and by measuring the level of MA in untimed, triplicate urine collections on at least two and four separate visits, respectively, during a period of at least 24 months. RET was defined as RET of any type and MA as a urinary albumin-to-creatinine ratio (ACR) between 2 and 30 mg/mmol. Multiple logistic regression analysis was used to determine odds ratios (OR) and 95% confidence intervals (CI). The extent of the association (OR(assoc)) was estimated by the odds that a patient with RET has MA divided by the odds that a patient without RET has MA. Results: Common determinants of RET and MA were: systolic BP, HbA(1c), and triglycerides. Age, non-Caucasian ethnicity, and RET were associated with MA, whereas duration of diabetes and ACR were associated with RET. We estimated an overall OR(assoc) of 2.36 (95% CI, 1.72-3.24). The time-dependency of OR(assoc) showed a hyperbolically shaped curve, reaching a maximum value of 2.5 at 9.8 years after the diagnosis of type 2 diabetes. Conclusions: Our study, which supports what is currently known about independent determinants of diabetic RET and MA, suggests a drastic increase in clustering of RET and MA over the first 5 years before the diagnosis of type 2 diabetes.

The prevalence of type 2 diabetes and gestational diabetes mellitus in an inner city multi-ethnic population.

Zeeburg', a multiethnic town borough in the Amsterdam-East region, has one of the city's highest rates of immigrants. In the total population of 19,825 Surinam (mainly Creole), Turkish, Moroccan, and Dutch adults the prevalence of known type 2 diabetes in 1994 and of gestational diabetes mellitus (GDM) between January 1992 and January 1997 was investigated. Based on World Health Organization (WHO) criteria of 1985, the age-standardized prevalence of type 2 diabetes was similar in men (6.4%; 95% confidence interval [CI]: 5.6-7.2) and women (6.4%: 95% CI: 5.8-7.0) for all ethnic groups combined. However, the age- and sex-standardized prevalence of type 2 diabetes was significantly greater in the non-Dutch inhabitants than in the Dutch inhabitants (17.3% [95% CI: 12.9-21.6] in Surinam inhabitants, 10.9% [95% CI: 9.7-12.2] in Turkish inhabitants, 12.4% [95% CI: 9.7-15.0] in Moroccan inhabitants, and 3.6% [95% CI: 3.2-3.9] in Dutch inhabitants). The odds ratios for type 2 diabetes for the separate immigrant groups relative to the Dutch group were 5.88 (95% CI: 4.54-7.69) for Surinam inhabitants, 4.00 (95% CI: 2.86-5.55) for Turkish inhabitants, and 4.17 (95% CI: 3.03-5.55) for Moroccan inhabitants. GDM was present in 2.59% of women of non-Dutch origin compared with 0.62% of women of Dutch origin. A significant positive association was found between the non-Dutch origin and the occurrence of GDM (chi2 = 6.7; p < 0.01). The study highlights a high prevalence of known type 2 diabetes and GDM in the immigrant inhabitants and emphasizes that appropriate interventions are necessarily with implications for health targets and capitation based budgets.

Determinants of progression of microalbuminuria in patients with NIDDM.A prospective study.

