Progression of diabetic nephropathy from the stage of macroproteinuria with near-normal renal function until start of dialysis was compared in 16 patients with type I and 16 patients with type II diabetes mellitus. The mean creatinine clearance at the beginning of the study was 89 +/- 13 ml/min/1.73 m2 in patients with type I and 81 +/- 6 ml/min/1.73 m2 in those with type II diabetes. Dialysis was started after a mean interval of 77 (44-133) months, when creatinine clearance had decreased to 8 +/- 2 ml/min/1.73 m2 in type I diabetic patients. The respective figures for type II diabetic patients were 81 (40-124) months and 7 +/- 2 ml/min/1.73 m2. The mean rate of decrease in creatinine clearance was 1.05 +/- 0.45 ml/min/month in type I and 0.91 +/- 0.41 ml/min/month in type II diabetes. The mean rate of decrease was 1.46 +/- 0.30 ml/min/month in type I diabetic patients with a systolic BP > 160 mmHg versus 0.80 +/- 0.42 ml/min/month with < 160 mmHg (P < 0.01). In the type II diabetics the respective figures were 1.38 +/- 0.40 ml/min/month versus 0.78 +/- 0.15 ml/min/month (P < 0.01). During the observation period the prevalence of coronary heart disease increased from 6 to 50% in type I and from 31 to 87% in type II diabetes. In conclusion, the rate of progression of diabetic nephropathy during the predialytic phase is similar in type I and type II diabetes; BP adversely affects the rate of progression to the same extent in both groups.

Simultaneous pancreas-kidney transplantation (SPKT) has become the therapy of choice in patients with Type I (insulin-dependent) diabetes mellitus who have end-stage renal disease. During the last decade graft and patient survival have been improved, the 1-year pancreas graft survival rate is currently at 81 % for SPKT [1].Several studies have shown that diabetic retinopathy and peripheral neuropathy are positively influenced by pancreas transplantation [2,3]. A recent study also showed that pancreas transplantation in non-uraemic patients can reverse lesions of diabetic nephropathy, but this is not seen before 5 years of normoglycaemia [4]. Diabetologia (2000) Abstract Aims/hypothesis. The aim of the study was to examine the effect of pancreas-kidney transplantation on the progression of macrovascular diseases in Type I diabetic patients with end-stage renal disease.Methods. The progression of cerebrovascular disease, coronary heart disease and peripheral vascular disease in uraemic patients with Type I (insulin-dependent) diabetes mellitus and who had had simultaneous pancreas-kidney transplantation was compared with that of recipients of a kidney transplant alone. Between 1986 and 1998 a total of 11 uraemic diabetic patients received a simultaneous pancreaskidney transplantation and 10 diabetic patients a kidney transplant alone. All transplants functioned for at least 24 months, the mean observation period was 69 ± 37 compared with 70 ± 33 months in both patient groups. Macroangiopathic diseases were classified in four stages as described earlier.Results. In the group with simultaneous pancreas-kidney transplantation progression of cerebrovascular and coronary heart disease was observed in four patients (36 %) and progression of peripheral vascular disease in five subjects (45 %). In the cohort with kidney transplant alone four patients (40 %) showed progression of cerebrovascular and coronary heart disease and five progression of peripheral vascular disease (50 %); the difference is not significant. Mean values of HbA 1 c (5.8 ± 0.2 vs 7.5 ± 0.6 %, p < 0.001) and serum triglycerides (1.2 ± 0.4 vs 2.0 ± 1.0 mmol/l, p < 0.05) were significantly lower in the patients with pancreas-kidney transplantation than in the patient group with kidney transplant alone. Serum cholesterol concentrations and blood pressures were similar in both cohorts. Conclusion/interpretation. From our results we concluded that pancreas-kidney transplantation reduces risk factors for the development of macroangiopathy but fails to halt progression of macrovascular diseases similar to Type I diabetic patients with kidney transplant alone. [Diabetologia (2000) 43: 231±234]

No abstract

We report on a Mycobacterium marinum infection in a diabetic woman 8 years after undergoing a combined pancreas-kidney transplantation. This is, to our knowledge, the first case report on an isolated skin infection with atypical mycobacteria after simultaneous pancreas-kidney transplantation. A genetic probe categorization revealed an infection with M. marinum. Skin tuberculosis caused by M. marinum is an uncommon complication in kidney or pancreas-kidney transplant recipients, hence the diagnosis can be delayed.

Facing organ shortages, increasing wait times and considerable mortality on dialysis, we question the current policy of HU allocation and propose more restrictive criteria with regard to individuals with vascular complications or repeated retransplantations in order to support patients on the non-HU waiting list with a much better long-term prognosis.

