New Treatments for Diabetic Neuropathy: Pathogenetically Oriented Treatment

Angelika Bierhaus, PhD, Per M. Humpert, MD, Gottfried Rudofsky, MD, Thoralf Wendt, MD, Michael Morcos, MD, Andreas Hamann, MD, and Peter P. Nawroth, MD

Address Department of Medicine I, University of Heidelberg, Bergheimer Str. 58, Heidelberg 69115, Germany. E-mail: Peter.Nawroth@med.uni-heidelberg.de Current Diabetes Reports 2003, 3:452458 Current Science Inc. ISSN 1534-4827 Copyright 2003 by Current Science Inc.

Oxidative Stress in Diabetic Neuropathy

Animal models have demonstrated an improvement of experimental diabetic neuropathy (EDN) through lowering oxidative stress by supplementation of antioxidative substances (Fig. 1). Subcutaneous injections of M40403, a functional mimetic of superoxide dismutase, reduced the appearance of superoxide in epineurial vessels and significantly improved the diabetes-induced decrease in endoneurial blood flow, acetylcholine-mediated vascular relaxation, and motor nerve conduction velocity (NCV) [5]. Dietary supplementation with antioxidative scavengers such as butylated hydroxytoluene, probucol, dehydroepiandrosterone, taurine, vitamin E, transition metal chelators and thiol agents such as acetyl cysteine, glutathione, and -lipoic acid prevented loss of motor and sensory conduction velocity and latency in pain perception of diabetic animals [6]. It is noteworthy that lipoic acid not only acts as radical scavenger and metal chelator, but also regenerates thioredoxin, vitamin C, and glutathione (recycling vitamin E), and induces cyclooxygenase (having anti-inflammatory properties) [7]. However, the optimal dose of antioxidants is not yet known. Extremely large doses of potentially radical scavenging concentrations are often used to achieve protective effects, whereas low concentrations, which regulate the cycle-dependent ROS metabolism and may have beneficial effects apart from radical scavenging, have not yet been studied. A pilot study testing the effect of vitamin E on electrophysiologic parameters in patients with symptomatic diabetic sensory polyneuropathy (DSPN) resulted in improvement of motor NCV, but not sensory NCV [8]. A small study in 14 type 2 diabetic patients demonstrated that a 6-week treatment with the thiamine derivate benfothiamine improved vibratory sensitivity and parasympathetic control of heart rhythm [9]. Large randomized, placebo-controlled clinical trials in patients with symptomatic DSPN using -lipoic acid demonstrated a reduction of major neuropathic symptoms such as pain, paresthesia, and numbness in short-term application [10], and a reduction in neuropathic deficits and improvement of cardiac autonomic neuropathy and motor and sen-

Although there is clear evidence from experimental diabetic neuropathy (DN) models that the multiple pathways involved in neuronal degeneration cause overproduction of reactive oxygen species, oxidative stress, and cellular dysfunction, therapeutic approaches addressing these mechanisms have not yet provided a basis for a successful treatment of patients with DN. This review discusses the current knowledge on the pathomechanisms of unchecked reactive oxygen species accumulation, implications for specific treatment, and the need for carefully designed experimental studies and clinical trials closing the gap between promising results in experimental DN and its implementation into a pathogenetically oriented treatment.

Introduction
Accumulating data indicate that diabetes is a state of increased production of reactive oxygen species (ROS) with parallel depletion of antioxidant defense mechanisms [1,2]. Polyunsaturated fatty acids in neuronal tissues are vulnerable targets of ROS-dependent peroxidation, which in turn initiate autocatalytic chain reactions to form peroxide and other fatty acids [3]. Although a large number of studies demonstrated alterations in the antioxidative defense of diabetic non-neuronal tissues, little is known about changes in peripheral nerves. Even though these have cytosolic and lipophilic antioxidant defense mechanisms, their radical defense is reduced in comparison to central nervous tissue [4]. In addition, ROS induces the dysfunction of microvessels supplying peripheral nerves and ganglia, and promotes ischemic damage of the tissue.

