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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