angiotensinogen and Hypertension--Pregnancy-Induced

Pregnancy induced hypertension and pre-eclampsia, defined as hypertension and proteinuria after 20 weeks of pregnancy with no history of such symptoms, are a great challenge in the field of perinatology They are a serious threat to the mother and the child. Regardless of numerous studies on the subject, the pathogenesis of pregnancy-induced hypertension and pre-eclampsia is still unknown, although a crucial role of genetic factors combined with environmental factors has been confirmed. New theory based on genetic analysis of Renin-Angiotensin System and its impact on blood pressure in pregnant women, has been subject to much debate recently Numerous genes have been studied but angiotensinogen remains to be the best known. Little is known about angiotensin receptor type 1 and 2. This paper presents the knowledge about selected genes of RAS and their impact on pregnancy

Topics: Angiotensinogen; Female; Genotype; Humans; Hypertension, Pregnancy-Induced; Polymorphism, Genetic; Pregnancy; Receptor, Angiotensin, Type 1; Receptor, Angiotensin, Type 2; Receptors, Angiotensin; Renin-Angiotensin System; Women's Health

There have been many studies concerning the associations of angiotensin-converting enzyme (ACE) I/D, angiotensinogen (AGT) M235T polymorphisms with pregnancy induced hypertension (PIH) among Chinese populations. However, the results were inconsistent, prompting the necessity of meta-analysis.. Studies published in English and Chinese were mainly searched in EMbase, PubMed and CBM up to January 2012.. Twenty-three studies with 3,551 subjects for ACE I/D and seven studies with 1,296 subjects for AGT M235T were included. Significant associations were found between ACE I/D and PIH under dominant, recessive and allelic models. A separate analysis confined to preeclampsia suggested that ACE I/D was associated with preeclampsia under recessive model and allelic model, but not dominant model. Stratified analyses were conducted as meta-regression analysis indicated that the sample size of case group was a significant source of heterogeneity, which suggested no significant association between ACE I/D and PIH in the subgroup of more than 100 cases. Associations were found between AGT M235T and PIH under dominant genetic model (OR = 1.59; 95 %CI: 1.04-2.42), recessive genetic model (OR = 1.60; 95 %CI: 1.07-2.40), and allelic model (OR = 1.40; 95 %CI: 1.17-1.68). No publication bias was found in either meta-analysis.. The present meta-analysis suggested significant associations between ACE I/D, AGT M235T and PIH in Chinese populations. However, no significant association was found between ACE I/D and PIH in the subgroup of more than 100 cases. Studies with larger sample sizes are necessary to investigate the associations between gene polymorphisms and PIH in Chinese populations.

Topics: Alleles; Angiotensinogen; Asian People; China; Female; Gene Frequency; Genetic Predisposition to Disease; Genetics, Population; Genome-Wide Association Study; Humans; Hypertension, Pregnancy-Induced; Incidence; Models, Genetic; Peptidyl-Dipeptidase A; Polymorphism, Genetic; Pregnancy; Publication Bias; Regression Analysis; Sensitivity and Specificity

The angiotensinogen gene M235T polymorphism is related to an increased risk of hypertension. Hypertension and pregnancy-induced hypertension have been suggested to share common etiologic factors. We examined whether this mutation also increases the risk of preeclampsia/eclampsia.. Pubmed/Medline, Web of Science and EMBASE were searched and a hand search of bibliographies was conducted. In all, 17 studies (including 1446 cases and 3829 controls) published in English between 1993 and October 2006 on the association of angiotensinogen gene M235T polymorphism with preeclampsia/eclampsia were selected.. The overall odds ratio (OR) under a random effects model revealed that individuals homozygous for the T allele were 1.62 times more likely to develop preeclampsia/eclampsia [95% confidence interval (CI), 1.12 to 2.33; P = 0.01) compared to individuals homozygous for the M allele. The relation in Caucasians (OR = 1.99; 95% CI, 1.18-3.36; P = 0.01) was similar to that in East Asian populations (OR = 1.74; 95% CI, 0.92-3.28; P = 0.09), although the latter was not statistically significant due to lower numbers of studies. Under additive, recessive and dominant genetic models positive associations were also found. A meta-regression analysis showed that ethnic background was a significant source of between-study heterogeneity (P = 0.04) but design of the study, study size and Hardy-Weinberg equilibrium deviation were not. There was a low probability of publication bias.. Our meta-analysis expands the findings on hypertension by showing that the presence of the T allele of the angiotensinogen gene is associated with an increased risk to develop preeclampsia/eclampsia.