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Figure 1. Pathways involved in the pathogenesis of diabetic neuropathies and sides for possible intervention. AGEsadvanced glycation end products; ARaldose reductase; ARIsaldose reductase inhibitors; NF-kBnuclear factor-kB; NGFnerve growth factor; O2-superoxide; ONOO-peroxynitrite; PARPpoly(ADP-ribose) polymerase; PKCprotein kinase C; RAGEreceptor for advanced glycation end products.

sory NCV upon long-term treatment [11,12]. The SYDNEY trial confirmed that metabolically stable patients with symptomatic DSPN benefit from long-term intravenous treatment with -lipoic acid therapy by a significant improvement of the total symptom score, summing up the presence, severity, and duration of lancinating pain, burning pain, prickling, and numbness while asleep [12]. Despite beneficial effects, the clinical trials so far did not live up to the expectations originally provided by EDN studies implicating oxidative stress as a central mediator in diabetic neuropathy (DN). This may be due to the fact that oxidative stressdependent activation of the transcription factor nuclear factor-B (NF-B) may be deleterious to microvessels of the vasa nervorum, while it is supposed to have neuroprotective effects in neuronal cells. Thus, the role of oxidative stress for the development of DN is still not clear due to lack of experimental studies comparing the effects of antioxidant therapies on different cellular compartments at different time points of the disease. In addition, the time course of EDN and clinical trials is different. The development of diabetes in experimental settings is a well-controlled event, generally targeted by the respective treatments right after the onset of hyperglycemia. In

EDN, antioxidants are, therefore, given much earlier than in patients with DN.

The Consequences of Oxidative Stress

Neuroprotective and neurodegenerative NF-B activation One major target of oxidative stress is the transcription factor NF-B, which is rapidly activated by a variety of stimuli such as ROS, high glucose, proinflammatory cytokines, and growth factors [13]. NF-B activates the transcription of target genes, such as cytokines, adhesion molecules, the procoagulant tissue factor, endothelin-1 (ET-1), inducible nitric oxide (NO) synthase, inducible cyclooxygenase, heme oxygenase type 1, 5-lipoxygenase, receptor for advanced glycation end products (RAGE), and I kBa . Remarkably, all antiapoptotic genes known thus far, including BcL-XL, Bcl-2, and the Bcl-2 homologue A1, are also controlled by NF-B. Therefore, NF-B activation provides a rapid and sensitive cellular response and ensures cellular survival [13]. A number of studies provide evidence for NF-B having a protective role in sensory neurons, although only

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limited data are available with respect to DN. Purves and Tomlinson [14] have demonstrated a decrease in NF-B in dorsal root ganglia (DRG) obtained from 12-week-old streptozotocin (STZ)-induced diabetic rats. Conversely, two recent studies show that hyperglycemia and diabetes result in upregulation of NF-B in epineural and endoneural vessels and the perineurium in both STZ-induced diabetic rats [15] and in patients with long-standing diabetes [16]. A combined treatment with two NF-Bspecific inhibitors, PDTC and TLCK, did not only reduce NF B activation in sciatic nerves of diabetic rats, but also improved NCVs in these animals [15]. Experimental models have provided ample evidence that neuronal dysfunction and neuropathic pain are induced and increased through NF-Bcontrolled proinflammatory cytokines, such as interleukin-6 and tumor necrosis factor- [17]. NF-Bregulated adhesion molecules are also induced during pain and initiate the migration of opioid-containing immune cells into inflamed sites [18]. Further evidence for an involvement of NF-B in the pathology of neuronal dysfunction comes from studies in which NF-B decoys injected into the endoneurium at sites of nerve lesions suppress cytokine and adhesion molecule expression, and subsequently thermal hyperalgesia in a rat neuropathic pain model [19]. This observation implies that increased NF-B activation may also contribute to pain in DN. Immunohistochemical analysis of sural nerve biopsies from patients with DN, however, demonstrated increased NF-B activation, particularly in the vasa nervorum of all diabetic patients with long-standing diabetes and painful as well as painless neuropathy [16]. Therefore, studies are required to address the time course of NF-B activation from the early stages of diabetes (often associated with pain) to long-standing diabetes. Thus, it is not yet clear whether the increased NF-B activation observed in the peripheral nerves and ganglia of diabetic animals and patients has neuroprotective or neurodegenerative effects. Evidence for a dual role of NF-B in neuronal function comes from studies in chick embryos either unlesioned, or after a unilateral tectal lesion, which axotomizes ganglion cells. Although the number of dying cells in the retina contralateral to the lesion were reduced in embryos receiving NF-B inhibitors, the same NF-B inhibitors administered as pretreatment before intraocular injection of toxic substances drastically raised neuronal death and induced degenerative changes in the retina [20]. A comparable stimulus-dependent activation of NF-B, resulting in either apoptosis or neuroprotection, has recently been observed in cultured cerebellar granule cells [21] and suggests that activation of NFB is a double-edged sword. This strongly demands reconsideration of the use of high doses of antioxidants. Furthermore, it will be necessary to carefully investigate defined models of EDN and to validate the effects of antioxidants on both neuroprotective and neurodestructive properties of NF-B in different cellular compartments.

