Diabetologia 9 Springer-Veflag 1986

Transcription

1 Diabetologia (1986) 29: Diabetologia 9 Spinge-Veflag 1986 Renal kallikein in diabetic patients with hypetension accompanied by nephopathy T. Baba 1, S. Muabayashi 1, T. Ishizaki 2, Y. Ido t, K. Aoyagi t and K. Takebe 1 1Thid Depatment of Intenal Medicine, Hiosaki Univesity School of Medicine, Hiosaki, and 2Division of Clinical Phamacology, Clinical Reseach Institute, National Medical Cente, Tokyo, Japan Summay. We measued the 24-h excetion of uinay kallikein in 27 patients with Type 2 (non-insulin-dependent) diabetes and in 10 nomal contol subjects. Mean (_+ SD) kallikein excetion in diabetic patients with nephopathy ( naphthyl units (NU)/day, n= 13) was significantly lowe than in contol subjects ( NU/day, p<0.01) and in diabetic patients without nephopathy ( NU/day, n= 14, p< 0.05). Kallikein excetion in hypetensive diabetic patients with nephopathy (5.1 +_ 1.6 NU/day, n = 8) was significantly lowe (p < 0.05) than in nomotensive patients with nephopathy ( NU/day, n= 5). Thee wee no significant diffeences in kallikein excetion ate (24-h excetion of uinay kallikein/24-h ceatinine cleaance) among contol subjects (9.9_+4.3 NU/ml), diabetic patients with (9.0+_ 3.2NU/ml) and without (9.3 _+ 3.5 NU/ml) nephopathy. Howeve, kallikein excetion ate in hypetensive diabetic patients with nephopathy (7.7 _+ 3.3 NU/ml) was significantly lowe (p< 0.05) than in nomotensive diabetic patients with nephopathy (11.8 _+ 2.0 NU/ml, n = 10). Respective basal and post-stimulated (with intavenous fuosemide 40mg plus 60 ain ambulation) plasma aldosteone concentations measued in contol subjects and in hypetensive diabetic patients with nephopathy wee simila and inceased to the same extent in the 2 goups ( vesus 5.3 +_ 3.2 and vesus _ 3.4 ng/ml), although the espective plasma enin activity tended to be lowe in diabetic patients than in contol subjects ( vesus and vesus ng -a. ml-1. h-l). The esults indicate that uinay kallikein excetion is deceased in hypetensive diabetic patients with nephopathy, and that the decease might not be attibutable to an alteed enin-aldosteone system. Key wods: Renal kallikein, uinay kallikein excetion, diabetes mellitus, hypetension, nephopathy, plasma aldosteone concentation, plasma enin activity. It has been epoted that the pevalence of hypetension in diabetic patients is geate than in non-diabetic subjects [1-3]. The development of hypetension appeas to be associated with diabetic nephopathy in patients with Type l (insulin-dependent) diabetes [4] and in those with Type 2 (non-insulin-dependent) diabetes [5]. Howeve, the pecise mechanism(s) fo developing hypetension in diabetes mellitus has not yet clealy been elucidated. The kidney is known to poduce and secete vasodilato-system substances such as postaglandins and kallikein, as well as the vasoconsticto-system substance, enin. Although much emphasis has been placed on the activity of the enin-angiotensin system [6-9], the vasodilato system has been elatively ignoed [10]. The enal kallikein-kinin system has been poposed to be involved in egulating wate and electolyte tanspot at the site of the distal nephons [11]. Howeve, thee ae almost no epots which discuss the enal kallikein-kinin system in diabetes mellitus in elation to diabetic nephopathy and/o hypetension. This study was designed to examine the uinay kallikein excetion pofiles in patients with Type 2 diabetes who did and did not have high blood pessue with and without nephopathy. Subjects and methods Subjects Twenty-seven Type 2 diabetic patients (11 males and 16 females aged 52.5 _+ 8.0 yeas, mean SD), whose plasma glucose levels wee elatively well contolled, and t0 nomal contol subjects without a family histoy of hypetension and without taking any medication (6 males and 4 females aged yeas), wee studied. Infomed consent had been obtained fom each of the subjects. Patients wee selected pospectively fo the study on the basis of age (30-65 yeas), duation of diabetes (3-15 yeas) and 24-h uinay albumin excetion data. The patients associated with uinay tact infection wee excluded fom the study. None of them had eceived any

