The economic burden of nephropathy in diabetic patients in Germany in 2002

OBJECTIVE

The objective was to describe the resource use and costs due to predefined stages of nephropathy in diabetic patients and to evaluate its economical impact in Germany.

DESIGN AND METHODS

In this retrospective, observational study information about socio-demographics, clinical characteristics and resource use on adult type 1 and type 2 patients with nephropathy in diabetic patients were collected from 23 general practitioners, 10 internists and 24 diabetologists, who were randomly selected from a physicians' database. Based on these results average costs per patient were evaluated for each complication stage from the societal perspective and the perspective of the health insurance.

RESULTS

The costs due to nephropathy in diabetic patients increase dramatically with the progression of the disease. The main cost drivers were dialysis and hospitalization which accounted for 68% of the total costs due to nephropathy in diabetic patients. The total estimated costs related to nephropathy in diabetic patients were euro1332 (from the perspective of the health insurance) and euro2019 from the societal perspective.

CONCLUSION

Patients at high risk should be identified as early as possible and intensive diabetic case management should be provided to them to prevent or decelerate the expensive complications of nephropathy in diabetic patients.

Prevalence of cholecystolithiasis and its management among kidney/pancreas-transplanted type 1 (insulin-dependent) diabetic patients

BACKGROUND

Simultaneous pancreas/kidney transplantation (SPK) should be the procedure of choice for (pre)uremic patients with type 1 diabetes. All standard immunosuppressive protocols for SPK include a calcineurin-inhibitor. Both calcineurin inhibitors, cyclosporine (CyA) and probably tacrolimus (FK506) too, are associated with the occurrence of cholelithiasis due to their metabolic side effects.

PATIENTS AND METHODS

We evaluated the prevalence of cholelithiasis in 83 kidney/pancreas transplanted type I-diabetic patients (46 males, 37 females, mean age 42.8 +/- 7.5 years) by conventional B-mode ultrasound 5 years after transplantation. 56 patients received CyA (group 1) and 27 received tacrolimus (group 2) as first-line-immunosuppressive drug. Additional immunosuppression consisted of steroids, azathioprine or mycophenolate mofetil. Additionally, laboratory analyses of cholestasis parameters (gamma-GT and alcalic phosphatasis) were performed.

RESULTS

In total, 23 patients (28%) revealed gallstones and 52 patients (62%) revealed a completely normal gallbladder. In eight patients (10%) a cholecystectomy was performed before or during transplantation because of already known gallstones. No concrements in the biliary ducts (choledocholithiasis) could be detected. In group 2 the number of patients with gallstones was slightly lower (22%) compared with group 1 patients (30%), but without statistical significance. - Cholestasis parameters were not increased and HbA1c values were normal in both groups of patients.

CONCLUSION

The prevalence of biliary disease in kidney/pancreas transplanted type I-diabetic patients with 28% is increased in comparison to the general population (10-15%). Lithogenicity under tacrolimus seems to be lower as under cyclosporine based immunosuppressive drug treatment. We recommend regular sonographical examinations to detect an acute or chronic cholecystis as early as possible, which may develop occultly in these patients.

Immune challenge induces differential corticosterone and interleukin-6 responsiveness in rats bred for extremes in anxiety-related behavior

Disturbances in mood such as anxiety and depression are often associated with altered hypothalamo-pituitary-adrenal (HPA) axis reactivity, but also with changes in cytokine production, such as interleukin-6 (IL-6), an essential immune factor produced by macrophages and lymphocytes during inflammatory processes. The reciprocal relationship between the HPA axis and the immune system is now well established. In order to understand better the endocrine reactivity of anxious individuals faced with an immune challenge, a model of innate anxiety-related behavior, HAB and LAB rats (HABs, high and LABs, low anxiety-related behavior) was used in this study. We sought to determine whether injection of lipopolysaccharide (LPS) induced a differential HPA axis reactivity and plasma IL-6 release in HABs and LABs. After LPS injection, the plasma adrenal corticotrophic hormone increase did not differ between HABs and LABs, whereas a larger increase in plasma corticosterone levels occurred in HABs than in LABs at 2 h after injection. Moreover, basal IL-6 levels were lower in HABs than in LABs, leading to a higher IL-6 2 h/basal ratio in HABs. In conclusion, we propose for the first time a link between the endocrine and immune systems of HABs and LABs and suggest that IL-6 could be a neuroendocrine correlate of trait anxiety in HABs.

