Weight gain adequacy and pregnancy outcomes in gestational diabetes: a meta-analysis

The Institute of Medicine updated guidelines for gestational weight gain in 2009, with no special recommendations for gestational diabetes. Our objectives were to describe the prevalence of weight gain adequacy and their association with adverse pregnancy outcomes in gestational diabetes. We searched MEDLINE, EMBASE, COCHRANE and SCOPUS. We calculated the pooled prevalence of gain adequacy and relative risks for pregnancy outcomes within Institute of Medicine categories. Thirty-three studies/abstracts (88,599 women) were included. Thirty-one studies provided data on the prevalence of weight gain adequacy; it was adequate in 34% (95% CI: 29-39%) of women, insufficient in 30% (95% CI: 27-34%) and excessive in 37% (95% CI: 33-41%). Excessive gain was associated with increased risks of pharmacological treatment, hypertensive disorders of pregnancy, caesarean section, large for gestational age and macrosomic babies, compared to adequate or non-excessive gain. Weight gain below the guidance had a protective effect on large babies (RR: 0.71; 95% CI: 0.56-0.90) and macrosomia (RR 0.57; 95% CI 0.40-0.83), and did not increase the risk of small babies (RR 1.40; 95% CI 0.86-2.27). Less than recommended weight gain would be beneficial, while effective prevention of excessive gain is of utmost importance, in gestational diabetes pregnancies. Nevertheless, no ideal range for weight gain could be established.

The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation is less accurate in patients with Type 2 diabetes when compared with healthy individuals

AIMS

To analyse the performances of Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) and of Modification of Diet in Renal Disease (MDRD) study equations to estimate glomerular filtration rate (GFR) in patients with Type 2 diabetes mellitus with GFRs >60 ml/min and in healthy volunteers.

METHODS

This cross-sectional study included 111 individuals (56 patients with Type 2 diabetes and 55 healthy volunteers), aged 58 ± 9 years; 54 individuals were men (49%) and ninety-eight (88%) were white. Glomerular filtration rate was measured by the (51) Cr-EDTA single-injection method ((51) Cr-GFR) and estimated according to the standardized MDRD and CKD-EPI equations. Serum creatinine was measured by a traceable Jaffe method. Bland-Altman analysis was used to examine the agreement between measured and estimated GFR. Bias, accuracy and precision were evaluated.

RESULTS

In diabetic individuals, (51) Cr-GFR was 106 ± 27 ml/min/1.73 m(2) , CKD-EPI-estimated GFR 82 ± 18 ml/min/1.73 m(2) and MDRD-estimated GFR 80 ± 21 ml/min/1.73 m(2) (P < 0.001). In healthy volunteers, the corresponding values were 98 ± 20, 89 ± 13 and 84 ± 14 ml/min/1.73 m(2) (P < 0.001). The accuracy of CKD-EPI (P30) was higher in healthy volunteers than in diabetic patients (90 vs. 66%, respectively, P < 0.001). The MDRD equation performed as poorly as the CKD-EPI equation in individuals with Type 2 diabetes.

CONCLUSIONS

The CKD-EPI equation is less accurate in patients with Type 2 diabetes when compared with healthy individuals, with a 2.5-fold greater bias.

Vascular complications of black patients with type 2 diabetes mellitus in Southern Brazil

Ethnicity has been shown to be associated with micro- and macrovascular complications of diabetes in European and North American populations. We analyzed the contribution of ethnicity to the prevalence of micro- and macrovascular complications in Brazilian subjects with type 2 diabetes attending the national public health system. Data from 1810 subjects with type 2 diabetes (1512 whites and 298 blacks) were analyzed cross-sectionally. The rates of ischemic heart disease, peripheral vascular disease, stroke, distal sensory neuropathy, and diabetic retinopathy were assessed according to self-reported ethnicity using multiple logistic regression models. Compared to whites, black subjects [odds ratio = 1.72 (95%CI = 1.14-2.6)] were more likely to have ischemic heart disease when data were adjusted for age, sex, fasting plasma glucose, HDL cholesterol, hypertension, smoking habit, and serum creatinine. Blacks were also more likely to have end-stage renal disease [3.2 (1.7-6.0)] and proliferative diabetic retinopathy [1.9 (1.1-3.2)] compared to whites when data were adjusted for age, sex, fasting plasma glucose, HDL cholesterol, hypertension, and smoking habit. The rates of peripheral vascular disease, stroke and distal sensory neuropathy did not differ between groups. The higher rates of ischemic heart disease, end-stage renal disease and proliferative diabetic retinopathy in black rather than in white Brazilians were not explained by differences in conventional risk factors. Identifying which aspects of ethnicity confer a higher risk for these complications in black patients is crucial in order to understand why such differences exist and to develop more effective strategies to reduce the onset and progression of these complications.