OBJECTIVE: To assess the degree of interindividual variation in the rate of progression of microalbuminuria and to identify determinants of progression of microalbuminuria in patients with NIDDM. RESEARCH DESIGN AND METHODS: In a prospective cohort study, 58 microalbuminuric NIDDM patients were followed for a period of at least 24 months. During this period, the level of microalbuminuria in these patients was assessed in triplicate 24-h urine samples on at least four separate visits. All patients had stable metabolic control and controlled blood pressure during follow-up. Microalbuminuria was defined as an albumin-to-creatinine ratio in 24-h urine of between 3 and 30 mg/mmol. The individual rates of progression of microalbuminuria were calculated from linear regression analysis. At baseline, the following data were collected for all patients: age, sex, ethnicity, time since diagnosis of NIDDM, smoking habits, drug use, blood pressure, BMI, HbA1c, serum creatinine, cholesterol, triglyceride, and HDL cholesterol concentrations. RESULTS: Microalbuminuria was found to progress linearly in time. Considerable differences in rates of progression of microalbuminuria were found, the absolute yearly change in albumin-to-creatinine ratio ranging from -5.2 to 12.9 mg/mmol. In bivariate analyses, serum triglyceride concentration, use of ACE inhibitors, mean arterial blood pressure, HDL cholesterol, and time since diagnosis of NIDDM correlated with progression of microalbuminuria (P < or = 0.05). In stepwise multiple regression analysis, a high triglyceride-to-HDL cholesterol ratio at baseline (P = 0.006) and the use of ACE inhibitors (P = 0.007) were identified as the only independent predictors of progression of microalbuminuria. CONCLUSIONS: The rate of progression of microalbuminuria in NIDDM differs considerably between subjects. Diabetic dyslipidemia (high serum triglyceride and low HDL cholesterol) is a predictor of more rapid progression of microalbuminuria in patients with well-controlled blood pressure.

Vascular complications in relation to ethnicity in non-insulin-dependent diabetes mellitus.

The purpose of this study was to investigate the effect of ethnicity on the development of diabetic retinopathy and nephropathy as markers for microvascular complications and of angina pectoris as a marker for macrovascular complications. We evaluated data from 1124 patients with non-insulin-dependent diabetes mellitus (NIDDM) of Caucasian, Mongoloid, Asian, Armenian, Northern African and Negroid origin who were referred between January 1993 and December 1994. Logistic regression analyses showed that the occurrence of microvascular complications was significantly associated with duration of NIDDM. In addition, retinopathy was significantly associated with glycated haemoglobin A1c (HbA1c) and nephropathy with triglycerides (P < 0.05 and P < < 0.001 respectively). Northern African origin was associated with retinopathy (P < 0.05) and Asian origin with nephropathy (P < 0.005). Macrovascular complication was associated with age and triglyceride level (P < 0.001 and P < 0.05 respectively). Northern African and Negroid ethnicity exclusively did not show a gradual increase in the risk for angina pectoris with increasing age. Moreover, a negative association between Northern African as well as Negroid ethnicity and macrovascular complication was observed (P = 0.05 and P < 0.05 respectively). In support of these observations, we found a favourable lipid profile in both mentioned groups. In summary, we have shown that, in patients with NIDDM, ethnicity is associated with macrovascular complications and duration of the disease with microvascular complications.

Can reduction in hypertriglyceridaemia slow progression of microalbuminuria in patients with non-insulin-dependent diabetes mellitus?

The objective of this study was to investigate whether reduction in hypertriglyceridaemia is associated with a slower rate of progression of microalbuminuria in patients with non-insulin-dependent diabetes mellitus (NIDDM). Fifteen normotensive NIDDM patients with hypertriglyceridaemia (> 2.5 mmol L-1) and microalbuminuria were randomly selected to receive either placebo (eight patients) or gemfibrozil 600 mg b.i.d. (seven patients). Progression of microalbuminuria was assessed during a 12-month follow-up period with measurements, consisting of blood tests and triplicate 24-h urine collections, at 1, 3, 6, 9 and 12 months. All but one patient in the treatment group showed a favourable response (> or = 20% reduction) of hypertriglyceridaemia to gemfibrozil. One patient in the placebo group showed a spontaneous reduction in triglyceride levels. Progression of microalbuminuria was lower, although not statistically significantly so, in the treatment group (36%) than in the placebo group (65%). In the group with > or = 20% reduction in triglyceride levels, progression of MA was significantly lower than in the group with stable or increasing triglyceride levels (+1%, range -56% to +49% vs. +97%, range -35% to +202% respectively) (P = 0.03). Continued follow-up data of patients switching from placebo to gemfibrozil after the trial further support the role of serum triglyceride reduction in stabilizing albumin excretion. In conclusion, the results indicate that, in microalbuminuric NIDDM patients, effective treatment of dyslipidaemia could be associated with stabilization of urinary albumin excretion.