Topics: Angiotensinogen; Eclampsia; Female; Genetic Predisposition to Disease; Humans; Hypertension, Pregnancy-Induced; Polymorphism, Genetic; Pre-Eclampsia; Pregnancy; Regression Analysis

Topics: Angiotensinogen; Cytokines; Endothelium, Vascular; Epoprostenol; Female; Humans; Hypertension, Pregnancy-Induced; Ischemia; Placenta; Polymorphism, Genetic; Pregnancy; Prognosis; Thromboxane A2

The study included pregnant women aged 23-41 years with preeclampsia and gestation-associated arterial hypertension at weeks 27-40 and patients with essential arterial hypertension developing under conditions of the metabolic syndrome and without it. Frequency analysis of polymorphisms of the renin-angiotensin system genes (ACE, AGT, and AGTR1), ITGB3, FTO and their associations confirmed the syndrome nature of hypertensive disorders in pregnancy. The presence allele T of AGT gene and/or allele C of AGTR1 gene in the genotype of patients with preeclampsia was associated with higher BP and pressure load over 24 h. Allele D of ACE gene was also essential for BP parameters (pressure load) in patients with preeclampsia and gestation-associated arterial hypertension. Due to high genetic heterogeneity of the preeclampsia syndrome and genetic differences in the incidence of the studied gene polymorphisms in preeclampsia and gestation-associated arterial hypertension, no direct associations between these gestation disorders and polymorphic markers of the renin-angiotensin system genes can be established. However, polymorphisms of the renin-angiotensin system genes are essential for the 24-h dynamics of BP and pressure load under conditions of hypertensive disorders in pregnancy.

Topics: Adult; Alpha-Ketoglutarate-Dependent Dioxygenase FTO; Angiotensinogen; Female; Humans; Hypertension, Pregnancy-Induced; Integrin beta3; Peptidyl-Dipeptidase A; Polymorphism, Genetic; Pregnancy; Prospective Studies; Receptor, Angiotensin, Type 1; Renin-Angiotensin System

Background AGT (angiotensinogen) synthesis occurs in renal proximal tubular epithelial cells, independent from systemic AGT , as a component of the intrarenal renin-angiotensin system. We investigated urinary AGT , as a biomarker for renin-angiotensin system activation, and electrolyte concentrations, in relation to glomerular volume, as a proxy for glomerular endotheliosis in renal biopsy tissue from pregnant normotensive control and hypertensive women. Methods and Results Urine samples were collected from normotensive control (n=10), gestational hypertensive (n=6), and pre-eclamptic (n=16) women at the time a renal biopsy was obtained. Samples were collected from Lund University Hospital between November 1999 and June 2001. Urinary AGT , potassium, and sodium were measured, normalized to urinary creatinine. Mean glomerular volume was estimated from biopsy sections. AGT protein expression and localization were assessed in renal biopsies by immunohistochemistry. Urinary AGT concentrations were higher in hypertensive pregnancies (median, gestational hypertension: 11.3 ng/mmol [interquartile range: 2.8-13.6]; preeclampsia: 8.4 ng/mmol [interquartile range: 4.2-29.1]; normotensive control: 0.6 ng/mmol [interquartile range: 0.4-0.8]; P<0.0001) and showed a positive relationship with estimated mean glomerular volume. Urinary potassium strongly correlated with urinary AGT ( P<0.0001). Although numbers were small, AGT protein was found in both glomeruli and proximal tubules in normotensive control but was present only in proximal tubules in women with hypertensive pregnancy. Conclusions This study shows that pregnant women with gestational hypertension or preeclampsia have increased urinary AGT and potassium excretion associated with signs of glomerular swelling. Our data suggest that the kidneys of women with hypertensive pregnancies and endotheliosis have inappropriate intrarenal renin-angiotensin system activation, which may contribute toward the pathogenesis of hypertension and renal injury.