Degree of catecholamine hypersecretion is the most important determinant of intra-operative hemodynamic outcomes in pheochromocytoma

Pheochromocytoma resection is often complicated by intra-operative hypertension and post-resection hypotension. Factors associated with these hemodynamic alterations are not well defined. The aim of this study was to analyse the clinical-laboratory features associated with hemodynamic parameters during pheochromocytoma resection. Twenty-seven patients submitted to tumor resection - either open (no.=18) or video laparoscopic - between 1978-2007 were included. Nineteen received pre-operative alpha-blockers. Intra-operative hemodynamic data analysed were: maximum and minimum mean arterial blood pressure (MABP), no. of severe hypertensive (systolic BP >200 mmHg) and hypotensive episodes (MABP <60 mmHg), maximum and minimum heart rate (HR), no. of episodes of tachycardia and bradycardia, need to receive iv intra-operative treatment for hypertension and hypotension and the volume of fluids administered during surgery. Patients were 39.4+/-14.4-yr-old, 66% women. Intra-operative hemodynamic parameters were not different in patients submitted to open or video laparoscopic resection. Maximum intraoperative HR and the percentage of patients with HR>100 beats/min were higher in patients without pre-operative alpha- blocker treatment (no.=8). Pre-operative urinary vanylmandelic acid was positively associated with intra-operative maximum MABP (r=0.535, p=0.047) and with maximum transoperative systolic BP (r=0.805, p=0.016). Pre-operative urinary catecholamine (Pearson correlation r=0.575, p=0.03) and vanylmandelic acid (Pearson correlation r=0.605, p=0.04) levels were associated with maximum intra- operative MABP, adjusted for the presence of pheochromocytoma symptoms, surgical approach and pre-operative alpha-blockers. In conclusion, the degree of pre-operative catecholamine secretion was the most important aspect of transoperative BP control.

High-normal levels of albuminuria predict the development of micro- and macroalbuminuria and increased mortality in Brazilian Type 2 diabetic patients: an 8-year follow-up study

AIM

To analyse the risk factors for the development of micro- and macroalbuminuria and mortality rates in a cohort of normoalbuminuric Type 2 diabetes mellitus (DM) patients.

METHODS

In this prospective study, 193 Type 2 DM patients with urinary albumin excretion (UAE) < 20 microg/min, 96 men (50%), aged 56.5 +/- 9 years, were followed for a mean period of 8 +/- 3 years. UAE and estimated glomerular filtration rate (eGFR; Modification of Diet in Renal Disease) were measured. The outcomes were development of persistent micro- and macroalbuminuria and mortality.

RESULTS

Twenty patients were lost to follow-up. Of the 173 remaining patients, 33 (19%) died. The Cox analysis [hazard ratio (HR), 95% confidence interval] revealed that the baseline significant predictors of mortality were higher UAE [above median (5 microg/min); HR 2.7, 1.2-6.1; P = 0.02], male sex (HR 3.9, 1.7-9.2; P = 0.002), age (HR 1.6, 1.3-1.9; P = 0.0001), and fasting plasma glucose (HR 1.2, 1.1-1.3; P = 0.004). Smoking and eGFR were not significant in this model. Follow-up renal data were available for 158 patients: 34 (22%) progressed to microalbuminuria and seven (4%) to macroalbuminuria, and the baseline predictors were a higher UAE (> 5 microg/min, HR 2.5, 1.2-5.1; P = 0.02), presence of diabetic retinopathy (HR 2.5, 1.3-5.0; P = 0.009), fasting glucose (HR 1.1, 1.0-1.2; P = 0.015), and male sex (HR 2.2, 1.1-4.7; P = 0.04), independently of smoking and hypertension. Lower GFR (HR 0.98, 0.97-1.00; P = 0.07) was of borderline significance.

CONCLUSIONS

In normoalbuminuric Type 2 DM patients, the development of micro- or macroalbuminuria and mortality rates was independently and positively associated with higher levels of albuminuria, although still in the traditionally established normal range.