Influence of heparin, protamine and polybrene on the time integral of thrombin generation (endogenous thrombin potential).

We investigated the anticoagulating and heparin-neutralizing properties of protamine and polybrene (hexadimethrine bromide), using the endogenous thrombin potential (ETP) as the parameter to access plasma coagulability. The hypocoagulability induced by high doses of heparin (3 IU/ml) could be reversed by addition of protamine to a very limited extent only. Polybrene on the other hand did neutralize heparin at the equivalent concentration and a two-fold excess did not influence the ETP parameters. In vivo neutralization of high-dose heparin with protamine should therefore be reconsidered. Our experiments suggest polybrene to be superior over protamine with respect to neutralization of high doses of heparin.

Induction of autoantibodies to human enzymes following viral infection: a biologically relevant hypothesis.

Macro enzymes, i.e. complexes of normal (iso-)enzymes with an immunoglobulin, may be due to immunological cross-reactions evoked by specific viral antigenic determinants that are homologous to regions in the target enzymes. A search of the National Biomedical Research Foundation protein databank with the amino-acid sequence of human pancreatic amylase revealed a marked homology with a fragment of the yellow fever virus major envelope protein E: i.e. an overall identity of 19.7 per cent and a high degree (40.9 per cent) of conservative amino-acid substitutions over 119 amino acids. At each identical position, the corresponding residue of Taka amylase A was examined by three-dimensional structure analysis, to determine whether the position is likely to be buried or exposed. The existence of a site (epitope) on amylase recognized by an anti-amylase antibody is discussed.

[Fructosamine values in hyperthyroidism, hypothyroidism and gammopathy]. / Fructosaminwerte bei Hyperthyreose, Hypothyreose und Gammopathie.

Fructosamine values in two groups of hypo- and hyperthyroid patients were compared with the values in a reference group of non-diabetics. In hyperthyroid patients the fructosamine values were significantly lower than in the reference group. Also the mean concentrations of albumin and total protein in serum are significantly lower for hyperthyroid patients compared to hypothyroid patients. The results do not provide evidence for a simple relationship between fructosamine and protein values in these patient groups. Therefore we do not recommend to relate fructosamine to protein or albumin using correction factors. Under conditions of thyrotoxicosis fructosamine is no reliable indicator of previous serum glucose concentrations. The test is not affected by monoclonal IgG gammopathy.

Improved purification of human lactate dehydrogenase isoenzyme-3 and studies with its fluorescein isothiocyanate and biotin conjugates.

Lactate dehydrogenase (L-lactate:NAD+ oxidoreductase, EC 1.1.1.27) isoenzyme-3 (LD-3) has been isolated in milligram quantities from human erythrocytes. Using an improved procedure--which involves complete hemolysis of the erythrocytes, diethylaminoethyl (DEAE)-Sephacel column chromatography, and 5'-AMP-Sepharose 4B affinity chromatography--we obtained 23,000-fold purified isoenzyme from the crude hemolysate (overall yield about 90%). The final product was homogeneous on polyacrylamide disc gel electrophoresis and had a specific activity of about 435 kU/g. Its amino acid composition is presented. With the eventual aim to make visible and isolate IgA kappa antibody-secreting B lymphocytes, we developed reproducible methods for preparing fluorescein isothiocyanate isomer-1-conjugated LD-3 with a fluorescein/LD-3 molar ratio between 1.3 and 3.3, and biotinylated LD-3 with a biotin/LD-3 molar ratio between 1.3 and 2.5. In evaluating the stability of these two conjugates, we determined that they still can react with IgA kappa to form the IgA kappa (LD-3)2 complex.

Characterization of immunoglobulin A kappa autoantibodies to human lactate dehydrogenase isoenzyme-3.