[HbA1c--the gold standard in the assessment of diabetes treatment?]

HbA1c is an important measure in monitoring treatment and management decisions in diabetic patients. It reflects the mean blood glucose level during the preceding 6 to 8 weeks. But this is true only for the population as a whole, not the individual patient. Differences between blood glucose and HbA1c values must be analysed precisely, because it is subject to numerous factors. HbA1c cannot replace blood glucose measurements for immediately assessing glucose metabolism and recognizing acute metabolic abnormalities. The mean HbA1c level predicts potential diabetic complications and is closely correlated with clinical angiopathic end-points. The quality of metabolic regulation can be assessed from HbA1c and blood glucose levels at defined times. But because of the numerous influencing factors HbA1c can be used as gold standard only with limitations. Developments, as in Great Britain and the USA, which take HbA1c as relevant basis for treatment ("pay for performance"), lead in a completely wrong direction and contribute neither to the validity of documented values in structured therapeutic programmes nor do they stimulate improvement in the overall management of diabetes. The quality of metabolic control should be determined entirely within the therapeutic target worked out together with the patient.

[Diabetes study in Bavaria: known risk factors correlate with an increased level of HbA1c]

BACKGROUND AND OBJECTIVE

Approximately six million Germans have been diagnosed with diabetes mellitus. A continuously increasing number of people with diabetes is expected within the next few years. Genetic disposition, age and especially lifestyle play an important role in the development of the disease. Diabetes normally develops during a long preclinical phase. During this preclinical phase an impaired glucose tolerance can easily be detected. Since an impaired glucose tolerance is often reversible the onset of diabetes can be prevented effectively by a change of lifestyle during this phase. The Bavarian Red Cross Blood Transfusion Service therefore determined the diabetes risk among its blood donors during two one-week study periods.

PATIENTS AND METHODS

The diabetes risk of the participating donors was assessed by using the FindRisk diabetes test published by the German Diabetes Foundation and the HbA1c test.

RESULTS

Approximately 12 percent of the participants (8187 persons aged 18-68 years) showed a moderate, high or even very high risk of developing diabetes within the next 10 years. The probability of developing the disease ranged from 17% (moderate risk) to 50% (very high risk). This corresponds to 3% of persons with unknown diabetes among the total population. An elevated HbA1c was found in approximately 5% of the donors in the first study week and in approximately 19% in the second study week. The analysis of the questionnaire and the HbA1c results indicated that elevated HbA1c values correlate with known diabetes risk factors. Persons with a body mass index greater than 25, an increased score in the FindRisk questionnaire and aged over 50 years more frequently showed an elevated HbA1c value.

CONCLUSIONS

The combination of a diabetes risk questionnaire and HbA1c testing could be used successfully for diabetes screening in an identified risk group.

Results of the pilot study of DIADEM: a comprehensive disease management programme for type 2 diabetes

AIMS

The purpose of the study was to evaluate the feasibility and preliminary clinical effects of the DIADEM disease management programme for type 2 diabetic patients.

METHODS

The study was performed at two test sites (Cardiff, UK: Aachen, Germany) including 137 and 166 patients, respectively. In 16 study centres any patients with type 2 diabetes capable of communicating by phone and able to perform blood pressure, blood glucose or urine glucose self-measurements were included. The maximum programme duration was 6 months at Cardiff and 4 months at Aachen, during which patients were assessed for glycaemic control, cardiovascular risk profile and the presence of complications of diabetes. Data were entered via the internet to a central server.

