1. Study Design and Renal Structural-Functional Relationships in Patients With Long-Standing Type 1 Diabetes
This study was designed to elucidate the cellular basis of risk of or protection from nephropathy in patients with type 1 diabetes. Entry criteria included diabetes duration of ≥8 years (mean duration, 22.5 years) and glomerular filtration rate (GFR) >30 ml·min−1·1.73 m−2. Patients were classified, on the basis of the estimated rate of mesangial expansion, as “fast-track” (upper quintile) or “slow-track” (lower quintile). A total of 88 patients were normoalbuminuric, 17 were microalbuminuric, and 19 were proteinuric. All three groups had increased glomerular basement membrane (GBM) width and mesangial fractional volume [Vv(Mes/glom)], with increasing severity from normoalbuminuria to microalbuminuria to proteinuria but with considerable overlap among groups. Vv(Mes/glom) (r = 0.75, P < 0.001) and GBM width (r = 0.63, P < 0.001) correlated with albumin excretion rate (AER), whereas surface density of peripheral GBM per glomerulus [Sv(PGBM/glom)] (r = 0.50, P < 0.001) and Vv(Mes/glom) (r = −0.48, P < 0.001) correlated with GFR. Vv(Mes/glom) and GBM width together explained 59% of AER variability. GFR was predicted by Sv(PGBM/glom), AER, and sex. Fast-track patients had worse glycemic control, higher AER, lower GFR, more hypertension and retinopathy, and, as expected, worse glomerular lesions than slow-track patients. Thus, there are strong relationships between glomerular structure and renal function across the spectrum of AER, but there is considerable structural overlap among AER categories. Given that normoalbuminuric patients may have advanced glomerulopathy, the selection of slow-track patients based on glomerular structure may better identify protected patients than AER alone.
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Received for publication 9 August 2001 and accepted in revised form 26 October 2001.
AIIRB, angiotensin II type 1 receptor blocker; ACEI, angiotensin-converting enzyme inhibitor; AER, albumin excretion rate; DBP, diastolic blood pressure; DN, diabetic nephropathy; ECM, extracellular matrix; EM, electron microscopy; GBM, glomerular basement membrane; GFR, glomerular filtration rate; HPLC, high-performance liquid chromatography; MBP, mean blood pressure; MC, mesangial cell; Mes, mesangium; MES, mesangial expansion score; MM, mesangial matrix; PGBM, peripheral glomerular basement membrane; SBP, systolic blood pressure; SF, skin fibroblast; TBM, tubular basement membrane.