[Role of nocturnal blood pressure in the onset of diabetic nephropathy]

The aim of this study was to assess the responsibility of night-time blood pressure in the onset of nephropathy in diabetic patients.

PATIENTS AND METHODS

This study included 98 diabetic patients (mean age: 54 +/- 15 years, diabetes duration: 15 +/- 10 years). An evaluation of diabetes and a 24-h ambulatory blood pressure were performed at the initial evaluation (Y0) and about five years later (Y5). At Y0, all patients had normal urinary albumin excretion (UAE) (<30 mg/24h). They were separated into two groups according to urinary albumin excretion at Y5: group (N +): UAE>30 mg/24h and group (N-): UAE<30 mg/24h. Twenty four hours ambulatory blood pressure, clinical and biological parameters recorded at Y0 were compared in both.

RESULTS

At Y5, there was 18 patients in group (N +) and 78 in group (N-). Patients of group (N +) were older than those of group (N-): 62.9 +/- 9.5 vs. 52.6 +/- 15.7 years, p<0.01, and their BMI was higher (28 +/- 5 vs. 25 +/- 4 kg/m2, p<0.03). Diabetes duration and Hb A1c levels did not differ from significant manner in both. At Y0, UAE was significantly higher in group (N +) than in group (N-): 13 +/- 7 vs. 8 +/- 6 mg/24h, p<0.01. At the initial evaluation, daytime systolic and diastolic blood pressures did not differ from significant manner in both. Systolic and diastolic BP night-time were higher in diabetic patients who developed microalbuminuria (SBP: 122 +/- 19 vs. 113 +/- 13 mmHg, p<0.05 and DBP: 70 +/- 6 vs. 65 +/- 10 mmHg, p<0.03). UAE collected at Y5 was correlated to night-time BP recorded at Y0 (SBP: r=0.381, p=0.001 and PAD: r=0.294, p=0.004) and night-time systolic BP explained 12.3% of the UAE variance. Progression of UAE between the two evaluations was found to be correlated to the night-time systolic BP recorded at Y0 (r=0.335, p=0.0008) and night-time systolic BP explained 11.7% of the progression variance. There was a negative correlation between UAE at A5 and the difference between daytime and night-time BP recorded during the same evaluation (r=- 0.230, p=0.024 with SBP and r=- 0.243, p=0.017 with DBP).

CONCLUSION

The results underlign the resposability of night-time blood pressure, and more especially of nighttime systolic blood pressure, for the onset of nephropathy in diabetic patients.

[Influence of blood pressure level on urinary albumin excretion rate and erythropoietin production in diabetic patients]

The purpose of this study was to investigate blood pressure variations during diabetic incipient nephropathy and to evaluate theirs consequences for erythropoietin (EPO) production.

PATIENTS AND METHODS

This study included 94 diabetic patients (mean age: 59.9 +/- 15.3 years, diabetes duration: 13.8 +/- 15.3 years). Patients were divided in two groups according to urinary albumin excretion rate (UAE): group 1: UAE <30 mg/24 hrs, N=64 and group 2: 30<UAE <300 mg/24 hrs; N=30 EPO levels and 24 hrs ABPM where compared between these two groups.

RESULTS

patients' age and BMI, diabetes duration and Hb A1c levels, blood pressure and creatinine clairance did not differ from significant manner between the two groups. 24 hrs BP and daytime BP did not differ according to UAE rate. Night-time BP was significantly higher in group 2 than in group 1 (SBP: 126 +/- 17 vs. 118 +/- 15 mmHg, p<0.04 and DBP: 71 +/- 10 vs. 67 +/- 8 mmHg, p < 0.02). UAE was positively correlated nigh-time BP (r = 0.263, p = 0.01 for SBP and r = 0.273, p = 0.008 for DBP) and negatively with the difference between daytime and night-time SBP (delta SBP) (r = -0.205, p < 0.05). Hemoglobin levels did not differ significantly between the two groups. EPO levels of group 2 were significantly lower than those of group 1 (15.1 +/- 5.6 vs. 17.7 +/- 6.2 mU/ml, p < 0.05). A negative correlation between UAE and EPO was found (r = -0.266, p < 0.01). UAE and delta SBP explained 12.2% of EPO variance.

CONCLUSION

in diabetic patients, elevation of night-time BP and reduction in nightime BP fall participate to the installation of incipient nephropathy. A significant decrease in EPO production is noted in the same time.

Diagnostic d’un syndrome de Klinefelter trois ans après chirurgie d’exérèse d’un tératome médiastinal

INTRODUCTION

The association between some types of tumor and Klinefelter's syndrome (KS) is often missed and diagnosis of the latter delayed, as in this case report.

CASE

We present the case of a 20 year-old patient for whom KS was not diagnosed until three years after thoracic surgery for a mediastinal teratoma.

DISCUSSION

The association between KS and mediastinal germ-cell tumors is not coincidental; it illustrates the relation between aneuploidy and oncogenesis. In a young adult male, palpation of the scrotum to look for microorchidism is justified when these tumors are diagnosed because 25% occur in patients with KS.