RESULTS

At entry into the programme the patient group in Cardiff had significantly lower mean age (60.3+/-9.4 years versus 64.9+/-8.7 years, p<0.001) and duration of diabetes (6.1+/-5.7 years versus 7.4+/-7.0 years, p<0.05) than in Aachen, however body mass index (31.6+/-5.2 kg/m(2) versus 29.5+/-4.9 kg/m(2), p<0.01), HbA1c (7.7+/-1.2% versus 7.1+/-1.2%, p<0.001) and systolic blood pressure (138.4+/-15.1 mmHg versus 133.5+/-11.5 mmHg, p<0.001) were significantly higher. In contrast, total cholesterol (4.7+/-1.0 mmol/l versus 5.5+/-1.1 mmol/l, p<0.001) was significantly lower in Cardiff compared to Aachen. Following entry into the programme highly significant improvements in HbA1c (Cardiff from 7.7% to 7.1%, p<0.001; Aachen from 7.2% to 6.8%, p<0.05) and total cholesterol concentrations (Cardiff: 4.66-4.46 mmol/l; Aachen: 5.33-5.15 mmol/l; both p<0.05) were observed. There were no significant changes in blood pressure at either site.

CONCLUSIONS

Intensive diabetes care was delivered to DIADEM patients and relevant and significant improvements in diabetes care were achieved demonstrating that an IT-based diabetes disease management service can improve care for patients with type 2 diabetes.

[Therapy of diabetes mellitus. Pancreas transplantation, islet transplantation, stem cell and gene therapy]

The long-term normalization of glucose metabolism - a prerequisite for the prevention of secondary complications in patients with diabetes mellitus - is only possible by transplantation of a whole pancreas or a reasonable number of islets. An absolute indication for pancreas grafting is given in type 1 diabetic patients with end-stage renal disease. The 1-year survival after simultaneous kidney/pancreas transplantation is, according to the international registry, 94-100% for patients, 89-92% for kidneys and 85-87% for the pancreas. The high success rate with long lasting normalization of glucose metabolism leads to a stabilization and/or amelioration of secondary complications, to an increase in quality of life and, most importantly, to a significant reduction in mortality when compared to diabetic kidney recipients. The indications for islet transplantation are similar to those for pancreatic grafting. Islet grafting is only a minor surgical procedure, but islet isolation is difficult. The 1-year survival for the recipients is 98%, for the islets 82% and for insulin-independency 42%. There is a significant decline of islet function to 10% 5 years after transplantation. Stem cell therapy would provide a definitive treatment solution not only for patients with type 1 diabetes. So far, this therapeutic option is still at an early stage of development.

HER2 therapy. HER2 (ERBB2): functional diversity from structurally conserved building blocks

EGFR-type receptor tyrosine kinases achieve a broad spectrum of cellular responses by utilizing a set of structurally conserved building blocks. Based on available crystal structures and biochemical information, significant new insights have emerged into modes of receptor control, its deregulation in cancer, and the nuances that differentiate the four human receptors. This review gives an overview of current models of the control of receptor activity with a special emphasis on HER2 and HER3.

Neural nitric oxide gene inactivation affects the release profile of oxytocin into the blood in response to forced swimming

This study was undertaken to examine the importance of nitric oxide (NO) generated by the neural isoform of the nitric oxide synthase (nNOS) on the activity of the hypothalamic neurohypophyseal system in neural nitric oxide synthase knock-out (KO) and wild-type (WT) mice under basal conditions and in response to forced swimming. The intensity of the hybridisation signal for vasopressin (AVP) in the hypothalamic supraoptic nucleus (SON) was significantly higher in KO mice when compared with WT, whereas oxytocin (OXT) basal mRNA levels were similar in both groups. Although the basal peripheral release of AVP and OXT was equivalent in both genotypes, we observed in KO mice a significant drop of AVP and OXT plasma values 15 min after stressor onset and a robust increase in the OXT plasma concentration at 60 min. These findings suggest that in the male mouse, NO inhibits AVP gene transcription in magnocellular neurones of the SON and collaborates in maintaining constant AVP and OXT plasma levels following acute stressor exposure, exerting a bimodal regulatory action on OXT secretion. We conclude that NO is involved in the regulation of magnocellular neurones of the SON, and it is preferentially implicated in the attenuation of the peripheral release of OXT induced by acute stressor exposure.