2 T. Baba et al.: Renal kallikein in diabetic nephopathy 163 -e.~ m.w. ~.. -- cq v~ --. O N e2~,,o N~ ~d a= az +l +1 ~.~ antihypetensive agents (i.e. diuetic, beta-blocke, calcium antagonist), fibinolytic (i.e. uokinase) o ascobic acid duing at least 2 weeks peceding the study. These patients selected pospectively wee divided into 2 goups accoding to the absence (Goup A, n = 14) o pesence (Goup B, n= 13) of nephopathy. Those patients in the 2 goups wee futhe subdivided etospectively accoding to the absence o pesence of hypetension: nomotensive and hypetensive patients in Goup A ae, hencefoth, designated as A-N and A-Hy espectively, and those in Goup B as B-N and B-Hy in the same manne. The clinical chaacteistics of each goup petinent to the pesent study ae summaized in Table 1, which gives the data fo blood pessue, seum ceatinine, ceatinine cleaance (CC o GFR), plasma enin activity (PRA) and uinay albumin excetion obtained befoe each of the subjects was enolled in the study. In addition, the espective mean (+_ SD) values fo haemoglobin Ale wee , 6.7 _+ 1.1, and % of total in Goups A-N, A-Hy, B-N and B-Hy. The individual value fo haemoglobin Ale in nomal contol subjects was within the nomal limit (anging fom 3.8 to 5.8% of total, with a mean of %). The espective mean duations of diabetes wee , 4.8_+1.1, and 12.8_+3.5 yeas in Goups A-N, A- Hy, B-N and B-Hy. The mean duations of diabetes in patient goups with nephopathy (B-N and B-Hy) wee significantly (p< 0.01) longe than those in the goups without nephopathy (A-N and A-Hy). t'n t"q t ~- ~z ~Seq ~z 9 v-, x-- dee d~ V Z as im d --~ ~V 9. ~ +-~.~ m Diagnostic citeia The diagnosis of diabetes was made by the esults of the 75-g oal glucose toleance test. A subject was classified as having diabetes accoding to the citeia of the National Diabetes Data Goup [12]. The diagnosis of hypetension was confimed when the mean systolic blood pessue of thee successive measuements on diffeent occasions was 160 mmhg o geate, and/o the mean diastolic blood pessue was 90 mmhg o geate. Blood pessue was measued by mecuy sphygmomanomety in the ight am with the subject seated, his o he am esting on a desk and with the same obseve pefoming all the measuements. The diastolic eading was taken as the level at which the sound disappeaed (phase V). The diagnosis of nephopathy was made when 24-h uinay excetion of albumin, which was detemined by adioimmunoassay (intaassay coefficient of vaiation, CV, 5.4%) [13], exceeded 200 mg [14, 15]. ~('-I Study design and measuements o9 y. +1 +l ~'~.~ Oh e~ '~ ~ =~.~ tt'3 ~ 9 ~,~ ~ 9 Q Ig5. ~.,~ "li~ t"l 1) dv < }g +la? i~m 9 ~ =? v All subjects wee advised to consume a diet containing appoximately 8-10 g/day of NaC1 fo 2 weeks befoe and duing the study. A 24-h uine sample was collected fo 2 days fom each of the subjects fo measuing kallikein, sodium and ceatinine excetions. The aveage of these 2 values obtained fom the 24-h samples collected fo 2 days was calculated. On a sepaate day (within a week befoe uine samplings as descibed above), venous blood samples wee obtained fom all the subjects at hous fo measuing PRA afte each subject had been kept in the supine position fo at least 30 ain. In addition, blood samples wee taken fom the contol subjects and fom the Goup B-Hy patients fo measuing plasma aldosteone concentations (PAC) and PRA befoe and afte each subject had been kept in the upight position fo 60 min following an intavenous administation of fuosemide (40 mg bolus). The data wee compaed between these 2 goups. This pat of the study was, howeve, not pefomed in the othe goups of diabetic patients. Uinay kallikein was detemined by measuing its esteolytic activity using L-polyl-L-phenylalanyl-L-aginine-a-naphthyleste (Po- Phe-Ag-NE) as the substate [16]. Biefly, to 0.1 ml of each uine sample wee added 0.1 ml of substate solution containing 3mmol Po-Phe-Ag-NE (Sanwa Kagaku Kenkyusho, Nagoya, Japan) and 1.0ml of 100 mmol sodium phosphate buffe (ph7.0) containing 0.03% sodium dodecyl sulfate. Incubations wee caied out at 37 ~ fo 30 ain to hydolyze the substate (A1). A blank test was done by incubating the mixtue without the substate (A2) o the mixtue without the sample uine (A3). Afte the incubation, 0.1 ml of 1% solution