Despite improvements in dialysis therapy, the mortality rate of patients with end stage renal disease (ESRD) has remained high. A relatively high proportion of uremic patients dies within one year after the initiation of dialysis treatment. The aim of this study was to evaluate predictors for this early mortality in patients with ESRD. A total of 66 uremic patients were included in the study. Patients were divided in those who survived < 1 year (n = 17) and those who survived > or = 1 year (n = 49). We compared the prevalence of diabetes and hypertension and of vascular diseases as well as the prevalence of heart insufficiency (EF < 30%) and left ventricular hypertrophy (LVH). Additionally, we estimated the laboratory parameters serum creatinine, creatinine clearance, BUN, cholesterol, triglycerides, fibrinogen, serum protein, serum albumin and hemoglobin, and evaluated the indications for the initiation of dialysis therapy in both patient groups. The patients with survival < 1 year were significantly older (64+/-12 vs. 54+/-14 years, p<0.01) and showed a lower BMI (22+/-3 vs. 25+/-3, p<0.01) than those who survived > 1 year. The prevalence of diabetes (70% vs. 31%, p<0.05), cardiac insufficiency (70% vs. 16%, p<0.025), cardiovascular disease (65% vs. 28%, p<0.05) and peripheral vascular diseases (70% vs. 28%, p<0.05) was significantly higher in the patients with early mortality. The prevalence of hypertension was similar in both groups, however, the prevalence of LVH was significantly higher in the patients who survived < 1 year (88% vs. 37%, p<0.05). Laboratory parameters were not significantly different in the two groups of patients, with the exception of serum albumin, which was significantly lower in the patients with early mortality (3.5+/-0.6 vs. 3.9+/-0.4 g/l, p<0.02). Hyperhydration was the most common indication for the start of dialysis in patients with early mortality (59% vs. 13%, p<0.025). Cardiac insufficiency was the most common cause of death in these subjects (n = 10, 59%). Six individuals (12%) died within four weeks after initiating dialysis therapy. Thus, there are several predictors for early mortality in end-stage renal disease patients, including high age, low BMI, the presence of diabetes, coronary heart disease, heart insufficiency and LVH, as well as low serum albumin levels. A relatively high percentage of patients die shortly after the start of dialysis therapy. Heart insufficiency is the most common cause of early death in these patients.

Bilateral nephrectomy for treatment of refractory hypertension in chronic hemodialyzed patients has been infrequently carried out. We analyzed the benefits of this operation on blood pressure, clinical state, drug treatment, and quality of life. In 10 hemodialyzed patients with refractory hypertension, systolic (SBP) and diastolic (DBP) blood pressure were measured 1 month before nephrectomy bilateral and 3, 6, 9, and 12 months after. In addition, the use of antihypertensive drugs before and after surgery was evaluated. Four patients had SBP and DBP values characteristic of malignant hypertension. In all 10 patients hypertension responded neither to reduction of plasma volume by ultrafiltration nor to multiple antihypertensive drug therapy. Hypertensive crises were associated with cerebral hemorrhage in two patients, severe encephalopathy with persistent neural dysfunction in one patient, and encephalopathy and diplopia in another. Three months after bilateral nephrectomy blood pressure decreased significantly (P < .005) and was normal in nine patients. In one noncompliant patient with intradialytic body weight increases of nearly 10%, blood pressure was still elevated. Malignant or drug-resistant hypertension with hypertensive crises is an indication for bilateral nephrectomy. The clinical state and quality of life improved in all patients in the present study and antihypertensive treatment is no longer necessary.

An inverse relationship between plasma insulin levels and homocysteine (Hcy) concentrations in type 2 diabetic patients has been previously reported (1) and discussed (2,3). An association between hyperinsulinemia and elevated Hcy levels has been found (4), and others (5) have observed that acute hyperinsulinemia reduces plasma Hcy levels in healthy men. In addition, it has been documented that plasma Hcy could be affected by both metabolic control and duration of disease in type 2 diabetic patients (6). By using the clamp technique, others have found that acute hyperinsulinemia did not influence plasma Hcy levels in patients with type 2 diabetes (7). Although hyperhomocysteinemia has been widely accepted as a risk factor for premature atherosclerosis (8), the complex relationship among insulin levels, insulin resistance, and plasma Hcy has yet to be entirely elucidated.As part of a screening procedure for detecting subjects with clinical characteristics of the metabolic syndrome in Hungary, we measured total plasma Hcy levels (Abbott IMx) in hyperinsulinemic subjects with different stages of glucose intolerance. In a cohort of middle-aged (40-60 years) hyperinsulinemic subjects (38 men and 53 women, [means ± SD] age 47.6 ± 4.3 years, BMI 34.6 ± 4.9 kg/m 2 , waist-to-hip ratio 0.92 ± 0.07, fasting plasma insulin level Ͼ15 µU/ml and/or postprandial [120 min after oral glucose tolerance test with 75 g glucose] plasma insulin level Ͼ45 µU/ml, actual blood pressure 146 ± 16/87 ± 9 mmHg, serum LDL cholesterol level 3.73 ± 1.09 mmol/l, HDL cholesterol level 1.12 ± 0.30 mmol/l, triglycerides level 2.97 ± 2.38 mmol/l, and uric acid level 279 ± 79 µmol/l), the plasma Hcy, vitamin B 12 , and folic acid levels were simultaneously determined. Subjects were classified as having normal glucose tolerance (NGT), impaired glucose tolerance (IGT) or diabetes; subgroups were matched for age, sex, BMI, and actual blood pressure. No antidiabetic or lipid-lowering drugs were used by the patients screened. Normal values of plasma Hcy, folic acid, and vitamin B 12 levels in a nondiabetic and nonhyperinsulinemic control group (19 men and 28 women aged 45.0 ± 7.8 years) were also measured.Although fasting plasma insulin levels were comparable, postprandial values were significantly higher in subjects with IGT or diabetes than in those with NGT. Plasma Hcy levels were not elevated and did not increase significantly with different stages of glucose intolerance in hyperinsulinemic subjects. Folic acid and vitamin B 12 levels were also comparable in the investigated subgroups (Table 1). In addition, no significant difference (P Ͼ 0.05) was observed between hyperinsulinemic subjects (n = 91) and control subjects (n = 47) when plasma Hcy (9.28 ± 3.81 vs. 9.63 ± 2.70 µmol/l, respectively), folic acid (8.5 ± 5.9 vs. 7.5 ± 2.1 ng/ml), and vitamin B 12 levels (423 ± 141 vs. 356 ± 121 pg/ml) were compared. Plasma Hcy levels were significantly (P Ͻ 0.001) higher in hyperinsulinemic men (11.34 ± 4.72 µmol/l, n = 38, age 48.1 ± 4.1 years) than in hype...