Apoptosis Studies in both experimental models and human sural nerve biopsies indicate an association of oxidative stress, mitochondrial membrane depolarization, and induction of programmed cell death. DRG isolated from STZ-induced rats with decreased peripheral NCVs demonstrate increased apoptosis associated with an elevated mitochondrial membrane potential [22,23]. The antiapoptotic genes Bcl-2, Bax, and Bcl-XL are primarily expressed in the inner mitochondrial membrane stabilizing the mitochondrial membrane by inhibiting the opening of the mitochondrial permeability transition pore [23]. Opening the permeability transition pore results in loss of the mitochondrial membrane potential and expansion of the intermembranous space, leading to outer membrane rupture and subsequent release of caspase-activating enzymes [23]. Diabetic sensory polyneuropathy is associated with a selective decrease in the levels of Bcl-2 and increased apoptosis in diabetic neurons [23]. Thus, the pathophysiology of early DSPN could involve activation of the apoptosis cascade. Besides excessive ROS production, downstream effectors such as caspases may represent potential targets for diagnosis and therapeutic intervention in DN. Remarkably, acute lowering of glucose levels under hypoxic conditions can also lead to apoptosis of DRG neurons [23], suggesting that there is an optimal glucose concentration for neuronal survival. This may be relevant for the acute painful neuropathy occurring in patients rapidly correcting their blood glucose levels after a period of hyperglycemia [22,24]. Consistent with the hypothesis of apoptosis playing a role in the development of DN, circulating soluble Fas and Fas ligand, two transmembrane glycoproteins involved in apoptosis, are significantly elevated in patients with DN. In addition, sera from patients with type 1 diabetes and DN contain an activator of Fas-regulated apoptosis that may also contribute to the pathogenesis of DN. Vascular dysfunction Increased ROS are known to promote endothelial dysfunction. Because vasoregulation of nerve microvessels is regulated at the arteriolar, venular, and endothelial cell level, the etiology of DN is considered to have a large vascular component. Therefore, the pathophysiology of nerve dysfunction in diabetes can also be explained by reduced endoneurial microcirculation, impaired blood flow due to a perturbed NO, prostanoid metabolism, and alterations in endoneurial metabolism. A number of experimental models have demonstrated that infusion of glucose or induction of diabetes results in abnormalities of vasodilatation by NO and prostacyclin. Reduced NO release can be improved in the presence of antioxidants; however, it is not yet known whether antioxidants primarily improve nerve blood flow or normalize systemic or endoneurial oxidative metabolism. An overactive polyol