3 164 T. Baba et al.: Renal kallikein in diabetic nephopathy '"2 Nz N~ 5._~ Contol Goup A Goup B subjects I I Diabetic patients Fig. 1. Uinay kallikein excetion expessed in naphthyl units (NU) pe day in the thee study goups. Type 2 diabetic patients with nephopathy (Goup B, n= 13) exceted the least amount and diffeed significantly (p<0.05) fom those without nephopathy (Goup A, n = 14) and (p < 0.0t) fom the nomal contol subjects (n = 10). Data ae pesented as mean+ SD. *p< 0.05 fom Goup A Type 2 diabetic patients; **p < 0.01 fom contol subjects.= ~" _~10. =3 >'~ S" ~J N Hy N Hy Goup A Goup B Fig.2. Uinay kallikein excetion in the 4 subdivided goups of Type2 diabetic patients. Hypetensive patients with nephopathy (Goup B-Hy, n= 8) exceted the least amount and diffeed significantly (p<0.05) both fom nomotensive patients with nephopathy (Goup B-N, n = 5) and fom nomotensive patients without nephopathy (Goup A-N, n= 10). The diffeence between Goup B-Hy patients and hypetensive patients without nephopathy (Goup A-Hy, n=4) did not each significance (p<0.1). The data ae pesented as mean + SD. *p<0.05 fom Goup A-N and fom Goup B-N Type2 diabetic patients. NU = naphthyl units c- o ~Z ~Elo- OJ'~._~ Z p--,,n 5- -6" x N Hy N Hy Goup B Goup A Fig.3. Kallikein excetion ate in the 4 subdivided goups of Type2 diabetic patients. Kallikein excetion ate is calculated fom a 24-h uinay excetion of kallikein divided by a 24-h CC (GFR) using the same uine sample collected on the same day and expessed as NU/ ml. Kallikein excetion ate in hypetensive diabetic patients with nephopathy (Goup B-Hy) was significantly lowe (p<0.05) than in nomotensive diabetic patients with nephopathy (Goup B-N). Othewise, thee wee no significant diffeences among the mean values fo kallikein excetion ate. The data ae pesented as mean + SD. *p< 0.05 fom Goup B-N Type 2 diabetic patients. NU = naphthyl units of Fast Red ITR salt was added, and the mixtue was allowed to stand at 37 ~ fo 5 min until 1.0 ml of acetic acid was added. Absobance of the colo developed by the diazo-coupling eaction was measued at 475 nm by a spectophotomete (Hitachi 228-A, Tokyo, Japan). The absobance due to the kallikein activity was calculated as [AI-(A2+A3)]. Enzyme activity was estimated fom the standad cuve which was obtained by using standad solutions of a puified kallikein of pig panceas (Sanwa Kagaku Kenkyusho, Nagoya, Japan). Enzyme activity of uinay kallikein was expessed in naphthyl units (NU). One NU is the amount of kallikein which can hydolyze 1.0 ~tmol of Po-Phe-Ag-NE pe min. By using this method, the intaassay CV was 2.8%. Kallikein excetion ate was calculated fom a 24-h uinay excetion of kallikein divided by a 24-h CC (GFR) using the same uine sample collected on the same day and expessed as NU/ml. The mean of two values fo the kallikein excetion ate obtained fom the samples collected fo 2 days was ecoded in each subject. Seum ceatinine was measued in an Auto-Analyze (SMAC I, Technicon, Taytown, NY, USA) by spectophotomety (intaassay CV, 4.1%). Uinay ceatinine and sodium wee measued by spectophotomety and ion-selective electode method espectively, in an Asta4 (Beckman, Fulleton, CA, USA) (intaassay CV, 2.8% fo ceatinine and 0.9% fo sodium). PRA [17] and PAC [18] wee measued by adioimmunoassay using commecial kits (CEA-IRE- SORIN) (intaassay CV, 2.3% fo PRA and 3.6% fo PAC). Glycosylated haemoglobin Aac was measued by high-pefomance liquid chomatogaphy [19] on a cation-exchange minieolumn (Auto Ale HA-8110, Kyoto Daiichi Kagaku, Kyoto, Japan) (intassay CV, 2.2%). Statistical analysis Aveage data ae given as the mean +_ 1 standad deviation (SD). Statistical compaison of goup