Topics: Adult; Angiotensinogen; Biopsy; Case-Control Studies; Edema; Female; Humans; Hypertension, Pregnancy-Induced; Immunohistochemistry; Kidney Glomerulus; Kidney Tubules, Proximal; Potassium; Pre-Eclampsia; Pregnancy; Renin-Angiotensin System; Sodium

Black ethnicity is associated with worse pregnancy outcomes in women with chronic hypertension. Preexisting endothelial and renal dysfunction and poor placentation may contribute, but pathophysiological mechanisms underpinning increased risk are poorly understood. This cohort study aimed to investigate the relationship between ethnicity, superimposed preeclampsia, and longitudinal changes in markers of endothelial, renal, and placental dysfunction in women with chronic hypertension. Plasma concentrations of placental growth factor (PlGF), syndecan-1, renin, and aldosterone and urinary angiotensinogen-to-creatinine ratio (AGTCR), protein-to-creatinine ratio (PCR), and albumin-to-creatinine ratio (ACR) were quantified during pregnancy and postpartum in women with chronic hypertension. Comparisons of longitudinal biomarker concentrations were made using log-transformation and random effects logistic regression allowing for gestation. Of 117 women, superimposed preeclampsia was diagnosed in 21% ( n = 25), with 24% ( n = 6) having an additional diagnosis of diabetes. The cohort included 63 (54%) women who self-identified as being of black ethnicity. PlGF concentrations were 67% lower [95% confidence interval (CI) -79 to -48%] and AGTCR, PCR, and ACR were higher over gestation, in women with subsequent superimposed preeclampsia (compared with those without superimposed preeclampsia). PlGF <100 pg/ml at 20-23.9 wk of gestation predicted subsequent birth weight <3rd percentile with 88% sensitivity (95% CI 47-100%) and 83% specificity (95% CI 70-92%). Black women had 43% lower renin (95% CI -58 to -23%) and 41% lower aldosterone (95%CI -45 to -15%) concentrations over gestation. Changes in placental (PlGF) and renal (AGTCR/PCR/ACR) biomarkers predated adverse pregnancy outcome. Ethnic variation in the renin-angiotensin-aldosterone system exists in women with chronic hypertension in pregnancy and may be important in treatment selection.

Topics: Adult; Angiotensinogen; Biomarkers; Black People; Chronic Disease; Creatinine; Endothelium, Vascular; England; Female; Humans; Hypertension, Pregnancy-Induced; Kidney; Longitudinal Studies; Placenta; Placenta Growth Factor; Pre-Eclampsia; Pregnancy; Prognosis; Randomized Controlled Trials as Topic; Risk Factors; Serum Albumin, Human; Time Factors

Pregnancy-induced hypertension (PIH, including preeclampsia [PE] and gestational hypertension [GH]) and cardiovascular diseases (CVDs) have some metabolic changes and risk factors in common. Many studies have reported associations between single nucleotide polymorphisms (SNPs) of renin-angiotensin-aldosterone system (RAAS) genes and CVDs (particularly hypertension), and their findings have provided candidate SNPs for research on genetic correlates of PIH. We explored the association between hypertension-related RAAS SNPs and PIH in a Chinese population. A total of 130 cases with PE, 67 cases with GH, and 316 controls were recruited. Six candidate SNPs of the RAAS system were selected. Multiple logistic regression analysis adjusting for maternal age, fetal sex, and gestational diabetes mellitus showed significant associations between angiotensinogen (AGT) rs3789678 T/C and GH (p = 0.0088) and between angiotensin II receptor type 1 (AGTR1) rs275645 G/A and PE (p = 0.0082). The study population was further stratified by maternal age (<30 and ≥30 years), and stratified and crossover analyses were conducted to determine genetic associations in different age groups. Our findings suggest that the impacts of different SNPs might be affected by maternal age; however, the effect of this potential gene-age interaction on PIH needs further exploration.