Epidemiology of the metabolic syndrome in 2045 French military personnel (EPIMIL study)

CONTEXT

The Metabolic syndrome is considered to be an important public health problem, but few epidemiological studies have defined the present situation in France. EPIMIL is a prospective epidemiological study that began on February 1, 2003.

SUBJECTS AND METHODS

This study was designed to identify the clinical and laboratory parameters of metabolic syndrome and cardiovascular risk factors in a population of 2045 male military personnel based in the Paris region. The initial 1-year cross-sectional study will be followed by a 10-year follow-up and patient care.

RESULTS

The 2045 subjects included 185 (9%) presented at least 3 of the 5 NCEP ATP III criteria defining metabolic syndrome. They were significantly older (42.2 +/- 8.5 yrs) than the other subjects (37.3 +/- 8.7 yrs, P<0.001), had a higher BMI (29.5 +/- 3.4 vs 24.8 +/- 2.9 kg/m2, P<0.001) and a greater body weight at age 20 (75.4 +/- 11 vs 70.4 +/- 8.5 kg, P<0.01). Smoking, little physical activity and family histories of diabetes and arterial hypertension were more frequent in these men. While levels of the cholesterol and CRP us were higher, Lp(a) and homocysteine concentrations were normal. Plasma insulin and BMI (r = 0.456 P<0.0001) and plasma insulin and waist circumference (r = 0.446 P<0.0001) were well correlated. Lastly, plasma insulin, free fatty acids and cardiovascular risk increased steadily with the increase in the number of metabolic syndrome criteria.

CONCLUSIONS

These results in a large and particularly uniform population of men show the prevalence of metabolic syndrome in adult men, and demonstrate its link with insulin resistance. Men with several risk factors require specific care, particularly for hypertension and dyslipidemia; the effectiveness of this care will be evaluated during the follow-up period.

Should pancreas imaging be recommanded in patients over 50 years when diabetes is discovered because of acute symptoms?

The relationship between diabetes mellitus and cancer of the pancreas is complex and incompletely understood. Nevertheless, it is generally agreed that new-onset diabetes in a patient over 50 Years old is a classical indication of pancreatic cancer. But there is no official directive in France that a scan should routinely be performed in such cases. We have studied 115 patients aged over 50 who were hospitalized for new-onset diabetes (fewer than 30 days) whose instability required insulin treatment. Routine imaging revealed abdominal disorders in 14 patients, 6 (5.2%) of whom were suffering from pancreatic adenocarcinomas. No clinical indication or laboratory test, apart from an unusually severe anorexia, suggested the discovered disorders. We therefore routinely carry out a pancreas scan, preferably by MRI, on all patients over 50 Years old presenting with new-onset diabetes, even if there are not clinical or laboratory indications of cancer. This is the only way in which small pancreatic cancers can be detected, thus providing the best hopes for successful treatment. Unfortunately, too often, this approach also detects only tumors that are already well developed. However, nowadays, it is not conceivable for a clinical team to discharge a patient from hospital with such a serious disease undiagnosed.

[Evolution of circadian blood pressure and urinary albumin excretion according to the type of diabetes over a 10-year period]

The aim of the present study was to evaluate the circadian blood pressure and rinary albumin excretion (UAE) according to the type of diabetes over a 10-year period.

PATIENTS AND METHODS

This study is based on 43 diabetic patients, 24 type 1 and 19 type 2. Ambulatory blood pressure monitoring was used to assess blood pressure at the initial evaluation (A0) and about 10 years later (A10). UAE was also checked at 10 years interval and was <30 mg/day at A0.

RESULTS

At A0, ABPM and UAE did not differ in a significant manner between type 1 and type 2 diabetics. Type 2 diabetic patients were older than type 1 (59.7 +/- 15.4 vs 42.9 +/- 12.9; p<0.0001) but the age of diabetes did not differ between the 2 groups. Between A0 and A10, there was an increase in 24 h SBP of type 1 and type 2 diabetics (type 1: 114 +/- 10 vs 124 +/- 12 mmHg; p<0.01 and type 2: 113 +/- 19 vs 135 +/- 13 mmHg; p<0.0001). 24 h DBP, as well as BP differences (day-night) did not differ between the 2 evaluations. At A10, 24 h SBP was higher in type 2 than in type 1 (135 +/- 13 vs 124 +/- 12 mmHg; p<0.001) but differences between day and night BP were not significant. In type 1 diabetes, progression of SBP was not associated with an increase in UAE rate, while this rate increased in type 2 betwwen A0 and A10 (9 +/- 7 vs 70 +/- 101 mg/24 h; p<0.01). AT A10, UAE was higher in type 2 than in type 1 diabetes (70 +/- 101 vs 14 +/- 31 mg/24 h; p<0.02). In type 2 diabetes, the progression of UAE was correlated with SBP at A10 (r=0.495; p<0.03).

CONCLUSION

The increase in BP levels and in UAE rate differ between type 1 and type 2 diabetes and these differnces are not due to patients age, nor to modifications in BP curves. They are probably linked to a physiopathology which could be more complex in type 2 than in type 1 diabetes.