Urinary albumin excretion rate and glomerular filtration rate in single-kidney type 2 diabetic patients

OBJECTIVE

To evaluate the urinary albumin excretion rate (UAER) and the glomerular filtration rate (GFR) of single-kidney type 2 diabetic patients (SKD) and of single-kidney non-diabetic patients (SKN).

RESEARCH DESIGN AND METHODS

Patients who had only one kidney for at least 5 years, with no renal disease or hypertension at the time of the nephrectomy and with no calculus or systemic disease at the time of the evaluation, were included in this controlled cross-sectional study A total of 20 SKD (8 men, age 62 +/- 9 years; diabetes duration 8.5 +/- 7 years), 17 SKN (2 men, age 57 +/- 13 years), and 184 type 2 diabetic patients who were matched to the single-kidney diabetic group for age, sex, and BMI were studied. UAER was measured by immunoturbidimetry in timed 24-h sterile urine, and GFR was determined by the 51Cr-EDTA single-injection method.

RESULTS

SKD patients presented a higher proportion (8 of 20, 40%) of microalbuminuria (UAER 20-200 microg/min) than SKN patients (3 of 17, 17.6%) and type 2 diabetic patients (37 of 184, 20%). SKD patients presented a higher proportion of macroalbuminuria (UAER >200 microg/min; 6 of 20, 30%) than SKN patients (1 of 17, 6%) but were similar to type 2 diabetic patients (43 of 184, 23%). The GFRs of normoalbuminuric SKN (71.7 +/- 21.4 ml x min(-1) x 1.73 m(-2)) and SKD patients (73.0 +/- 21.5 ml x min(-1) x 1.73 m(-2)) were similar but higher than the one-kidney GFR (GFR / 2) of the age-, sex-, and BMI-matched normal individuals (50.5 +/- 9.0 ml x min(-1) x 1.73 m(-2)) and normoalbuminuric type 2 diabetic patients (54.0 +/- 11.6 ml x min(-1) x 1.73 m(-2)).

CONCLUSIONS

Increased GFR related to single-kidney status confers an increased risk of developing renal disease in the presence of diabetes.

Hypothyroidism in a Brazilian kindred due to iodide trapping defect caused by a homozygous mutation in the sodium/iodide symporter gene

A 36 year old man with a large goiter was suspected of having iodide (I-) transport defect based on low thyroidal and salivary gland radioiodide uptake. Thyroid surgery was performed, because thyroid cytology could not exclude a malignancy. Sequencing of the entire Na+/I- symporter (NIS) cDNA derived from thyroidal mRNA revealed a homozygous substitution of the normal cytosine in nucleotide (nt) 1163 with an adenine, resulting in a stop (TGA) at codon 272. This nonsense mutation produces a truncated NIS with undetectable I- transport activity when expressed into COS-7 cells. Genotyping confirmed that the propositus was homozygous for the mutation whereas his unaffected mother, son, and paternal aunt were heterozygous. This nt substitution was not detected in any of 50 normal individuals, ruling out a polymorphism. While the homozygous mutant NIS-272X causes congenital hypothyroidism, expression of one normal allele in the heterozygote (C272X) is sufficient to maintain active thyroidal I- uptake and function.

Five-year prospective study of glomerular filtration rate and albumin excretion rate in normofiltering and hyperfiltering normoalbuminuric NIDDM patients

OBJECTIVE

To evaluate the evolution of glomerular filtration rate (GFR) and albumin excretion rate (AER) of normofiltering (NF) and hyperfiltering (HF) normoalbuminuric NIDDM patients.

RESEARCH DESIGN AND METHODS

A longitudinal study of 32 normoalbuminuric (AER < 20 micrograms/min) NIDDM patients and 20 age-, sex-, and BMI-matched normal individuals was done. Subjects had their GFR (51Cr-labeled EDTA single-injection method) measured at entry and after 40 and 60 months. At entry, 13 NIDDM patients had GFR values above the upper limit of the normal range in our laboratory (> 137 ml.min-1 x 1.73 m-2) and were considered as HF. In NIDDM patients, the 24-h AER (radioimmunoassay), HbA1c, urinary urea, and mean arterial blood pressure (MBP) were analyzed at entry and after 40 and 60 months.