Topics: Adult; Angiotensinogen; Asian People; Case-Control Studies; Female; Genetic Predisposition to Disease; Humans; Hypertension, Pregnancy-Induced; Male; Maternal Age; Peptidyl-Dipeptidase A; Polymorphism, Single Nucleotide; Pre-Eclampsia; Pregnancy; Receptor, Angiotensin, Type 1; Renin-Angiotensin System

High salt intake is an environmental factor that promotes increased blood pressure. We previously demonstrated that high salt diet causes aggravation of hypertension and impaired vasodilation in response to nitric oxide (NO) in young spontaneously hypertensive rats (SHR), which exhibit low sensitivity to salt in adulthood. Changes in offspring blood pressure and cardiovascular structures have been reported. However, it remains unclear to what extent a maternal high salt intake may affect cardiac and/or vascular function in offspring. Therefore, we investigated influence of exposure to a maternal high salt diet during gestation and lactation on offspring's cardiac and arterial functions in SHR.. SHR dams were fed either a high salt diet or a control diet. After weaning, the offspring were fed the high salt diet or control diet for 8weeks.. Compared with offspring of control diet-fed dams, at 12weeks of age, offspring of the high-salt diet-fed dams had lower blood pressure, heart rate, indices of both left ventricular systolic and diastolic function, and a decreased aortic vasodilation response to NO. Postnatal high salt intake did not affect blood pressure, vasodilatory response, or cardiac function in offspring of high-salt diet-fed dams. Neither maternal nor postnatal dietary salt altered levels of lipid peroxide, superoxide dismutase, or angiotensinogen mRNA in serum and ventricle of the offspring.. Exposure to high maternal dietary salt induces cardiac and vascular dysfunction in offspring. These results point to the possible importance of avoiding excess dietary salt during gestation and lactation.

Topics: Angiotensinogen; Animals; Aorta, Abdominal; Blood Pressure; Diet; Female; Hypertension, Pregnancy-Induced; Maternal Nutritional Physiological Phenomena; Mesenteric Arteries; Myocardium; Myocytes, Cardiac; Nitric Oxide; Nitric Oxide Synthase Type III; Oxidative Stress; Pregnancy; Prenatal Exposure Delayed Effects; Prenatal Nutritional Physiological Phenomena; Rats, Inbred SHR; Sodium Chloride, Dietary; Thiobarbituric Acid Reactive Substances; Vasodilation; Ventricular Dysfunction, Left

This study was to investigate whether the maternal and fetal angiotensinogen (AGT) M235T polymorphism were associated with the risk of pregnancy-induced hypertension (PIH) in Chinese Han ethnic women. Using a case-control mother-baby dyads study, a total of 226 maternal/offspring pairs were recruited at Anyang Maternal and Child Health Hospital from January 2008 to December 2009. Genomic DNA was extracted from maternal venous and cord blood. We genotyped the AGT M235T polymorphism by using PCR-RFLP assay and examined the association with PIH using logistic regression analysis. In the current study, the maternal AGT M235T polymorphism showed no effect on the risk of PIH (P = .786) while the fetal AGT M235T polymorphism is significantly associated with PIH in Chinese Han ethnic women (P = .004). The fetus carrying TT genotype is a protective factor in developing PIH in the study population (OR = .28, 95% CI = .14-0.59).

Topics: Adult; Angiotensinogen; Case-Control Studies; China; DNA; Female; Fetus; Genetic Predisposition to Disease; Genotype; Humans; Hypertension, Pregnancy-Induced; Infant, Newborn; Polymerase Chain Reaction; Polymorphism, Restriction Fragment Length; Polymorphism, Single Nucleotide; Pregnancy

As a noninvasive examination, urinary proteomics is a very useful tool to identify renal disease. The purpose of the present study was to find differential proteins among women with preeclampsia, gestational hypertension and normal pregnancy, and to screen potential biomarkers for the early diagnosis of preeclampsia.. Urinary proteins were identified by iTRAQ labeling coupled with 2-D LC-MS/MS. The bioinformatics analysis was performed with the Metacore software and the International Protein Index (IPI) and the Gene Ontology (GO) Database. The differentially expressed proteins were verified by ELISA.. 362 nonredundant proteins were identified, 113 of which were expressed differentially between preeclampsia and normal pregnant group and 31 differential proteins among three groups. These differential proteins were associated with biological processes of blood coagulation, cell adhesion and differentiation, immune response and cytoskeleton development, etc. They interacted with each other in the network. The urinary angiotensinogen (AGT) was downregulated, which was consistent with the ELISA validation results.. The present study found a multitude of differential proteins that might provide a clue for investigating the mechanism of proteinuria development in preeclampsia. Low urinary angiotensinogen levels were useful for identifying preeclampsia.

