VASCULAR REFLEXES IN DIABETIC AUTONOMIC NEUROPATHY

doi:10.1016/S0140-6736(73)93323-0

The Lancet

Volume 302, Issue 7842, 15 December 1973, Pages 1354-1356

https://doi.org/10.1016/S0140-6736(73)93323-0 Get rights and content

Abstract

The vascular responses to the Valsalva manœuvre and sustained handgrip were measured in thirty-seven diabetics with signs and symptoms suggestive of autonomic neuropathy. The Valsalva manœuvre was abnormal in twenty-three (62%) and the handgrip was abnormal in fifteen (41%) of the patients. There was a significant correlation between the results of the two tests. The responses to the two tests were less abnormal in the fifteen patients with impotence alone, and only when this symptom was associated with other clinical features of diabetic autonomic neuropathy could it be reliably attributed to this disorder. Of the fourteen patients with postural hypotension, all had abnormal Valsalva responses, and eight had reduced handgrip responses. Motor-nerve-conduction studies showed that patients with these abnormal vascular reflexes had evidence of greater peripheral-nerve damage in their legs than those patients with normal responses. It is concluded that both the Valsalva and handgrip tests are useful in providing an objective assessment of the integrity of the autonomic nervous system in diabetes mellitus.

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2024, Journal of Diabetes and its Complications
Cardiovascular autonomic neuropathy (CAN) is a frequent complication of diabetes mellitus and is associated with increased morbidity and mortality in patients with diabetes. Hence, early and correct diagnosis of CAN is crucial. Standard cardiovascular reflex rests (CARTs) have been the gold standard of CAN assessment. Originally, CARTs consisted of five reflex tests, but measuring diastolic blood pressure response to sustained handgrip exercise has no longer been suggested as an established clinical test.
Increasing body of evidence suggests that isometric handgrip test should no longer be used for the evaluation of sympathetic dysfunction during cardiovascular autonomic neuropathy assessment in diabetic patients. The associations of isometric handgrip test results with parameters of hypertension and markers of hypertension-related target-organ damage in diabetic and non-diabetic individuals point toward its potential role as a screening tool to identify patients with high cardiovascular risk. The current review summarizes historical view of standard cardiovascular reflex tests and latest data on isometric handgrip test.
Simultaneous islet-kidney and islet-after-kidney transplantation
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The focus of this chapter is on patients with type 1 diabetes and end-stage kidney disease with a need for life-long dialysis treatment or, preferably, kidney transplantation. Since reduced kidney function and higher age are risk factors for severe hypoglycemia, the avoidance of severe hypoglycemia is important and follows the same treatment algorithm as with a normal kidney function. For many patients with type 1 diabetes kidney transplantation is the preferred treatment option, because life-long dialysis carries a high risk of mortality and decreases quality of life considerably. A careful selection of the adequate procedure by interdisciplinary transplantation teams may help to ensure optimal care for patients with diabetes undergoing combined transplantation. If the e-GFR is < 60 mL/min, then an islet or pancreas transplant alone is no longer indicated due to the higher risk of a reduction in eGFR by the immunosuppression used for this transplant. An eGFR between 30 and 60 mL/min pretransplant as compared to eGFR > 90 mL/min/1.73 m² increases the risk for developing the end-stage renal disease after the introduction of calcineurin inhibitor-based immunosuppression by 2.25-fold.1, 2 Very recently, a 13-year follow-up of simultaneous pancreas- or islet-kidney transplantation or pancreas-/islets after kidney transplantation in the same institution showed that the very high rate of severe hypoglycemia in this group of patients could be reduced significantly from 3.5 to 0.05 and 0.1 per patient years in the SPK/PAK and SIK/IAK groups, respectively.³ In islet-kidney transplantation the focus is to avoid severe hypoglycemia and to protect the transplanted kidney from hyperglycemic damage, which can be achieved by both approaches (pancreas- and islet transplantation).⁴ The indication for a simultaneous islet-kidney or islet-after kidney transplantation is given if the e-GFR falls below 30 mL/min and the patient has contraindications for pancreas transplantation and/or prefers the transplant option with fewer complications. The indication for islet transplantation alone is problematic hypoglycemia (≥ 2 annual episodes of severe hypoglycemia or one episode associated either with impaired awareness of hypoglycemia, extreme glycemic lability, or major fear and maladaptive behavior). The indication for simultaneous islet-kidney or islet-after kidney transplantation is to achieve a good glucose and risk factor management to protect the transplanted kidney from hyperglycemic damage.
Individualized therapeutic targets in these patients should consider a composite target of optimal glucose control without problematic hypoglycemia. Based on the evidence for efficacy and limitations of educational, technological, and transplant interventions in meeting the composite treatment target in this patient population, a tiered, four-stage treatment algorithm was previously proposed.⁴ According to this algorithm, all patients with type 1 diabetes and problematic hypoglycemia (with or without end-stage kidney disease) should undergo structured or hypoglycemia-specific education (Stage 1). In those who fail to meet treatment targets, continuous subcutaneous insulin infusion (with or without continuous glucose monitoring (CGM) or flash glucose measurement) should be considered as second line (Stage 2). Sensor-augmented pumps with threshold glucose suspend feature or the newly introduced semi-automatic pump (Medtronic 670 G) and/or very frequent contact with a specialized hypoglycemia service reduce hypoglycemia even in those who have previously undergone stages 1 and 2 (Stage 3). Patients with problematic hypoglycemia despite education, optimal technology, and frequent contact should be evaluated for beta-cell replacement (islet or pancreas transplantation) (Stage 4). This algorithm can resolve problematic hypoglycemia in over 70% of patients, ensuring optimal utilization of scarce transplant resources. The major challenge is to receive preemptive kidney transplantation before dialysis has to be started and whether to go for islet or pancreas transplantation.
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Citation Excerpt :
The Ewing test performer was blinded to the GAD-7 results. The standard Ewing’s criteria were used to define normal, borderline and abnormal values (Ewing, Campbell, Burt, & Clarke, 1973). Patients were evaluated as having normal autonomic function or parasympathetic, sympathetic, and combined dysfunction.
Patients with generalised anxiety symptoms generally complain of autonomic arousal symptoms. The present study examined the relationships between cardiovascular autonomic dysfunction and generalised anxiety symptoms.
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Citation Excerpt :
Autonomic testing involves studies to assess cardiovagal parasympathetic, sympathetic cholinergic, and sympathetic adrenergic function. Examples of autonomic tests include heart rate variability to respiration to assess cardiac parasympathetic activity, Valsalva maneuvers to measure sympathetic and parasympathetic baroreceptor arc function, handgrip and cold pressor tests to define sympathetic activity, and heart rate and blood pressure responses to postural changes (Freeman, 2006; Aslam et al., 2015; Ewing et al., 1973). Many conditions with chronic nausea show associated autonomic function abnormalities (Singh et al., 2016).
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2010, Endocrinology: Adult and Pediatric, Sixth Edition

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VASCULAR REFLEXES IN DIABETIC AUTONOMIC NEUROPATHY

Abstract

Lancet

Am. J. Cardiol.

Postgrad. med. J.

Diabetes

Diabetes

J. Am. Geriat. Soc.

J. Am. med. Ass.