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pathway that competes with the endothelial NO synthase for NADPH, thereby resulting in pseudohypoxia and NO deficiency and the presence of advanced glycation end products (AGEs) able to quench NO, may further promote the depletion of NO [25]. A recent study demonstrated that elevated plasma homocysteine, a strong predictor for DN in patients with type 2 diabetes, increases asymmetrical dimethylarginine, an endogenous inhibitor of NO synthase, leading to a decreased NO generation by endothelial cells [26]. Recent studies have demonstrated that proinsulin Cpeptide stimulates the activity of Na+,K+-ATPase and endothelial NO synthase via a G-proteincoupled membrane receptor. Consistently, C-peptide replacement ameliorates nerve dysfunction in EDN [27]. This suggests that besides hyperglycemia, impaired insulin secretion could significantly contribute to defective nerve fiber regeneration in type 1 (but not type 2) DN [28]. In addition to impaired NO-mediated vasodilation, upregulation of NF- B is likely to support endoneural ischemia by inducing NF-Bregulated proinflammatory and procoagulant gene products including tissue factor and ET-1. Because the vasa nervorum expresses ET-1 receptors, it is susceptible to ET-1dependent vasoconstriction. Microvascular ischemia may be further promoted by a substantial reduction in vascular endothelial thrombomodulin expression recently reported in the human diabetic nerve microvasculature [29]. Recent observations that restoring vascularization of the vasa nervorum through vascular endothelial growth factor induced angiogenesis in mice results in reversal of EDN [30] support the notion that microvascular ischemia involving the vasa nervorum contributes to EDN. Initial studies using microlightguide spectrophotometry to measure intravascular oxygen saturation and blood flow in human sural nerve confirmed a reduced nerve oxygenation and impaired blood flow in patients with mild-moderate sensory motor DN. Intravascular oxygen saturation was higher in patients with painful neuropathy compared to those without pain [31]. This implies that hemodynamic factors could play an important role in the pathogenesis of neuropathic pain or, alternatively, that arterial O2-exchange is impaired [31]. Despite the solid theoretic background for a treatment with vasodilating drugs and a large number of experimental models, very few clinical studies have been performed so far. One reason for the lack of clinical trials may be that the role of peripheral nerve ischemia is still discussed antithetically. Some authors postulate that early reduction in nerve blood flow accounts for DN [32,33]. Other experimental studies do not support a role of early ischemia for DN, but demonstrate that vasodilatation after guanethidine sympathectomy actually worsened indices of neuropathy, although it increased nerve blood flow [34]. This suggests that vasodilators may exacerbate postural hypotension, particularly in diabetic patients with autonomic dysfunction [34]. Despite these considerations, the clinical studies performed so far demonstrate an effective reduction in some

(but not all) neuropathic symptoms. A placebo-controlled 1-year study with 41 normotensive type 1 or type 2 diabetic patients with mild neuropathy receiving the angiotensinconverting enzyme inhibitor trandolapril resulted in an improvement of NCV, whereas vibration-perception threshold, autonomic function, and the neuropathy symptom and deficit score did not change compared to control subjects [35]. Treatment of 364 diabetic patients with neuropathy or leg ulcers with prostaglandin E1 (PGE1) incorporated in lipid microspheres (lipo-PGE1) for 4 weeks improved motor conduction velocity [36]. Furthermore, lipo-PGE administration reduced elevated circulating plasma ET-1 levels. Interestingly, local administration of isosorbide dinitrate, an NO donor with local vasodilating properties, reduced overall neuropathic pain and burning sensations in a pilot study with 22 patients [37]. In accordance with the experimental data mentioned above, recent studies have demonstrated that administration of proinsulin C-peptide for 3 months ameliorates nerve dysfunction in patients with type 1 diabetes [38]. Thus, impaired insulin action may explain the differences in nerve fiber regeneration between type 1 and type 2 diabetes [28]. However, C-peptide deficiency may also play a role in DN in patients with type 2 diabetes, because patients with good residual C-peptide secretion seem to be better protected from endothelial dysfunction than patients with poor Cpeptide secretion.

Lipolysis and depletion of -linolenic acid Endoneurial ischemia promotes increased lipolysis, resulting in disturbances of the n-6 essential fatty acid metabolism. Peroxidation of arachidonic acids leads to formation of 4hydroxynonenal, which impairs glutamate transport and mitochondrial function in neurons and mediates oxidative stressinduced neuronal apoptosis. Essential fatty acid desaturation contributes to reductions in peripheral NCV and blood flow [39]. The fatty acid imbalance can be corrected by dietary supplementation with -linolenic acid (GLA)rich oils such as evening primrose oil [39]. In clinical studies, substitution with GLA had beneficial effects on NCV, paresthesias, and numbness, but not on neuropathic pain. Synergistic effects between GLA and aldose reductase inhibitors or GLA and antioxidants have been described [40]. Metabolic changes Brownlee [41] has demonstrated hyperglycemia-induced superoxide overproduction by the mitochondrial electron transport chain as an integrator of various metabolic changes contributing to the development of DN. Intracellular glucose oxidation during glycolysis results in NADH production, which donates reduction equivalents to the mitochondrial respiratory chain. The electron flow through the mitochondrial respiratory chain is triggered by four inner membraneassociated multi-enzyme complexes (complex IIV), cytochrome C, and the mobile electron carrier ubiquinone, and results in a potential difference at the inner mitochondrial

