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Query: UMLS:C0011881 (diabetic nephropathy)
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Diabetes mellitus and hypertension are common diseases that coexist at a greater frequency than chance alone would predict. Hypertension in the diabetic individual markedly increases the risk and accelerates the course of cardiac disease, peripheral vascular disease, stroke, retinopathy, and nephropathy. Our understanding of the factors that markedly increase the frequency of hypertension in the diabetic individual remains incomplete. Diabetic nephropathy is an important factor involved in the development of hypertension in diabetics, particularly type I patients. However, the etiology of hypertension in the majority of diabetic patients cannot be explained by underlying renal disease and remains "essential" in nature. The hallmark of hypertension in type I and type II diabetics appears to be increased peripheral vascular resistance. Increased exchangeable sodium may also play a role in the pathogenesis of blood pressure in diabetics. There is increasing evidence that insulin resistance/hyperinsulinemia may play a key role in the pathogenesis of hypertension in both subtle and overt abnormalities of carbohydrate metabolism. Population studies suggest that elevated insulin levels, which often occurs in type II diabetes mellitus, is an independent risk factor for cardiovascular disease. Other cardiovascular risk factors in diabetic individuals include abnormalities of lipid metabolism, platelet function, and clotting factors. The goal of antihypertensive therapy in the patient with coexistent diabetes is to reduce the inordinate cardiovascular risk as well as lowering blood pressure.
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PMID:Diabetes mellitus and hypertension. 156 57

Estimates of the cost of diabetes should take into account the development of complications. Patient records identified from the 1987 National Hospital Discharge Survey were used to evaluate the risk of hospitalization due to late complications. Hospitalization for diabetic nephropathy reached a peak of 6.74/1000 between the ages of 45 and 54 years, compared to 0.14 to 1.80/1000 in controls. Diabetic patients less than or equal to 45 years of age were 46 times more likely to be hospitalized due to neuropathy. The risk of cardiovascular complications is high, with a greater incidence of arterial than venous disorders. Diabetic patients were 22 times more likely to be admitted for skin ulcers/gangrene, 15 times more likely due to peripheral vascular disease, and 10 times due to atherosclerosis. The risk of cerebrovascular accident and heart disease was 6 to 10 times greater in diabetic patients. Seventy-five per cent of diabetic cardiovascular disorders are myocardial infarction or chronic ischaemia. Hospitalization from renal complications occurs at younger ages than in the general population. Ophthalmic complications increase with age. Diabetic complications account for 2% of the total hospital admissions in the US in 1987. The total cost of the treatment of late diabetic complications was estimated at +5091 million (cardiovascular 74%; renal diseases 10%; nephropathy 3.6%; ophthalmic disorders 1.5%; other unspecified diseases 10%).
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PMID:The cost of hospitalization for the late complications of diabetes in the United States. 182 50

We performed a retrospective study on 1,019 patients with noninsulin-dependent diabetes who were followed for the past 20 years in our Diabetic Unit in order to determine the prevalence of overt diabetic nephropathy in relation to the other known complications of diabetes. In comparison with neuropathy, retinopathy and peripheral vascular disease, whose prevalence was 23.4%, 28.0%, and 27.4% respectively, the prevalence of macroproteinuria was significantly lower (7.0%). The prevalence of complications was correlated directly with patient age and duration of diabetes, and inversely with the degree of metabolic control. The reasons for the low prevalence of overt diabetic nephropathy in our population of noninsulin-dependent diabetics may be related to genetic factors, diet, other unknown environmental factors, or higher mortality rates in patients with renal disease.
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PMID:Prevalence of overt diabetic nephropathy in patients with noninsulin-dependent diabetes mellitus. 201 50