means employed Student's t-test whee appopiate. Regession lines wee calculated by the least squaes analysis and the coefficient of coelation () was tested. We also evaluated the contibution of the individual factos to the oveall vaiability in systolic blood pessue o uinay kallikein excetion by using a multiple linea egession pogam (JMA Reseach Institute Inc., Tokyo, Japan). A p value less than 5% was consideed statistically significant. All statistical analyses wee done with a compute (PC-9801, NEC, Tokyo, Japan). Results The mean (+ SD) value fo uinay kallikein excetion in the Goup B diabetic patients ( NU/day, n=13) was significantly lowe (p<0.01) than in the contol subjects ( NU/day, n = 10), and even lowe (p<0.05) in the Goup A patients ( NU/day, n = 14) (Fig. 1). Although the uinay excetion of kallikein in Goup A-N (9.3_+ 3.4 NU/day, n = 10) was simila to that in Goup A-Hy ( NU/day, n=4), the kallikein excetion in Goup B-Hy ( NU/day, n = 8) was significantly educed (p<0.05) as compaed to that in Goup B-N ( NU/day, n=5) (Fig.2). The mean values fo the 24-h uinay excetion of sodium wee mmol/day in contol subjects, mmol/day in Goup A and mmol/day in Goup B, and thee wee no significant diffeences among the values. Similaly, thee wee no significant diffeences among the mean values fo kallikein excetion ate in contol subjects ( NU/ml), in Goup A ( NU/ml) and in Goup B ( NU/ml). Howeve, the kallik-

4 T. Baba et al.: Renal kahikein in diabetic nephopathy 165 Table 2. Summaized data deived fom multiple egession analysis obtained fom 27 patients with Type 2 diabetes meilitus Dependent vaiables 24-h uinay excetion of kallikein Systolicblood pessue Independent vaiables Patial Standadized F Patial egession patial egession coefficient egession coefficient coefficient Standadized patial egession coefficient Age Systolic blood pessue Diastolic blood pessue h ceatinine cleaance Pesence of nephopathy b uinay excetion of albumin h uinay excetion of kallikein b b b a ~' Statistically significant at p<0.05; b statistically significant at p<0.01 ein excetion ate in Goup B-Hy (7.7_+3.3 NU/ml) was significantly lowe (p<0.05) than that in Goup B-N (11.8 _+2.0 NU/ml) (Fig.3), wheeas this value in Goup A-Hy ( NU/ml) was not significantly diffeent fom that in Goup A-N ( NU/ml). Compaison of the uinay kalli~ein excetion with clinical paametes assessed in the pesent study (24-h CC, systolic blood pessue, diastolic blood pessue, 24-h uinay excetion of albumin, haemoglobin Ale) evealed no significant coelation within each of the study goups (Goup A, Goup B diabetic patients and contol subjects). Howeve, thee was a tend towad obsevations that 24-h uinay excetion of kallikein was positively elated (= 0.275) to the 24-h CC and negatively (= ) to the systolic blood pessue in the Goup B diabetic patients. The multiple egession analysis data deived fom 27 diabetic patients ae summaized in Table 2. Systolic blood pessue was negatively elated (p<0.05) to the 24-h uinay excetion of kallikein among the vaiables examined. Howeve, both diastolic blood pessue and nephopathy wee positively (p < 0.01) and 24-h uinay excetion of kallikein was negatively (p< 0.05) elated to the systolic blood pessue (Table 2). The following ode of the powe contibuting to the oveall vaiability in 24-h uinay kallikein excetion o systolic blood pessue was found: systolic blood pessue>24-h CC > age > pesence of nephopathy > diastolic blood pessue > 24-h uinay excetion of albumin fo 24-h uinay excetion of kallikein; and diastolic blood pessue > pesence of nephopathy> 24-h uinay excetion of kallikein > age > 24-h uinay excetion of albumin > 24-h CC fo systolic blood pessue. A simila tend towad the above obsevations was obtained when all study subjects (n = 37) wee included. The mean value fo basal PRA in Goup B-Hy (0.7 _+ 0.6 ng. ml- 1. h- 1) was significantly educed (p < 0.05) as compaed to that in contol subjects ( ng. ml-1. h-1). The PRA afte the stimulation with fuosemide and ambulation in Goup B-Hy (1.8 _+ 1.8 ng. m1-1- h -1) was lowe, but not significantly, than that in contol subjects (3.0_+2.6ng-ml-l.h-1). The mean value fo basal PAC in Goup B-Hy ( ng/ml) was simila to that in contol subjects (5.5 _+ 3.2 ng/ml). The stimulation with fuosemide plus ambulation inceased the PAC to a simila extent both in the contol subjects (9.3 _+ 2.6 ng/ml) and Goup B-Hy diabetic patients (10.5 _+ 3.4 ng/ml). Discussion It has been demonstated that uinay kallikein is synthetized by the kidney [20-22]. Renal kallikein is known to diffe fom plasma kallikein in its biochemical, immunological and functional chaacteistics [11], and uinay kallikein appeas to be chemically simila to enal kallikein [23]. Theefoe, uinay kallikein has been assumed to be an index of enal kallikein secetion [24-26]. Pevious studies have shown that uinay kallikein excetion is deceased in patients with essential hypetension [24, 27], in spontaneously hypetensive ats [28], and in patients with hypetension associated with enal paenchymal disease [29], implying that an alteed inta-enal activity of kallikein-kinin system may exist in some foms of hypetension. The obseved decease in uinay kallikein excetion in diabetic nephopathy (Goup B) is most likely attibutable to enal paenchymal damage due to diabetes mellitus. A decease in uinay kallikein excetion has been documented in patients with enal paenchymal disease [29] and in expeimental enal disease [30]. Thee was a tend towad obsevation that the 24-h uinay excetion of kallikein was positively elated to the 24-h CC in the Goup B diabetic patients, although the coelation did not each a statistically significant level. Futhemoe, no significant diffeences wee found among the values fo uinay kallikein excetion ate expessed as factoed by GFR in each of the study goups. These obsevations may suggest that enal impaiment would affect uinay kallikein excetion and that the low uinay kallikein excetion in Goup B would be a esponse to eduction in the nephon numbe due to diabetes mellitus. A decease in uinay kal-

5 166 likein may indicate an alteed tubula function in diabetic nephopathy, since kallikein is localized in the convoluted distal tubules [31] and kinin is fomed in the distal pats of the nephons [32]. The elatively high kallikein excetion ate in the Goup B-N diabetic patients may be explained by acceleation of the poduction of enal kallikein in ode to maintain sodium and wate excetion, o by the elatively good maintenance of enal tubula function as compaed with glomeula function [311, o both. A close elationship between the enal kallikeinkinin system and the enin-angiotensin-aldosteone system has been suggested by seveal investigatos: uinay kallikein is inceased in pimay aldosteonism [24], Batte's syndome [25], deoxycoticosteone-salt expeimental hypetension [28] o upon aldosteone administation [26], wheeas adenalectomy educes kallikein excetion in ats [33]. Kaizu and Magolius [341 have shown that aldosteone inceases kallikein activity in at kidney cell suspensions, while spionolactone deceases it. In diabetic nephopathy, PRA has been epoted to be educed [6] o to emain nomal [81, and some diabetic patients ae epoted to have low PAC and low uinay excetion ates of aldosteone [35]. We obseved that the PRA values befoe and afte stimulation with fuosemide and ambulation tended to be lowe in the Goup B diabetic patients with hypetension (B-Hy) than those in the contol goup. Howeve, the value fo PAC was not educed in this goup of the patients as compaed to the contol goup, implying that a decease in kallikein excetion in patients with hypetension complicated by diabetic nephopathy might not be due to abnomality in the enin-angiotensin-aldosteone system. Fistschka et al. [36] have epoted that teatment with a/q-ecepto blocke, metopolol, esulted in a decease in uinay kallikein excetion in essential hypetension. This obsevation implies that the synthesis o secetion of enal kallikein may be patially contolled by a sympathetic tone o fl-adenegic ecepto. Neuopathy is one of the common complications