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membrane that provides energy for adenosine triphosphate production. A high mitochondrial membrane potential results in increased half-life of the superoxide (O2-)-producing electron transport systems and promotes the production of ROS. One mechanism by which the mitochondrial-derived superoxides induce metabolic changes is by inhibition of glyceraldehyde-3-phosphate dehydrogenase (GAPDH) [41]. During glycolysis glucose is converted via glucose-6phosphate, fructose-6-phosphate, and fructose-1,6-biphosphate to form the triose glyceraldehyde-3-phosphate. The latter is oxidized by GAPDH to form 1,3-diphosphoglycerate using NAD + as substrate. An excess of superoxide and consumption of NAD+ due to an excess of NADH reduces GAPDH activity [41]. Inhibition of GAPDH results in accumulation of upstream metabolites, which are metabolized in pathways of glucose overutilization. These are 1) extrahepatic conversion of glucose to fructose by the polyolpathway, 2) increased flux of fructose-6-phosphate through the hexosamine pathway, 3) increased de novo synthesis of diacylglycerol, a cofactor of protein kinase C (PKC) from dihydroxyacetonphosphate, and 4) increased formation of reactive intracellular AGEs from accumulating trioses. Because an excessive activation of the polyol pathway increased PKC activation and increased AGE formation is supposed to contribute to the development of DN, this model implicates that controlling excessive oxidative stress may, at least in part, restore the metabolic and vascular imbalance observed in DN.

tion, mice with no or low polyol pathway activity still develop functional and structural DN [43]. Although no in vivo studies have demonstrated a direct inhibition of the polyol pathway by antioxidants, there is increasing evidence that excessive activation of AR may promote cellular oxidative stress. Transgenic mice overexpressing AR in Schwann cells show a significant reduction of glutathione in the sciatic nerves of AR transgenic mice [44]. Thus, excessive AR activation may deplete the antioxidant defense most probably through competing for NADPH, which is needed to recycle reduced glutathione from its oxidized form and to produce NO from arginine and oxygen. Consistently, the AR inhibitor sorbinil has been shown to restore reduced glutathione and ascorbate levels and arrest the diabetes-induced lipid peroxidation in early EDN [45]. Remarkably, this report postulates that only high concentrations of AR inhibitors able to completely inhibit increased sorbitol pathway activity are effective to reverse functional and metabolic deficits in DN; this suggests that problems with efficacy and toxicity of AR inhibitors in most of the clinical trials resulted from either inadequate doses and insufficient inhibition of the sorbitol pathway activity or unacceptably high systemic toxicity [45].

Oxidative Stress As an Integrator of Metabolic Changes

Increased polyol pathway activity Hyperglycemia increases the glucose flux through the polyol pathway, particularly in neuronal tissues, characterized by an insulin-independent glucose uptake. Neuronal tissues highly express the enzymes aldose reductase (AR) and sorbitol dehydrogenase catalyzing the conversion from glucose to fructose. It is thought that an increased flux through the polyol pathway promotes a cellular redox imbalance. Depletion of myo-inositol, reduced Na+,K+ ATPase activity, reduced glutathione and NO synthesis, and increased PKC activity have been identified as critical changes secondary to enhanced AR activity. The exact role of AR activation and sorbitol accumulation in DN, however, is still not clear. Sorbitol-dehydrogenase inhibitors do not show any beneficial effect on nerve function, whereas animal models demonstrate correction of decreased conduction velocity by AR inhibitors [42]. However, the efficacy and specificity of AR inhibitors in both experimental and clinical trials is still discussed controversially, particularly because studies in giant cell arteritis imply that AR may represent an oxidative defense mechanism able to neutralize the toxic effects of lipid peroxidation. In addi-

PKC activation In cells and tissues that take up glucose independently of insulin, PKC is activated by a hyperglycemia-dependent increase in diacylglycerol. In contrast to other tissues, however, diacylglycerol levels are reduced in diabetic nerves and a consistent pattern of change in PKC activity has not been observed [46]. However, PKC activation results in multiple changes in the vasculature, such as increased vascular permeability, altered vascular blood flow, modulation of NO, and activation of NF-B and NF-Bdependent gene expression, resulting in increased leukocyte adhesion. Consistently, inhibition of PKC with LY333531 (ruboxistaurin) corrected the reduced nerve blood flow and improved NCV in rat models of EDN [6]. Ongoing first clinical trials indicate that PKC inhibitors could form a basis for therapeutic intervention in DN [47]. Advanced glycation end products Advanced glycation end products are the result of nonenzymatic glycation and glycoxidation processes, which are enhanced with concomitant hyperglycemia, oxidant stress, carbonyl stress, and delayed macromolecular turnovers. Extensive intra- and extracellular accumulation of AGEs, in particular carboxymethyllysine, has been described in perineural basal laminae, axons, Schwann cells, endoneurial and epineurial microvessels, and the perineurium of human diabetic subjects [48]. An association between diabetes and AGE accumulation in peripheral nerves is also provided by the observation that AGEs in the sciatic nerve of diabetic rats were decreased by pancreatic islet cell transplantation [48]. Furthermore, AGE immunoreactivity

