Most limbs with complications had superficial reflux either alone or combined with deep reflux, and few had deep reflux alone. Reflux was more frequent in posterior tibial veins for limbs with complications compared with those with uncomplicated primary varicose veins. Outward flow in perforators was common in limbs with complications and with uncomplicated primary varicose veins, but isolated outward flow in perforators was uncommon. Treatment directed to the superficial veins alone may be sufficient for most patients with complications.

OBJECTIVE -To investigate the role of intrarenal vascular disease in the pathogenesis of nonalbuminuric renal insufficiency in type 2 diabetes.RESEARCH DESIGN AND METHODS -We studied 325 unselected clinic patients who had sufficient clinical and biochemical information to calculate an estimated glomerular filtration rate (eGFR) using the Modified Diet in Renal Disease six-variable formula, at least two estimations of urinary albumin excretion rates (AER), and a renal duplex scan to estimate the resistance index of the interlobar renal arteries. The resistance index, measured as part of a complications surveillance program, was compared in patients with an eGFR Ͻ or Ն60 ml/min per 1.73 m 2 who were further stratified into normo-(AER Ͻ20), micro-(20 -200), or macroalbuminuria (Ͼ 200 g/min) categories.RESULTS -Patients with an eGFR Ͻ60 ml/min per 1.73 m 2 had a higher resistance index of the renal interlobar arteries compared with patients with an eGFR Ն60 ml/min per 1.73 m 2 . However, the resistance index was elevated to a similar extent in patients with an eGFR Ͻ60 ml/min per 1.73 m 2 regardless of albuminuric status (normo-0.74 Ϯ 0.01, micro-0.73 Ϯ 0.01, and macroalbuminuria resistance index 0.75 Ϯ 0.11). Multiple regression analysis revealed that increased age (P Ͻ 0.0001), elevated BMI (P ϭ 0.0001), decreased eGFR (P Ͻ 0.01), and decreased diastolic blood pressure (P Ͻ 0.01), but not an increased AER, were independently associated with an elevated resistance index in patients with impaired renal function.CONCLUSIONS -Subjects with type 2 diabetes and reduced glomerular filtration rate had similar degrees of intrarenal vascular disease, as measured by the intrarenal arterial resistance index, regardless of their AER status. The pathological mechanisms that determine the relationship between impaired renal function and AER status in subjects with type 2 diabetes remain to be elucidated. Diabetes Care 29:1560 -1566, 2006T raditionally, microvascular disease resulting in a glomerulopathy and an increase in albumin excretion rate (AER) is believed to be the only significant mechanism by which diabetic renal disease develops. However, recent results have challenged the concept that a decline in renal function in patients with diabetes is always accompanied by an increased AER. Results from our group (1,2) and from the Third National Health and Nutrition Survey (NHANES III) (3,4) have suggested that the finding of nonalbuminuric renal insufficiency is not an uncommon discovery for subjects with diabetes, especially those with type 2 diabetes.The structural basis of nonalbuminuric renal insufficiency in type 2 diabetes remains to be elucidated. However, the use of techniques such as duplex Doppler ultrasound allows for the rapid, noninvasive evaluation of the intrarenal vasculature (5). In particular, the presence of intrarenal vascular disease can be documented by the use of established methods such as the calculation of the resistance index (5,6). Intrarenal arteriosclerosis, as opposed to other forms of renal dama...

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Renal function was measured sequentially in 32 patients with proven renovascular hypertension who were treated with the oral angiotensin converting enzyme inhibitor captopril. Renal function was assessed by serial measurement of serum creatinine. Six patients showed acute rises in serum creatinine concentration compatible with acute renal failure. Acute renal failure was confined to those patients with stenosis to a solitary kidney (transplant or native, occurring in 3 of 8 patients) or bilateral renal artery stenosis (occurring in 3 of 13 patients). No rise in serum creatinine concentration was observed in 11 patients with unilateral renal artery stenosis during long-term angiotensin converting enzyme inhibitor therapy. Acute renal failure during angiotensin converting enzyme inhibitor therapy was not related to the degree of blood pressure fall or the plasma angiotensin II level. Eleven patients with renovascular hypertension were followed prospectively with estimation of renal function by 99mTc-diethylenetriaminepentaacetic acid (DTPA) clearance (determined by computer analysis of scintillation camera renography). In six patients with unilateral renal artery stenosis, total 99mTc-DTPA clearance and serum creatinine level remained constant following angiotensin converting enzyme inhibitor therapy, while in five patients with bilateral renal artery stenosis 99mTc-DTPA clearance fell from 40 +/- 9 to 27 +/- 5 ml/min (p less than 0.05). Split renal function studies revealed that 99mTc-DTPA clearance fell in most kidneys with stenosed arteries during angiotensin converting enzyme inhibition, including the stenosed kidney from patients with unilateral renal artery stenosis (16 stenosed kidneys studied; change in Tc-DTPA clearance, -7.5 +/- 2.7 ml/min).(ABSTRACT TRUNCATED AT 250 WORDS)

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