RESULTS

There was a significant decline of GFR in NIDDM patients and normal subjects at 60 months. The decline was significantly greater in HF patients (-0.61 ml.min-1.month-1; P = 0.001) than in NF (-0, 18) and control subjects (-0, 14); the rate of change in NF and control subjects was the same (P > 0.05). In stepwise multiple regression analysis, with GFR decline as the dependent variable and GFR and AER at baseline, age and change in MBP, change in urinary urea, change in HbA1c, and change in therapy as independent variables, only baseline GFR (R2 = 0.19, P = 0.002) and age (R2 = 0.31, P = 0.048) were significantly related to the outcome. At 60 months, AER raised > 20 micrograms/min in three HF and in four NF patients. In logistic regression analysis, only higher initial AER (although still in the normal range; P = 0.037) and an increase in urinary urea (P = 0.021) were significantly related to the later development of microalbuminuria.

CONCLUSIONS

The GFR of normoalbuminuric NIDDM patients declines significantly over 60 months. This decline is associated to baseline GFR and age. HF NIDDM patients show a faster decline in GFR than NF patients, whose GFR falls at a rate that is compatible with the age-related change observed in normal control subjects. The development of microalbuminuria is related to higher baseline AER and to increases in urinary urea and is similar in NF (4 of 19) and HF (3 of 13) NIDDM patients (P > 0.05).

Risk factors for development of proteinuria by type II (non-insulin dependent) diabetic patients

1. Renal involvement in non-insulin dependent diabetes mellitus patients is the single most important cause of renal failure. The aim of this study was to evaluate the clinical features and to assess the risk factors for the development of proteinuria by non-insulin dependent diabetic patients. 2. Risk factors (expressed as an odds ratio) were calculated by multiple logistic regression analysis taking into account age, sex, body mass index, known duration of diabetes, presence of arterial hypertension, fasting plasma glucose, cholesterol and triglycerides as independent variables and proteinuria as the dependent variable. Sixty-four normoalbuminuric (24-h albumin excretion rate < 30 micrograms/min, 27 females, mean age 53.7 years) and 53 proteinuric (24-h proteinuria > 0.5 g, 31 females, mean age 59.3 years) were studied. 3. Proteinuric patients were older, with a longer mean known duration of diabetes (12.4 vs 5.6 years), higher mean fasting plasma glucose (214 vs 168 mg/dl) and plasma creatinine (1.5 vs 1.1 mg/dl) and more frequently presented diabetic retinopathy (94% vs 23%), peripheral neuropathy (94% vs 23%) and arterial hypertension (73% vs 16%) than normoalbuminuric patients. Age > 50 years, body mass index > 28.6 kg/m2, known duration of diabetes > 10 years, presence of arterial hypertension, and fasting plasma glucose > 160 mg/dl were significantly and independently associated with development of proteinuria.

Glomerular hyperfiltration in NIDDM patients without overt proteinuria

OBJECTIVE--To evaluate the frequency and correlates of glomerular hyperfiltration in NIDDM patients without overt proteinuria. RESEARCH DESIGN AND METHODS--A cross-sectional study was conducted. Seventy-one consecutive NIDDM patients attending an outpatient clinic, with Albustix-tested negative urine and a 24-h AER < 200 micrograms/min, were examined for long-term complications of diabetes. We measured their GFR (51Cr-EDTA single-injection method), 24-h AER (RIA), plasma creatinine, HbA1c, total cholesterol, triglycerides, urinary glucose, and urea. RESULTS--GFR above the upper limit of the normal range for age-matched control subjects (137.1 ml.min-1 x 1.73 m2) was present in 15 of 71 (21%) NIDDM patients. Subjects with normal and hyperfiltration did not differ in terms of age, sex distribution, BMI, duration of NIDDM, BP, AER, or frequency of long-term complications. Plasma glucose was significantly higher in subjects with hyperfiltration (mean [range]: 12.8 [4.3-18.7] vs. 8.7 [2.6-17.5] mM). HbA1c failed to reach statistical significance, although it tended to be higher in the group with hyperfiltration (10.4 [6.7-13.9] vs. 9.4 [4.2-16.5]%, P = 0.10). Age (rS -0.37, P = 0.002), FPG (rS 0.45, P < 0.0005), total cholesterol (rS -0.31, P = 0.008), and glycosuria (rS 0.40, P = 0.001) correlated significantly with GFR. In a stepwise multiple regression analysis, FPG, age, and total cholesterol emerged as significant correlates of the dependent variable GFR. CONCLUSIONS--Hyperfiltration occurred in 21% of NIDDM patients without overt proteinuria. FPG and age significant correlates of the GFR in these patients. Cholesterol is significantly (although only modestly) correlated with the GFR.