The role of the sympatho-adrenomedullary system and adrenergic receptors in the pathogenesis of orthostatic hypotension in diabetes mellitus

Abstract

To clarify the role of the sympatho-adrenomedullary and renin-angiotensin-aldosterone systems, and catecholamine receptors, in the pathogenesis of orthostatic hypotension in diabetes mellitus (DM), urinary excretion of catecholamines, and plasma levels of norepinephrine (PNE), epinephrine (PE), renin activity (PRA), aldosterone (PAC), cyclic AMP (PcAMP) and cyclic GMP (PcGMP) were measured in 16 normal subjects (N) and 50 diabetic patients with or without orthostatic hypotension (DMOH(+), DMOH(-)). Changes in PNE, PE, PRA, PAC, PcAMP and PcGMP by standing, glucagon (G) administration and cold pressor test were examined. Furthermore, the effect of metoclopramide on catecholamine levels and blood pressure was investigated before and after cold pressor test. The results were following; (1) Urinary free norepinephrine excretion was significantly lower in DMOH(+), while urinary total norepinephrine excretion was normal in the two DM groups. Urinary free and total epinephrine excretions were lower in DMOH(+) than in N and DMOH(-). (2) PNE and PE were elevated after standing in all groups tested, and more pronounced in some cases of DMOH(+). Although PRA and PAC were elevated normally after standing in all groups, a dissociation between the two parameters was seen in some cases of DM. PcAMP after standing was correlated with PE(r = 0.829). Basal PcGMP was high in many cases of DMOH(+). However, no difference in the elevation of PcGMP after standing was noted between N and the two DM groups. (3) Systolic blood pressure (SBP) rose markedly in only DMOH(+) from 146 +/- 27mmHg to 178 +/- 34mmHg 5 minutes after G administration. The increment of PNE and PE 5 minutes after G administration were similar in all groups. In only DMOH(+), the increase in PcAMP 15 minutes after G test was proportional (r = 0.498) to that of epinephrine. (4) Responses of SBP, PNE, PE and PAC to cold pressor test apparently improved after administration of metoclopramide (MC) in some patients with DM. These results suggest that not only organic disturbance of sympathetic nerves but also functional inhibition of norepinephrine release mediated by dopamine receptor, may play an important role in the pathogenesis of orthostatic hypotension in diabetes mellitus. It is considered that catecholamine secretion from the adrenal medulla in DMOH(+) is increased by hypotension induced by standing. Furthermore, the vascular response to catecholamines may be accelerated through the increment of the extrajunctional receptor in DMOH(+).(ABSTRACT TRUNCATED AT 400 WORDS)