Diagnostic strategy to monitor diabetic nephropathy.

Although much evidence supports the theory that microalbuminuria is predictive of the development of clinical diabetic nephropathy, other experimental data fail to support this conclusion. It remains unclear whether random urine samples offer as much clinical information as timed overnight or 24 hour samples. Clinical decisions as to treatment based on improved glycemic control or enhanced antihypertensive treatment should be structured to the urinary albumin concentration. Tubular dysfunction is common in diabetes, but is clinical relevance remains unclear.

Measurement of urinary retinol binding protein by immunonephelometry.

A method is described for the determination of retinol binding protein (RBP) by immunonephelometry. The assay is sensitive to 5 microg/l and has acceptable imprecision. The method correlates with an established ELISA assay. A provisional normal range is proposed for daytime random urine samples. The increased excretion of RBP in adult subject with type 1 diabetes mellitus is demonstrated.

Longitudinal study of urinary albumin excretion in young diabetic patients--Wessex Diabetic Nephropathy Project.

AIMS: This study was established to follow changes in albumin/creatinine ratio (ACR) and to determine the prevalence and degree of progression of microalbuminuria (MA) or of clinical proteinuria (CP) in children with Type 1 diabetes. The study has investigated subjects for up to 12 years in establishing the correlation between MA and gender, age, duration of diabetes and glycated haemoglobin (HbA1c). The study has defined clinical cut-offs for MA in daytime clinic urine samples in young diabetic subjects. METHODS: Three hundred and sixty-one patients were involved in the study, with 221 (61.2%) having over six sets of data. Urine samples were collected at routine annual clinic visits and analysed without prior freezing for ACR. Blood samples were taken for HbA1c measurement. Data including sex, age and duration of diabetes were recorded. RESULTS: A random clinic ACR of < 4.5 mg/mmol (males) and 5.2 mg/mmol (females) creatinine was used as the 'clinical cut-off' to define the presence of MA. The presence of MA was independent of HbA1c and duration of diabetes but appeared be associated with the adolescent years (> 10 years). There was little evidence of progression from normoalbuminuria to MA, or from MA to CP. Of patients aged 10-18 years, 30.9% of males and 40.4% of females had one or more episodes of MA. CONCLUSIONS: Persistent MA and random episodes of MA or CP may be associated with the adolescent years but not with duration of diabetes. Further study will reveal if the substantial increases in ACR sometimes seen during adolescence are predictive of diabetic nephropathy. Clinical cut-offs of < 4.5 and < 5.2 mg/mmol creatinine for males and females, respectively, are suggested for the interpretation of changes in ACR in random urine samples in young people with Type 1 diabetes.

An assessment of paediatric diabetes care in three centres in Russia and in Southampton, UK. The Paediatric Teams in Moscow, Tula, Tambov, Southampton.

AIMS: Young people in Russia with diabetes have an increased morbidity and a 10-fold increase in mortality compared with many European countries. This joint international study was set up to compare of care and outcomes against published guidelines in three Russian centres and one UK centre. METHODS: An assessment of the diabetic care of 368 children, based on the principles of the St Vincent Declaration, was undertaken in each centre. Data on prevalence, management, control and complications were collected in young people with diabetes < 16 years of age in each of the four centres over a 4-week period. RESULTS: The prevalence of diabetes was greater in Southampton (1:702 vs. 1:1378). At diagnosis Russian children had a higher incidence of ketoacidosis (69 vs. 29%) and stayed in hospital longer (30 vs. 3 days). In management Russian children received more injections per day (5 vs. 2). There was no significant difference in insulin dose for those under 10 years between countries (Southampton 0.69 U/kg vs. Russian 0.73 U/kg, P=NS). Older Russian children did not increase their insulin dosage, while children over 10 years in Southampton received significantly more insulin than the Russian children (Southampton 1.0 U/kg vs. Russian 0.77 U/kg, P< or =0.001). Twenty-nine per cent of the Russian children reported that they had insufficient insulin and 14% had to buy extra. HbA1c was higher in the Russian children (9.8% vs. 8.3%), increasing significantly with age. The Russian children showed a height deficit which correlated with HbA1c and diabetes duration. The Southampton children were heavier and with a higher body-mass index and their HbA1c did not rise similarly as in Russia. Severe hypoglycaemia was more common in the Southampton children (32 vs. 12%). Retinopathy was reported in 12% of the Russian children (Southampton 0%) and systolic blood pressure > 95th centile in 21% (Southampton 8%). CONCLUSIONS: This study demonstrates a significant difference in diabetic control and complications between the two countries which could be partially explained by a decreased availability and prescribing of insulin and blood glucose monitoring in Russia. Southampton has an education and management policy based on ambulatory care resulting in reduced hospital stay.