ABSTRACT Objective Our objective was to evaluate gestational weight gain (GWG) patterns and their relation to birth weight. Subjects and methods We prospectively enrolled 474 women with gestational diabetes mellitus (GDM) at a university hospital (Porto Alegre, Brazil, November 2009-May 2015). GWG was categorized according to the 2009 Institute of Medicine guidelines; birth weight was classified as large (LGA) or small (SGA) for gestational age. Adjusted relative risks (aRRs) and 95% confidence intervals (95% CIs) were determined. Results Adequate GWG occurred in 121 women [25.5%, 95% CI: 22, 30%]; excessive, in 180 [38.0%, 95% CI: 34, 43%]; and insufficient, in 173 [36.5%, 95% CI: 32, 41%]. In women with normal body mass index (BMI), the prevalence of SGA was higher in those with insufficient compared to adequate GWG (30% vs. 0%, p < 0.001). In women with BMI ≥ 25 kg/m2, excessive GWG increased the prevalence of LGA [aRR 2.58, 95% CI: 1.06, 6.29] and protected from SGA [aRR 0.25, 95% CI: 0.10, 0.64]. Insufficient vs. adequate GWG did not influence the prevalence of SGA [aRR 0.61, 95% CI: 0.31, 1.22]; insufficient vs. excessive GWG protected from LGA [aRR 0.46, 95% CI: 0.23, 0.91]. Conclusions One quarter of this cohort achieved adequate GWG, indicating that specific ranges have to be tailored for GDM. To prevent inadequate birth weight, excessive GWG in women with higher BMI and less than recommended GWG in normal BMI women should be avoided; less than recommended GWG may be suitable for overweight and obese women.

Type 1 diabetes mellitus (T1DM) is associated with chronic complications that lead to high morbidity and mortality rates in young adults of productive age. Intensive insulin therapy has been able to reduce the likelihood of the development of chronic diabetes complications. However, this treatment is still associated with an increased incidence of hypoglycemia. In patients with “brittle T1DM”, who have severe hypoglycemia without adrenergic symptoms (hypoglycemia unawareness), islet transplantation may be a therapeutic option to restore both insulin secretion and hypoglycemic perception. The Edmonton group demonstrated that most patients who received islet infusions from more than one donor and were treated with steroid-free immunosuppressive drugs displayed a considerable decline in the initial insulin independence rates at eight years following the transplantation, but showed permanent C-peptide secretion, which facilitated glycemic control and protected patients against hypoglycemic episodes. Recently, data published by the Collaborative Islet Transplant Registry (CITR) has revealed that approximately 50% of the patients who undergo islet transplantation are insulin independent after a 3-year follow-up. Therefore, islet transplantation is able to successfully decrease plasma glucose and HbA1c levels, the occurrence of severe hypoglycemia, and improve patient quality of life. The goal of this paper was to review the human islet isolation and transplantation processes, and to describe the establishment of a human islet isolation laboratory at the Endocrine Division of the Hospital de Clínicas de Porto Alegre – Rio Grande do Sul, Brazil.

O uso de aspirina é recomendado como estratégia de prevenção cardiovascular em pacientes com diabete melito. Em decorrência do risco de eventos hemorrágicos e da hipótese de que poderia haver um agravamento das complicações microvasculares associado ao uso da aspirina, tem havido importante sub-utilização dessa terapia. Entretanto, está definido que o uso de aspirina não piora a retinopatia diabética e existem evidências de que também não afeta a função renal em doses usuais (150 mg/dia). Por outro lado, pacientes com diabete melito parecem necessitar de doses maiores do agente antiplaquetário, o que sugere que esses indivíduos apresentem a chamada "resistência à aspirina". Os mecanismos dessa resistência ainda não estão completamente esclarecidos, estando provavelmente relacionados à atividade plaquetária intrínseca anormal. Portanto, o emprego de terapêuticas antiplaquetárias alternativas ou a administração de doses maiores de aspirina (150-300 mg/dia) devem ser melhor avaliados em relação a um aumento da eficácia na prevenção da doença cardiovascular e também a possíveis efeitos nas complicações microvasculares no diabete melito.

Aspirin is recommended as cardiovascular disease prevention in patients with diabetes mellitus. Due to the increased risk of bleeding and because of the hypothesis that there could be a worsening of microvascular complications related to aspirin, there has been observed an important underutilization of the drug. However, it is now known that aspirin is not associated with a deleterious effect on diabetic retinopathy and there is evidence indicating that it also does not affect renal function with usual doses (150 mg/d). On the other hand, higher doses may prove necessary, since recent data suggest that diabetic patients present the so called "aspirin resistance". The mechanisms of this resistance are not yet fully understood, being probably related to an abnormal intrinsic platelet activity. The employment of alternative antiplatelet strategies or the administration of higher aspirin doses (150-300 mg/d) should be better evaluated regarding effective cardiovascular disease prevention in diabetes as well as the possible effects on microvascular complications.