Since the late 1970s patients with diabetic nephropathy have formed an increasing proportion of new entrants to the Hospital renal dialysis and transplantation programme, reaching 28% for the three year period to December 1988. Between 1 January 1975 and 31 December 1988, 87 diabetic patients were accepted for treatment. Fifty-one per cent were European, predominantly type I diabetics. Maori (9% of the total reference population) accounted for a disproportionately high 47% due to an over-representation by type II diabetic patients (34 of 41 Maori). These findings cannot be explained by the higher prevalence in Maori of type II diabetes but appear to be due to a more prevalent and/or aggressive diabetic renal lesion in this group. On commencing treatment, nearly all patients had retinopathy and the majority had evidence of peripheral vascular disease, hypertension and neuropathy. CAPD was the initial mode of renal replacement therapy in 70% of patients. Overall patient survival was 77% at one year and 42% at three years, and survival on CAPD was 76% and 37% at one and three years, respectively. Patient survival on transplantation was 63% at one year and 58% at three years. Graft survival was 51% at one year and 46% at three years. Although the short term outlook for diabetic patients on renal replacement therapy is encouraging, longer term survival compared to non-diabetic patients is poor. Vascular disease is the major cause of death and an important factor in patient morbidity.
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PMID:Diabetic end stage renal failure--the Wellington experience 1975-1988. 203 73

The treatment of end-stage renal diabetic nephropathy remains a challenge. A large experience allows us to clearly outline the advantages and the drawbacks of continuous ambulatory peritoneal dialysis (CAPD) and continuous cyclic peritoneal dialysis (CCPD). Eighty-one patients, mean age 51.3 years, were treated over the last 9 years by CAPD-CCPD. Extrarenal complications, mainly vascular lesions, were present in this high-risk group of patients. The technique was modified in order to inject intraperitoneally, 4 times per day, insulin to control blood glucose level in CAPD patients. Actuarial survival was 92% at 1 year, 50% at 4 years mainly influenced by age: 85% survival at 2 years in 35 patients aged less than 50 years old and 62% at 2 years in 46 patients aged more than 50 years old. The main causes of death were of cardiovascular origin: myocardial infarction, stroke, atherosclerotic vasculopathy. The main causes of transfer to hemodialysis were due to technical complications. Peritonitis rate was one episode every 14 patient-months. Control of blood pressure, blood glucose levels, main biological parameters, and visual status were the clear advantages of the method. Peripheral vascular disease is not influenced by the technique. CAPD-CCPD is the technique of first choice in young diabetics and the preferential technique for home dialysis.
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PMID:Clinical aspects of continuous ambulatory and continuous cyclic peritoneal dialysis in diabetic patients. 248 84

Overnight albumin excretion rates were measured in 940 diabetic patients, 416 with insulin dependent and 524 with non-insulin dependent diabetes, and in 106 healthy volunteers. A significantly higher number of non-insulin dependent diabetic patients had abnormal albumin excretion compared with the insulin-dependent group (X2 = 15.2, p less than 0.002). Ten per cent of non-insulin-dependent and 7 per cent of insulin-dependent diabetic patients had albumin excretion rates in the range 30-150 micrograms/min and thus were at risk of the cardiovascular and renal complications of diabetes. Six per cent of non-insulin-dependent and 5 per cent of insulin-dependent diabetic patients had albumin excretion rates above 150 micrograms/min and thus were entering the phase of clinical diabetic nephropathy. Multivariate analysis revealed that male sex and retinopathy in insulin-dependent diabetes, and systolic blood pressure and retinopathy and peripheral vascular disease in non-insulin-dependent diabetes, were significantly related to albumin excretion. Only one patient with insulin-dependent diabetes of less than 5 years known duration had an albumin excretion rate in the range 30-150 micrograms/min, whereas such an excretion rate indicating patients at risk was observed at all durations of non-insulin-dependent diabetes. It is possible that during the long silent phase of non-insulin-dependent diabetes, before diagnosis, significant renal damage occurred.
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PMID:Comparison of the prevalence and associated features of abnormal albumin excretion in insulin-dependent and non-insulin-dependent diabetes. 259 49