We have purified with a cumulative recovery of 48% from the serum of a patient the immunoglobulin A kappa subunit of the lactate dehydrogenase-immunoglobulin A kappa (LD-IgA kappa) complex. It appears that the pI range of the complex is 5.4-5.8. The Ig part of the complex showed a monoclonal character, and the complex exhibited a 1:2 molar ratio of the Ig to the LD isoenzyme. From reconstitution experiments by two different methods we concluded that LD-3 is essential for restoring the original complex. Additional studies showed a recombination of the IgA kappa with both autologous and homologous LD-3, and a binding of LD-3 at the Fab region of the Ig. The estimated value of the affinity constant (Keq) was 2.1 X 10(9) liters/mol. Analysis of the specific LD-3-binding IgA kappa concentrations in the sera of five cases revealed a broad range of the individual immune response. Our first quantitative data on the lymphocyte subpopulations revealed a significantly increased OKT4/OKT8 ratio due to a reduction in the absolute number of T suppressor cells.

Partial characterization, properties, and clinical significance of a lactate dehydrogenase-immunoglobulin A kappa complex in serum.

The existence of a lactate dehydrogenase-immunoglobulin A kappa complex was demonstrated as a marked increase of lactate dehydrogenase activity at the lactate dehydrogenase-3 band in the agar-agarose gel-electrophoresis pattern of sera from seven patients from an unselected group of 21 800 patients. The complex was isolated, in an almost pure form, by gel filtration and affinity chromatography, from the serum of a patient with circulating hepatitis B surface antigen. The complex had a relative molecular mass (Mr) of approximately 445 000 as determined by gel filtration. Electrophoresis in sodium dodecyl sulfate in the absence of reducing agents showed the presence of two subunit bands with Mr 170 000 and 34 000. We therefore propose that the native complex consists of one monomeric immunoglobulin A kappa linked to two tetrameric lactate dehydrogenase molecules. The enzymic activity of the complex is probably from lactate dehydrogenase isoenzyme-5.

Purification of an alkaline phosphatase-lipoprotein-X complex.

An alkaline phosphatase isoenzyme was observed in an abnormal position in the agar-agarose gel pattern of sera from several patients suffering from intrahepatic and extrahepatic cholestasis. We purified this isoenzyme, by gel filtration and affinity chromatography, from the serum of a patient suffering from extrahepatic cholestasis. Analysis demonstrated an alkaline phosphatase-lipoprotein-X complex with a relative molecular mass of at least 669,000. We discuss the interpretation of alkaline phosphatase isoenzyme patterns produced by different techniques.

Properties and clinical significance of an alkaline phosphatase-lipoprotein-X complex.

The existence of an alkaline phosphatase-lipoprotein-X complex was demonstrated as an abnormally moving band in the agar-agarose gel alkaline phosphatase pattern of sera from 58 patients in a group of 72 patients whose sera contained lipoprotein-X. The position of the abnormally moving band in the agar-agarose gel alkaline phosphatase pattern and the percentage of alkaline phosphatase activity in the complex in relation to the total serum alkaline phosphatase activity depend on the serum lipoprotein-X concentration. The presence of the complex is a reliable indicator for cholestasis and of limited value in the differentiation between intrahepatic and extrahepatic cholestasis.

Low urinary oestrogen excretion during pregnancy, due to an impairment of fetal adrenocorticotrophic hormone secretion.

Four cases of newborn infants whose mothers had a low urinary oestrogen excretion during pregnancy are reported. Placental sulphatase deficiency in placental insufficiency were excluded by a dehydroepiandrosterone sulphate loading test. Postnatally, they developed a clinical picture characterized by an inappropriate secretion of cortisol which, by the results of an adrenocorticotrophic hormone stimulation test, appeared to be due to an impairment of adrenocorticotrophic hormone secretion. The prenatal and postnatal steroid metabolism is discussed.