A nefropatia diabética (ND) é uma complicação do diabete melito (DM) associada a grande morbi-mortalidade. A identificação de indivíduos de maior risco tornará a sua prevenção mais efetiva. A excreção urinária de albumina (EUA) ainda é o melhor marcador da instalação e progressão da ND, além de ser fator de risco para o desenvolvimento de doenças macrovasculares. A albuminúria nos limites superiores da normalidade (< 20 µg/min) já está associada ao desenvolvimento de micro e macroalbuminúria. A EUA apresenta correlação contínua com o desenvolvimento de doença renal e cardiovascular, sem um ponto determinado a partir do qual ocorre um aumento mais importante do risco. No entanto, na prática clínica se faz necessário o estabelecimento de um valor crítico para guiar o tratamento dos pacientes. Algumas evidências apontam para valores de EUA ente 5 e 10 µg/min como um novo ponto de corte para o diagnóstico de microalbuminúria. Concluindo, a associação entre a EUA e o desfecho renal e cardiovascular parece ser contínuo e já está presente até mesmo com níveis de EUA considerados normais. A adoção de um valor entre 5 e 10 µg/min como de risco poderá identificar os pacientes que deveriam receber tratamento mais precoce e agressivo dos fatores de risco modificáveis.

Diabetic nephropathy (DN) is a complication of diabetes mellitus (DM) associated with increased morbi-mortality. The identification of individuals at high risk for DN will make its prevention more effective. Urinary albumin excretion rate (UAER) is still the best marker for DN development and progression. It is also a major risk factor for macrovascular disease. High-normal albuminuria (< 20 µg/min) is still associated with development of micro- and macroalbuminuria. UAER has a continuous relationship with the development of renal and cardiovascular disease, without a cutoff point from which there is a highly increased risk. However, in clinical practice we need a reference value in order to guide the patient's treatment. Some evidence indicates values of UAER between 5 and 10 µg/min as a new cutoff point for the diagnosis of microalbuminuria. In conclusion, the association between UAER and the renal and cardiovascular outcomes seems to be continuous and is already present with UAER within the normal range. The adoption of a UAER value around 5 to 10 µg/min as risky could identify patients that should receive earlier and more aggressive treatment of modifiable risk factors.

Diabetes e alterações da tolerância à glicose são freqüentes na população adulta e estão associados a um aumento da mortalidade por doença cardiovascular e complicações microvasculares. O diagnóstico destas situações deve ser feito precocemente, utilizando métodos sensíveis e acurados, já que mudanças no estilo de vida e a correção da hiperglicemia podem retardar o aparecimento do diabetes ou de suas complicações. O teste oral de tolerância à glicose é o método de referência, considerando-se a presença de diabetes ou tolerância à glicose diminuída quando a glicose plasmática de 2h após a ingestão de 75g de glicose for > ou = 200mg/dl ou > ou = 140 e <200mg/dl, respectivamente. Quando este teste não puder ser realizado, utiliza-se a medida da glicose plasmática em jejum, considerando-se como diabetes ou glicose alterada em jejum quando os valores forem > ou = 126mg/dl ou > ou = 110 e <126mg/dl, respectivamente. A medida da glico-hemoglobina não deve ser utilizada para o diagnóstico, mas é o método de referência para avaliar o grau de controle glicêmico a longo prazo. A classificação etiológica proposta atualmente para o diabetes melito inclui 4 categorias: diabetes melito tipo 1, diabetes melito tipo 2, outros tipos específicos de diabetes e diabetes gestacional. A classificação do paciente é usualmente feita em bases clínicas, mas a medida de auto-anticorpos e do peptídeo C pode ser útil em alguns casos.

Diabetes mellitus and other categories of impaired glucose tolerance are frequent in the adult population and are associated with an increased risk for cardiovascular disease and microvascular complications. The diagnosis of these entities should be performed early and using sensitive and accurate methods, since lifestyle changes and correction of hyperglycemia may delay the incidence of diabetes and its complications. Glucose tolerance test is the reference method and the diagnosis of diabetes and impaired glucose tolerance are established when the 2h plasma glucose after an oral intake of 75g of glucose is > or = 200mg/dl or > or = 140 and <200mg/dl, respectively. When it is not possible to perform this test, fasting plasma glucose levels > or = 126mg/dl or > or = 110 and <126mg/dl, respectively, are used to establish the diagnosis of diabetes and impaired fasting plasma glucose. Glycohemoglobin should not be used for the diagnosis but it is the reference method for evaluation of the long-term glucose control. The etiological classification of diabetes mellitus includes 4 categories: type 1 diabetes, type 2 diabetes, other specific types of diabetes and gestational diabetes. The assignment of the patient in each category usually is made on clinical grounds, however in some case the measurement of C-peptide and autoantibodies are necessary.