Decreased Response of Plasma Renin Activity to Orthostasis in Diabetic Patients with Orthostatie Hypotension

Plasma renin activity (PRA) was studied in eight patients maintained on a 100 mEq sodium diet who had diabetes mellitus with orthostatie hypotension (OH) and in eight diabetic matched controls without orthostatie hypotension. Signs of neuropathy and nephropathy were more frequent in patients with OH. Supine PRA was 1.2 ± .2 ng./ml. (S.E.M.) in OH and 3.0 ± .9 in controls (P < .1). Following upright posture for one-half hour, patients with OH demonstrated a fall in mean blood pressure from 102 ± 8 mm. Hg. to 72 ± 8 (P < .001). Despite this stimulus for renin release, PRA was 1.5 ± .3, significantly lower than controls, 4.2 ± .8 (P < .01). In patients with OH, mean blood pressures remained lower after four hours of upright posture (80 ± 8) than supine (P < .005). PRA was 2.5 ± .6, again lower than in control diabetic patients (5.6 ± .9) (P < .02). These results contrast with those in ten out of fifteen reported cases of idiopathic orthostatie hypotension who demonstrated an increase in PRA to the stimulus of upright posture. One explanation for decreased renin release in diabetic patients with OH would be defective catecholamine stimulation. In one patient who was given infusions of norepinephrine for one-half hour on two successive days, no increase in PRA was observed. The associated nephropathy in diabetic patients with OH suggests the possibility of defective renal renin stores or renin releasing mechanisms. When combined with other possible defects in blood pressure homeostatic mechanisms such as catecholamine deficiencies and blood volume abnormalities, an inadequate response of the renin-angiotensin system may be etiologically related to the OH in patients with diabetes.