The treatment of end stage renal diabetic nephropathy remains a challenge. A large experience allows us to clearly outline the advantages and the drawbacks of continuous ambulatory peritoneal dialysis (CAPD). 81 patients, mean age 51.3 years, were treated over the past nine years by CAPD-CCPD. Extrarenal complications, mainly vascular lesions, account for qualifying these patients as a high risk population. The technique was modified in order to inject insulin intraperitoneally, four times per day, to control blood glucose level. Peripheral vascular disease was prospectively studied in 19 patients. Actuarial survival was 92% at one year, 50% at four years mainly influenced by age: 85% survival at two years in 35 patients aged less than 50 years and 62% at two years in 46 patients aged more than 50 years. The main causes of death were of cardiovascular origin: arteritis, myocardial infarction, stroke. The main causes for transfer to an alternative method of treatment were technical complications. Peritonitis rate was one episode ever 14 months. Satisfactory control of blood pressure, blood glucose levels, main biological parameters, visual status were the clear advantages of the method. Peripheral vascular disease is not influenced by the technique. CAPD can be the technique of first choice in young diabetics awaiting a kidney transplant and the reference technique for home dialysis.
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PMID:[Clinical aspects of continuous ambulatory peritoneal dialysis in diabetics]. 306 89

The nephropathy complicating insulin-dependent diabetes mellitus (IDDM) has been well studied, but that complicating non-insulin-dependent diabetes mellitus (NIDDM) is less well defined. In patients with IDDM, the glomerular filtration rate is often increased early in the course of the disease, approaches normal with insulin therapy, but tends to remain slightly elevated throughout the ensuing 10-15 yr of insulin dependency. After the onset of overt azotemia, end-stage renal disease (ESRD) develops in approximately 5 yrs. Proteinuria may be intermittently positive in the earliest stages of diabetes, evolving into intermittent and then persistent microalbuminuria, which in turn blossoms into macroalbuminuria. Because 40-50% of IDDM patients develop proteinuria and two-thirds of this subpopulation develop ESRD, some 20-30% of any given cohort of IDDM patients eventually need dialysis or transplantation. Evidence indicates that diabetic nephropathy is associated with a greater incidence of eye, nerve, heart, and peripheral vascular disease. Nondiabetic renal disease complicating IDDM and NIDDM is associated with a lesser frequency and severity of these extrarenal manifestations. The prevalence of retinopathy increases with advancing nephropathy. Roughly two-thirds of the deaths from IDDM are related to renal failure, and most of the remainder are caused by associated cardiovascular disease. Transplantation from living relatives carries the best prognosis for survival, and little difference is seen between hemodialysis, peritoneal dialysis, and cadaver transplantation. The health-care costs of treating diabetic nephropathy are also reviewed.
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PMID:Clinical features and health-care costs of diabetic nephropathy. 307 74

A total of 125 patients with severe peripheral vascular disease were examined with translumbar aortography. The mean dose of contrast medium injected was 65 ml of Angio Conray (containing 31.2 g of iodine). Forty patients were pretreated with mannitol, and 32 received furosemide. Thirty-eight patients (30%) had diabetes and, presumably, diabetic nephropathy. Eleven of them had significant azotemia (creatinine values greater than or equal to 4 mg/dl). Administration of contrast material did not significantly reduce renal function in any patient group. We conclude that acute renal failure following the injection of contrast material is uncommon, is reversible, and almost always occurs when avoidable complicating factors are present.
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PMID:Contrast media for angiography: effect on renal function. 307 23

Over a period of 3 months 32 general practitioners in the Waikato kept copies of all consultations with patients with noninsulin-dependent diabetes mellitus. Of 229 patients with diabetes known to the practices 189 were seen on a total of 438 occasions. Mean fructosamine level was 2.93 mmol/L. Each consultation was analysed as to history obtained, examinations performed, investigations ordered and referrals made. Overall care was satisfactory except for the low incidence of checking for early signs of peripheral vascular disease or diabetic neuropathy affecting the feet and for diabetic nephropathy.
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PMID:The management of diabetes in general practice. 339 81


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