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increased with diabetes and correlated with a reduction in myelinated fiber density in EDN [48]. The functional consequences of AGEs deposition, however, are still poorly understood. AGE formation preferentially occurs on long-lived proteins such as myelin, where it promotes the myelin uptake by macrophages and subsequent demyelinization, and extracellular matrix proteins, thereby altering permeability, cell interaction, and cell adhesion. Intracellular-formed AGEs influence the assembly of the cytoskeleton, promote protein aggregation, and modify nuclear proteins and nucleic acids. Several inhibitors of AGE formation such as aminoguanidine, OPB-9195, and pyridoxamine have been demonstrated to reduce AGE accumulation in diabetic rats and to improve NCV and morphometric parameters in EDN [48]. In contrast, in a type 1 baboon model aminoguanidine did not restore conduction velocity or autonomic dysfunction [48]. Recent studies demonstrate that ligation of AGEs to their surface receptor RAGE perpetuates activation of the redox-sensitive transcription factor NF- B in cultured endothelial and neuronal cells [49]. Because RAGE is expressed in both vascular and neuronal tissue, it is likely that RAGE-dependent NF-B activation may promote neuronal dysfunction [50]. However, direct proof for AGE- or RAGE-mediated impairment of neuronal function is missing. Ongoing experiments with recently developed RAGE-/mice may provide data leading to inhibition of the AGE/ RAGE/NF-B axis as a new therapeutic option [16].

diabetes [43]. Only a minority of studies in EDN focused on autonomic neuropathy. In addition, mice models which are often favored due to the availability of knock-out, knock-in, and transgene manipulations, are difficult to interpret with respect to determination of NCV and blood flow due to the relatively short distances between measure points. Experimental studies normally focus on isolated nerves and compartments rather than on the multiple changes occurring in clinical DN. Thus, adverse effects in different cell types and in different compartments are often not noticed, resulting in a too optimistic view that cannot be confirmed by clinical trials. This may be one reason for the many unexpected side effects observed when initially promising experimental approaches enter clinical trials. Besides these considerations, it is important to better understand the time course of metabolic changes in DN to ensure that a pathogenetically oriented treatment targets certain metabolic pathways at time points where they are most vulnerable, thereby maximizing the therapeutic benefit. Ad hoc panels on end points for DN and defined criteria for assessing the neuropathy symptom score in both EDN and clinical trials are required to close the gap between promising results in EDN and its implementation into a pathogenetically oriented treatment, which will most probably consist of a combination of inhibitors targeting different pathways at different time points.

Acknowledgment Conclusions
Although a large number of studies strongly suggest overproduction of ROS as a major cause for neuronal damage and degeneration in DN, therapeutic approaches addressing these mechanisms are thus far rather disappointing. Identification of multiple pathways causing or promoting oxidative stress has not yet provided the basis for a successful pathogenetically oriented treatment of DN. One reason may be that there is still no clear definition of animal models suitable to investigate defined subgroups of DN. The majority of investigations are still using STZinduced diabetic mice and rats, which resemble type 1 diabetes. The results obtained, however, are often uncritically universalized, implicating general rather than specific mechanisms for the pathology of a specific subgroup of DN. Because at least short-term STZ models do not require insulin, they are often strikingly different from the clinical situation. Although a number of type 2 models are available, only a limited number of studies have focused on EDN in type 2 diabetes. Besides differences in the pathomechanisms of type 1 and 2 diabetes, the characteristic structural changes in DN are different and less severe in type 2 diabetes [43]. Models describing primary axonal disorders resemble the changes in type 1 diabetes, whereas those describing Schwann cell disorders are closer to type 2 This work was in part supported by grants from the Deutsche Forschungsgemeinschaft (Na 138/5-3, DFG/SFB 405 to PPN).

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