microalbuminuria. This longitudinal study sought to examine the development of vision-threatening reti- nab disease. (VIRD). (proliferative retinopathy and.
Early Nephropathy Disease in Patients RICHARD DEBORAH
Predicts Vision-Threatening Retinal with Type I Diabetes Mellitus
E. GILBERT,* COLVILLE,t
Departments
of
*Medici,ie
CON TSALAMANDRIS,* and GEORGE JERUMS*
and
Ophthalmologv.
Austin
TERRI
and
J. ALLEN,*
Repatriation
Medical
Centre,
Heidelberg,
Victoria, Australia.
In type
Abstract. phropathy
opment sought nab
may
I (insulin-dependent) be
identified
of persistent to examine
disease
edema)
diabetic
diabetes
and
Glycated measured
at least
such
at least evolving
disease.
Eighty
data
yearly.
Thirteen
patients
were
type
I
identified.
13 (62%)
five
patients
of 69 (7%)
with
who
as
in AER
(P < 0.05) and more common
In such
patients,
proliferative
AER
was
with
150
evolving
X/±
1 .7 p.g/min
at the
persistently
normoalbuminuric
and
clinically
significant
macular
edema
also
sought
to examine
whether
the
topathologic
changes
( I ), only although
all
retinal
diseases
patients
affect
sociation
between
with
clinical
in some type
with
and
I diabetes,
of patients
and
nephropathy
but
in other
studies
studies
have
not
Ihese
potentially
confounded
control. diabetes
may
stages
identified
in its early
persistent microalbuminuria tion of nephropathy at which
is uncertain, sight-threatening
as
is the
(3,4).
(6-8) been
macubopathy.
taken to examine the relationship nephropathy and the development
may
be,
An
assug-
of patients mostly
mellitus, by
the
present
in
nephropathy and
addition,
could
diabetes
other
to both
Materials
Soc
gly-
Nephrol
9:
be explained
duration
factors
(CSME).
relationship
or
entirely
whether
involved
in
there
a common
complications.
and
Starting
Centre
of diabetes
diabetic
development
of
of evoludevelops
nephropathy was
and under-
between such early, evolving of VIRD, both proliferative
Methods
Patients
cross-
nephropathy
study
and control
in 1978,
diabetes
patients
clinic and
BP,
between
1978 and
data
diabetes
were
evolving
patients
were
during
had
persistent
the study
on
period
as defined in two
Second,
such
patients
were
Received March 28, 1997. Accepted July 22. 1997. Correspondence to Dr. Richard E. Gilbert, Department of Endocrinology. Austin and Repatriation Medical Centre (Austin Campus), Studley Road, Heidelberg 3084, Victoria, Australia.
gressed
throughout
1046-6673/0901 -0085$03.00/0 Journal of the American Society of Nephrology Copyright © 1998 by the American Society of Nephrobogy
nephropathy
in type
such
were
Because influence
the
the
basis
period.
as
between
I diabetes,
included.
Using
and 8 yr of longitudinal
only
two
data
these
follow-up
criteria.
First,
rate (AER)
specimens
to have
an AER
defined
by
AER
(10).
that pro-
a statistically
and
time
( 1 1).
enzyme inhibitors early ( I 2) and late before
criteria,
I
microalbuminuria excretion
log10
type
on presentation,
consecutive
also required
study
plasma
All other patients were classified as
of
by an albumin
regression
clinical
as having loss
persistent
of three
for
excretion,
designated weight
therapy with angiotensin-converting the rate of progression of both
therapy
I diabetes
were
developed
g/min
positive
3 mo
within I mo of diagnosis. type II diabetes. Patients to have
Medical
of evolving
Diabetic patients studied was at least 8 yr of bongitu-
ketonuria,
nephropathy required
every albumin
there
Patients
Repatriation
for a study
seen
hemoglobin.
of 20 to 200
significant
were
1995 for whom
evaluated.
and
of urinary
glycated
and insulin dependency were deemed to have having
Austin
recruited
Patients
and
if they
been
measurement
creatinine, dinal
of the
have
complications.
management
between Ihe
VIRD
glycemic
predisposition
been
(9). However, the stage time neovascularization
association
in
(J Am
neovascu-
has
by the effects
duration and long-term glycemic In type I (insulin-dependent) be
develops and
study
by
of diabetes.
1998)
between
Similarly.
vision-threatening
retinopathy (4,5),
his-
thickening
(2).
eventually
30%
blindness.
membrane
as macubopathy
approximately
I diabetes.
sectional
type
such
and
gbomerular
nephropathy
retinopathy
(VIRD)
larization
failure
develop
as basement
develop
nonproliferative
virtually
gested
such
one-third
renal
diabetes
duration
long-term
The
of both
with
85-89,
and
similar
retinopathy
cause
patients
control
despite
Diabetes
all
time
of laser photocoagulation for VIRD. These data suggest that patients with type I diabetes and evolving nephropathy may be at higher risk of developing VIRD than patients who remain cemic
is a leading
were
(P < 0.01) nephropa-
retinopathy
in patients
and the presence of microalbuminuria during the study period. Sixty-seven patients remained persistently normoabbuminuric.
Although
evolving
patients
normoalbuminuric
bar edema were both thy.
identified
of
with
(P < 0.001) in the absence of any difference in long-term glycemic control or duration of diabetes between the two groups. Clinically significant macu-
(AER) were was per-
increase
in eight
compared
persistently
and
with
developed
nephropathy
clinically early
were
by a progressive
VIRD
devel-
study reti-
with
patients
8 yr of longitudinal
nephropathy
ne-
the
and
patients
hemoglobin and albumin excretion rate every 3 mo. Ophthalmologic examination
formed having
by
retinopathy
in
kidney
mellitus,
stages
This longitudinal of vision-threatening
(proliferative
macular
evolving
early
microalbuminuria. the development
(VIRD)
significant
diabetes
in its
the
introduction
98 patients
were
identified.
may ( I 3) of
with
type
Eleven
86
of the American
Journal
of these
patients
urinary
albumin
kidney
were
disease.
4), cardiac
These
failure
Other
patients
initial
specimens
a study
(n
that
causes
other
urinary
tract
known
because
evolving
in Research
Table
other
renal
disease.
of the Austin
and
the clinical
nephropathy
on
attendance
Repatriation
for statistical acid
Each’
patient
Statistical
diagnosis
and treatment
the patient’s ipating
renal
Retinopathy
Study
Retinopathy
Study
retinopathy tions
and
was
Academy
used (DRS)
(14,15)
imal retinopathy were that was not clinically with
Preferred
were
for
diagnosis
or proliferative
of CSME
VTRD
was
considered
within
by Treatment
diagnosis
of Diabetic examinaAmerican
with
no or mm-
were
seen
every
due within
to CSME or 4 wk of the
retinopathy.
The
development
point
was
related
end
of the diagnosis
3
by the ophthalmobo-
photocoagulation was initiated
and
Urinary
of
to AER
with an interassay
was
coefficient
laboratory
data
obtained
pensation,
such
as ketoacidosis,
ment
for urinary
Table
1.
by a coated
of variation
during
periods
Baseline
Age
at diagnosis
creatinine
(tmolfL) Systolic BP (mmHg) Diastolic a
hemoglobin
bp