Topics: Acute Kidney Injury; Adult; Angiotensinogen; Case-Control Studies; Chromatography, Liquid; Computational Biology; Enzyme-Linked Immunosorbent Assay; Female; Gene Expression Regulation; Humans; Hypertension, Pregnancy-Induced; Pre-Eclampsia; Pregnancy; Proteinuria; Proteomics; Reproducibility of Results; Staining and Labeling; Tandem Mass Spectrometry

We investigated the variations in genes encoding endothelial nitric oxide synthase (NOS3), angiotensin-converting enzyme (ACE) and angiotensinogen (AGT) in hypertensive disorders of pregnancy and the relationship between the polymorphisms and circulating nitric oxide (NO) and ACE levels in pregnant north Indian women. Frequencies of NOS3 G894T, 4b/a and T(-786) --> C, AGT T704C and ACE ins/del polymorphisms were studied in 342 subjects: 120 with preeclampsia (PE), 104 with gestational hypertension and 118 normotensive pregnant women. Variations were evaluated by polymerase chain reaction-restriction fragment length polymorphism. NO and ACE levels were determined using ELISA. There was no difference in the distribution of individual NOS3 and ACE polymorphisms in the study groups. Haplotype analysis showed a global difference in the NOS3 haplotype distribution between the PE and non-PE subjects (P=0.03). The presence of AGT 704C allele was associated with a reduced risk of developing PE (odds ratio: 0.33, 95% CI: 0.19-0.59 in recessive mode). Circulating total NO and ACE levels were similar in three groups. No relationship was found between circulating NO levels and any of the NOS3 polymorphisms, but the circulating ACE levels were higher in those with DD genotype (P<0.05). In conclusion, there was no association between individual NOS3 and the ACE gene polymorphisms and hypertensive disorders of pregnancy in north Indian women. The presence of minor alleles at all the three sites in NOS3 seemed to increase the risk of PE, and AGT 704C allele was associated with a reduced PE risk. The complexity of interaction between these genetic abnormalities requires further studies.

Topics: Alleles; Analysis of Variance; Angiotensinogen; Enzyme-Linked Immunosorbent Assay; Female; Gene Frequency; Genetic Association Studies; Genetic Variation; Genotype; Haplotypes; Humans; Hypertension, Pregnancy-Induced; India; Nitric Oxide; Nitric Oxide Synthase Type III; Odds Ratio; Peptidyl-Dipeptidase A; Polymerase Chain Reaction; Polymorphism, Genetic; Pregnancy

Pregnancy-induced hypertension (PIH) is a common cause of perinatal mortality. It is believed to result from the interaction of several factors, including those related to the blood coagulation system. We performed genotyping and subgroup analyses to determine if the 4G/5G genotypes of the plasminogen activator inhibitor-1 gene (PAI-1) play a role in the pathogenesis of PIH, and to evaluate possible interactions of the PAI-1 polymorphisms with those of the angiotensinogen gene (AGT) and the endothelial nitric oxide synthase gene (NOS3).. An association study of PAI-1 polymorphism, and subgroup analyses of common variants of AGT and NOS3, among 128 patients with PIH and 376 healthy pregnant controls.. No significant differences were found between the cases and controls in the frequencies of allele 4G or the 4G/4G genotype. In subgroup analyses, after adjustment for multiple comparison, a significant association with the AGT TT genotype was found among women with the PAI-1 4G/4G genotype, and an association with the NOS3 GA+AA genotype was found among women with the 5G/5G or 4G/5G genotypes.. Our findings suggest that there are at least 2 pathways in the pathogenesis of severe PIH. However, with respect to early prediction and prevention of severe PIH, although the PAI-1 4G/4G genotype alone was not a risk factor for severe PIH, the fact that PAI-1 genotypes are associated with varying risks for severe PIH suggests that PAI-1 genotyping of pregnant women, in combination with other tests, may be useful in the development of individualized measures that may prevent severe PIH.

