Diabetic Angiopathy Part 1

There is an epidemic of diabetes, obesity, and cardiovascular/renal disease of global proportions. Prevention and treatment will require an in-depth understanding of the extremely complex pathophysiology of these syndromes and diseases. It is therefore timely and appropriate that two issues of {{ERR}}Seminars in Vascular Medicine have been dedicated to the topic of diabetic angiopathy.

As guest editors, we are fortunate to have persuaded a number of leading authorities in the field to provide detailed discussions of current concepts and challenges. We have deliberately included experts from the disciplines of epidemiology, clinical medicine, and both clinical and experimental physiology, because we feel strongly that progress in this field will depend on integrating these different approaches.

In this first issue, Angela Shore discusses the importance of early and late microvascular changes in the microangiopathy that often complicates type 1 diabetes and is ultimately responsible for much of the morbidity and mortality in this disease. Michael Clark and colleagues provide a balanced review of the very contentious issue of how insulin resistance and microvascular function are linked. Similarly contentious is the role of early growth patterns and intrauterine programming in the causation of adult metabolic and vascular disease. The mechanisms potentially responsible are explored by Richard Holt and Christopher Byrne.

Juliana Chan tackles the complex interrelationships comprising the ``insulin resistance syndrome'' and uses novel techniques to disentangle cause and consequence. Markku Laakso usefully summarizes our current state of knowledge of the pathogenesis and management of diabetic dislipidemia. The growing recognition of the role of inflammation in atherothrombosis in diabetes is elegantly discussed by Russ Tracy, who poses challenging questions as to the origins of the chronic low-grade inflammation that seems to be part and parcel of the diabetic state and how this is linked to vascular disease. Impaired regulation of coagulation and fibrinolysis may be one such mechanism. However, this is very difficult to study in humans. J.D. Banga explains what tools we have, what their limitations are, and what results have been obtained in trying to understand the hypercoagulability and hypofibrinolysis that often seem to occur in diabetes.

What role does the ``novel'' risk factor, homocysteine, play in diabetes? While definitive answers are not yet available, Coen van Guldener and Coen Stehouwer review the epidemiology and pathophysiology of hyperhomocysteinemia and conclude that a case can be made for folic acid treatment of individuals at very high risk of cardiovascular disease.

The incidence and prevalence of end-stage renal disease are increasing at an alarming rate. Much of this is caused by diabetes, especially type 2 diabetes. In type 1 diabetes, early death is very strongly linked to the presence of diabetic nephropathy. On the other hand, there has been very important progress in the management of both early- and late-stage diabetic nephropathy. Michel Marre and Romano Nosadini discuss these issues for type 1 and type 2 diabetes, respectively.

We hope that you will enjoy reading these chapters, as we have, and that you will find them both practical and thought provoking.

Coen Stehouwer, M.D., Ph.D.

John S. Yudkin, M.D., FRCP

Guest Editors