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Blackwell Science, Ltd

Book reviews

Book reviewsBook reviews

Lipids and Vascular Disease Current Issues

Betteridge D. J. Martin Dunitz Publishers. 2000 ISBN 1-85317-627-3. 262 p.

Most doctors find books on lipids intimidating. Knowing thatyou are one of maybe two or three people in your district ofover 500 000 people who are looked upon as an ‘expert’ onlipids makes agreeing to write a review of this book even moreanxiety-provoking, in case you do not understand it. Fortun-ately, this book of 18 essays on topical aspects of lipidologyare very clinically based and generally very readable andenlightening. The range, however, is wide; from complex topicssuch as the PPAR system and the regulation of lipoproteinmetabolism to the practical issues as whether we still needfibrates. If I learned anything (and I think I absorbed a little),it was that whilst the complex cannot always be simplified, itcan at least be made interesting and relevant. The chapter on‘Genetics: determinants of lipid and lipoprotein concentra-tions’ by Ole Faergeman was, for example, a masterpiece andthe book was worth reading just for that.

With a diverse collection such as this and multiple authors,some duplication is inevitable. This is not a problem, as eachchapter is there in its own right, but the Editor’s task is toensure consistency where this is appropriate. It was thereforefrustrating in the various chapters on fibrates, fibrinogen andHDL that the recently published VAHIT and BIP studies weresometimes referred to or written about as if the results werestill awaited, but perhaps that reflects that the book was a longtime coming.

Highlights for me were the chapters on Homocysteine(Hcy), which was a good review of its role in the pathogenesisof arterial disease and the potential of preventing CHD bylowering Hcy with vitamins. Chronic infection and coronaryheart disease (CHD), and an excellent essay on women andCHD, were well worth reading and an update on statinsincluded a review of their pleotropic effects. These are probablynot often considered by the average clinician, but the possibilityof these drugs being prescribed for non-lipid effects such asthe treatment of diabetic nephropathy or even the preventionof cancer is intriguing. The chapter on the PPAR system I amafraid left me none the wiser, and those on lipid managementpost-cardiac transplantation and diabetes made me realizehow little is known about these two important areas.

‘HDL: are there any benefits in raising it’ is misnamed, as itconcentrates mainly on the

in-vivo

effects rather than clinicalintervention trials. It should probably be read in conjunctionwith the chapter on ‘Is there still a place for the fibrates’.

If you like lots of illustrations this is not the book for you,but in general the figures were clear and relevant. Why DavidWood, the author of ‘New guidelines for the prevention ofCHD’, chose to publish the 1998 version of the European

Coronary Risk Chart rather than the more recent Joint BritishSocieties chart (which uses TC:HDL ratio and is available forpeople with diabetes), however, is a mystery. That said, this isa useful book to have in the departmental library (if only as asource of some comprehensive references).

A. Scott

19Book reviewsBook reviewsBook reviewsBook review

Diabetic Nephropathy

Hasslacher C, ed. Chichester: John Wiley, 2001. ISBN 047148992 1. 250 pp. £55.00

There is no stronger argument for the need for a modern texton diabetic nephropathy (DN) than the rising tide of end-stagerenal failure due to this disease and the poor outcome ondialysis which many of these patients face. This enormouspublic health problem is particularly poignant since it is inprinciple largely preventable.

Diabetic Nephropathy

, editedby Hasslacher, thoroughly reviews this common condition,drawing together contributions from a European faculty ofexperts in diabetes, nephrology, paediatrics and pathology.

It is essential for clinicians managing patients with incipientDN to understand its natural course, and this is thoroughlydiscussed in the first section of the book using a classificationbased on urinary albumin excretion rates and changes in GFR.The development of DN in children and adolescents is dealtwith separately, highlighting some of the challenges that thisage group presents, as well as pointing out the potential forimprovements in diabetic care to reduce the incidence of DNto < 10% from 30%. One of the strengths of the book is thedetailed consideration of pathogenesis from the perspective ofglomerular structure, haemodynamic alterations and renalstructure–function relationships supported by an instructiveselection of light and electron micrographs. Significantly, 50%of patients with IDDM do not develop DN despite poormetabolic control, and the contribution of genetics to suscept-ibility is reviewed, with a valuable discussion of methodologicaldifficulties in this field.

In the second section central clinical issues pertaining toDN are discussed, such as cardiovascular issues, retinopathyand pregnancy as well as screening for diabetic nephropathyand the differential diagnosis of proteinuria in diabetes.Importantly, hypertension is tackled in detail, since it forms acentral component in the evolution of DN. Consideration isgiven to definition, pathogenesis, prevalence and treatmenttargets as well as the differential diagnosis of hypertensionin these patients, including renal artery stenosis. There isdetailed discussion of blood pressure measurement, includingthe difficulties posed by orthostatic hypotension and the roleof 24-h ambulatory BP. Anti-hypertensive management

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strategies in diabetes are tackled by at least two authors withwell-researched discussions. There is a slight difference ofemphasis in each of these chapters with respect to the debateon dihydropyridine calcium antagonists and cardiac risk, andwhether angiotensin converting enzyme inhibitors (ACEI)have a particular advantage over other drug classes in DN.

The increased cardiac risk in these patients is given dueimportance, with a thorough review of dyslipidaemia and itsmanagement, as well as detailed discussion of other aetiolog-ical factors, including ventricular dysrhythmias, and the rele-vance of electrocardiographic QTc dispersion. The chapter onretinopathy outlines eye care in patients with DN, anddiscusses pathogenic similarities in the two diseases. Clearly,proliferative retinopathy is so common in this group that itmust be actively sought. Pregnancy in proteinuric diabetics isparticularly challenging and is rigorously researched, with apractical algorithm for management and a detailed reviewof outcomes, including pregnancy in women with functioningrenal allografts.

The third section of the book presents conclusive evidencefor the role of glycaemic control in the development of DN.Equally, the argument for tight blood pressure control indiabetic patients with proteinuria is clear, aiming for blood

pressure values < 130/80. Intriguing but early evidence is pre-sented on the use of ACEI in IDDM before the developmentof microalbuminuria to prevent the fall of GFR while in thenormal range. There are short chapters on dietary advice,making the case for moderate protein restriction combinedwith reductions in saturated fat and sodium intake, andstrategies for training patients in DN. The penultimate chapterfocuses on aspects of end-stage renal disease management inDN, and I felt that this section could have been usefullyexpanded, with more discussion of the potentially valuablerole of peritoneal dialysis.

In summary, this short text book is essential reading fordiabetic physicians and nephrologists. It is well researched andcomprehensively covers the subject with strong contributionsfrom respected specialists. I would have liked a chapter to havebeen included on the issues of patient co-operation, withevidence from successful schemes that have improved patientpartnership in diabetes. That aside, this book provides awealth of information on all aspects of DN, making the pointthat the real challenge is to apply the strategies that are alreadyknown to improve patient outcome.

M. Wilkie

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