in diabetes mellitus [37], and the pesence of diabetic autonomic neuopathy is moe common in patients with nephopathy than those without [38]. Accodingly, an impaied autonomic neve function is anothe likely cause of the lowe kallikein excetion obseved in ou patients with nephopathy, although the autonomic neve function o fl-adenegic ecepto sensitivity was not evaluated in the pesent study. Although hypetension is moe commonly seen in patients with diabetes mellitus than in non-diabetic subjects [1-3, 5], the pecise mechanism(s) leading to hypetension still seems unclea. Ou obsevation that uinay kallikein excetion was educed in patients with diabetes mellitus associated with nephopathy (Goup B) as compaed to those without nephopathy (Goup A) suggests that poduction and/o secetion of enal kallikein may decease with the pogession of diabetic T. Baba et al.: Renal kallikein in diabetic nephopathy nephopathy. Since coelations between uinay kallikein activity and enal blood flow [39], sodium excetion [40] o wate excetion [41] have been epoted, the decease in enal kallikein secetion may be consideed as a cause of sodium and wate etention, which could lead to a ise in blood pessue. Nevetheless, it is not possible, with the pesent data, to know if the deceased uinay kallikein excetion is a cause o a consequence of the condition combining diabetic nephopathy and high blood pessue. In this context, futhe studies ae obviously equied to claify the possible ole(s) of enal kallikein in diabetic patients who do and do not develop and/o maintain hypetension with and without nephopathy. In addition, the inteaction o countebalance between this system and the enin-angiotensin-aldosteone system in diabetic patients associated with nomotension o hypetension in the absence of nephopathy, and with nomotension in the pesence of nephopathy, should also be elucidated in futue studies. Acknowledgements. The authos wish to thank Ms. Kaoi Naita and Noiko Togashi fo thei secetaial assistance, and Sanawa Kagaku Kenkyusho Co., Ltd., Nagoya, Japan, fo thei donation of the eagents fo the measuement of uinay kallikein acitivity used in this study. This wok was suppoted by a gant-in-aid fom the Ministies of Education and Science and of Human Health and Welfae, Japan Refeences 1. Moss AJ (1962) Blood pessue in childen with diabetes mellitus. Pediatics 130: Pell S, D'Alonzo CA (1967) Some aspects of hypetension in diabetes mellitus. J Am Med Assoc 202: Pell S, D'Alonzo CA (1971) Factos associated with long-tem suvival of diabetes. J Am Med Assoc 214: White P (1956) Natual couse and pognosis of juvenile diabetes. Diabetes 5: Baba T, Muabayashi S, Aoyagi K, Sasaki K, Imamua K, Kudo M, Takebe K (1985) Pevalence of hypetension in diabetes mellitus: Its elation to diabetic nephopathy. Tohoku J Exp Med 145: Chistlieb AR, Kaldany A, D'Elia JA (1976) Plasma enin activity and hypetension. Diabetes 25: Peez GO, Lespie L, Jacobi J, Oste JR, Katz FH, Baamonde CA, Fishman L (1977) Hypoeninemia and hypoaldosteonism in diabetes mellitus. Ach Int Med 137: Fenandez-Cuz A, Noth RH, Lassman MN, Hollis JB, Mulow PJ (1981) Low plasma enin activity in nomotensive patients with diabetes mellitus: Relationship to neuopathy. Hypetension 3: Tomita K, Matsuda O, Ideua T, Shiigai T, Takeuchi J (1982) Renin-angiotensin-aldosteone system in mild diabetic nephopathy. Nephon 31: Wilson TW, Tan LK (1985) Low plasma enin activity in diabetes: Relation to uine postaglandin excetion. Diabetes 34: Caeteo OA, Scicli AG (1981) Possible ole of kinins in ciculatoy homeostasis. Hypetension 3 (Suppl 1): National Diabetes Data Goup (1979) Classification of diagnosis of diabetes mellitus and othe categoies of glucose intoleance. Diabetes 28: Miles DW, Mogensen CE, Gundesen HJG (1970) Radioimmunoassay fo uinay albumin using a single antibody. Scand J Clin Lab Invest 26:5-11