Topics: Adult; Angiotensinogen; Female; Genotype; Humans; Hypertension, Pregnancy-Induced; Nitric Oxide Synthase Type III; Plasminogen Activator Inhibitor 1; Polymorphism, Single Nucleotide; Pregnancy

We recently demonstrated that renin-angiotensin system (RAS) overactivity during late gestation in rats is associated with increased kidney and urine levels of ANG-(1-7) and enhanced kidney immunostaining of ANG-(1-7) and angiotensin-converting enzyme 2 (ACE2). To understand the temporal-spatial changes in normal and hypertensive pregnancies, the renal distribution of ANG-(1-7) and ACE2 in association with kidney angiotensin peptides and ACE2 activity was examined in virgin, normal pregnant (NP; gestational days 5, 15, and 19) and reduced uterine perfusion pressure (RUPP at day 19) pregnant Sprague-Dawley rats. ANG-(1-7) and ACE2 immunocytochemical staining increased 1.8- and 1.9-fold and 1.7- and 1.8-fold, respectively, at days 15 and 19 of NP, compared with virgin rats. ANG-(1-7) and ANG II concentrations were increased in the kidney at 19 days of gestation. ACE2 activity measured using a fluorescent substrate was increased 1.9- and 1.9-fold in the cortex and 1.9- and 1.8-fold in the medulla at days 15 and 19 of NP. In the RUPP animals, ANG-(1-7) immunostaining and concentration were significantly decreased compared with 19-day NP rats. ACE2 activity was unchanged in the cortex and medulla of RUPP rats. In conclusion, during NP, the concurrent changes of ACE2 and ANG-(1-7) suggest that ACE2 plays an important role in regulating the renal levels of ANG-(1-7) at mid to late gestation. However, the decrease in renal ANG-(1-7) content in the absence of a concomitant decrease in ACE2 implicates the participation of other ANG-(1-7) forming or degrading enzymes during hypertensive pregnancy.

Topics: Angiotensin I; Angiotensin-Converting Enzyme 2; Angiotensinogen; Animals; Blood Pressure; Body Weight; Estradiol; Female; Fluorescent Antibody Technique; Hypertension, Pregnancy-Induced; Immunohistochemistry; Kidney; Peptide Fragments; Peptidyl-Dipeptidase A; Pre-Eclampsia; Pregnancy; Pregnancy, Animal; Proteinuria; Rats; Rats, Sprague-Dawley; Regional Blood Flow; Renin; Urodynamics; Uterus

In 2003, the angiotensinogen (AGT) gene was found to be associated with infants small for gestational age (SGA). The present study of 107 pregnancies affected by SGA infants and 101 normal pregnancies was designed to further investigate this association. Maternal or fetal AGT genotype or haplotype frequencies did not differ between SGA and normal pregnancies (P > 0.35). Quantitative trait analysis of mothers with normal pregnancies demonstrated an association between AGT haplotype and blood pressure and body mass index at antenatal booking (P = 0.04), suggesting that AGT may play a role in the complex relationship between body mass and blood pressure in healthy pregnant women.

Topics: Adult; Angiotensinogen; Blood Pressure; Body Mass Index; Case-Control Studies; Female; Genetic Predisposition to Disease; Genetic Variation; Genotype; Gestational Age; Humans; Hypertension, Pregnancy-Induced; Infant, Newborn; Infant, Small for Gestational Age; Maternal Age; Pre-Eclampsia; Pregnancy

To examine whether polymorphisms in the renin-angiotensin system (RAS) are associated with pregnancy-related hypertensive disorders in a black South African population.. The angiotensin-converting enzyme (ACE) insertion/deletion, angiotensinogen M235T and angiotensin II receptor type 1 1166A<--C polymorphisms were assessed in study groups comprising 204 women with pre-eclampsia, 120 with eclampsia, 67 with early onset pre-eclampsia and 78 with gestational hypertension.. Using chi analysis, results were compared with those obtained from 338 ethnically matched normotensive pregnant women following normal full term pregnancies. No significant differences in the distribution of any of these polymorphisms were found between patients with pre-eclampsia or eclampsia and the normal control subjects. Patients with gestational hypertension were less frequently homozygous for the ACE insertion polymorphism compared with controls (5 versus 13%, respectively; P = 0.049; odds ratio 0.36 [95% confidence interval (CI) 0.09-1.04]).. The commonly occurring RAS polymorphisms are not predictive of pre-eclampsia or eclampsia in the Black South African population.

Topics: Adult; Angiotensinogen; Black People; Female; Genetic Predisposition to Disease; Heterozygote; Homozygote; Humans; Hypertension, Pregnancy-Induced; Peptidyl-Dipeptidase A; Polymorphism, Genetic; Pre-Eclampsia; Pregnancy; Receptor, Angiotensin, Type 1; South Africa