6 T. Baba et al.: Renal kallikein in diabetic nephopathy Vibeti GC, Hill RD, Jaett RJ, Agyopoulos A, Mahmud U, Keen H (1982) Micoalbuminuia as a pedicto of clinical nephopathy in insulin-dependent diabetes mellitus. Lancet 1: Mogensen CE, Chistensen CK (1984) Pedicting diabetic nephopathy in insulin-dependent patients. N Engl J Med 311: Hitomi Y, Niinobe M, Fujii S (1980) A sensitive coloimetic assay fo human uinay kallikein. Clin Chim Acta 100: Habe E, Koene T, Page LB, Klinman B, Punode A (1969) Application of a adioimmunoassay fo angiotensin I to the physiologic measuements of plasma enin activity in nomal human subjects. J Clin Endocinol Metab 29: Ogihaa T, Iinuma K, Nishi K, Aakawa Y, Takagi A, Kuata K, Miyai K, Kumahaa Y (1977) A non-chomatogaphic non-extaction adioimmunoassay fo seum aldosteone. J Clin Endocinol Metab 45: Davis JE, McDonald JM, Jaett L (1978) A high-pefomance liquid chomatogaphy method fo hemoglobin Ale. Diabetes 27: Nustad K, Vaaje K, Piece JV (1975) Synthesis of kallikeins by at kidney slices. B J Phamacol 53: Robleo J, Coxatto H, Gacia R, Cothon J, De Vito E (1976) Kallikein-like activity in pefusates and uine of isolated at kidneys. Am J Physiol 231 : Scicti AG, Caeteo OA, Hampton A, Cotes P, Oza NB (1976) Site of kininogenase secetion in the dog nephon. Am J Physiol 230: Nustad K (1970) The elationship between kidney and uinay kininogenase. B J Phamaco139: Magolius HS, Gelle RG, Pisano JJ, Sjoedsma A (1971) Alteed uinay kallikein excetion in human hypetension. Lancet 2: Lechi A, Covi G, Lechi C, Manteo F, Scuo LA (1976) Uinay kallikein excetion in Batte's syndome. J Clin Endocinol Metab 43: Rapelli A, Dessi-Fulghei P, Mededdu P, I_~oni C, Fioi C, Cocco F, Sanna G, Gloioso N (1982) Plasma active and inactive enin and uinay kallikein in nomal subjects in esponse to hydochloothiazide, spionolactone o aldosteone administation. Clin Exp Hypetens 4: Elliot AH, Nazum FR (1934) The uinay excetion of a depesso substance (kallikein of Fey and Kaut) in ateial hypetension. Endocinology 18: Keise HR, Gelle RG, Magolius HS, Pisano JJ (1976) Uinay kallikein in hypetensive animal models. Fed Poc 35: Mitas JA, Levy SB, Holle R, Figon P, Stone RA (1978) Uinay kallikein activity in the hypetension of enal paenehymal disease. N Engl J Med 299: Glasse 1LI, Michael AF (1976) Uinay kallikein in expeimental enal disease. Lab Invest 34: TB (1980) The kallikein-kinin system in exocine ogans. J Histochem Cytochem 28: Scicli AG, Gandolfi R, Caeteo OA (1978) Site of fomation of kinins in the dog nephon. Am J Physiol 234:F36-F Gelle RG, Magolius HS, Pisano JJ, Keise HR (1972) Effects of minealocoticoids, alteed sodium intake and adenalectomy on uinay kallikein in ats. Ci Res 31 : Kaizu T, Magolius HS (1975) Studies on at enal cotical cell kallikein. I. Sepaation and measuement. Biochim Biophys Acta 411: DeLeiva A, Chistlieb AR, Melby JC, Gaham CA, Day RP, Leutsche JA, Zage PG (1976) Big enin and biosynthetic defect of aldosteone in diabetes mellitus. N Engl J Med 295: Fitschka E, Gotzen R, Kittle R, Schoneshofe M (1984) Effect of metopolol on 24-hou uinay excetion of adenal steoids and kallikein in patients with essential hypetension. B J Phamacol 81 : Fase DM, Campbell IW, Ewing DJ, Muay A, Neilson JMM, Clake BF (1977) Peipheal and autonomic neve function in newly diagnosed diabetes mellitus. Diabetes 26: Dybeg TM, Benn J, Sandahl C J, Hilsted J, Neup J (1981) Pevalence of diabetic autonomic neuopathy measued by simple bedside tests. Diabetologia 20: Levy SB, Lilley J J, Figon RP, Stone RA (1977) Uinay kallikein and plasma enin activity as deteminants of enal blood flow: the influence of ace and dietay sodium intake. J Clin Invest 60: Adetuyibi A, Milles IH (1972) Relation between uinay kallikein and enal function, hypetension and exetion of sodium and wate in man. Lancet 2: Milles IH, Wad PE (1975) The elationship between kallikein and wate excetion and the conditional elationship between kallikein and sodium excetion. J Physio1246: Received: 11 Septembe 1985 and in evised fom: 17 Decembe 1985 D. Tsunehau Baba The Thid Depatment of Intenal Medicine Hiosaki Univesity School of Medicine Zaifu-cho 5 Hiosaki City Aomoi-ken 036 Japan