No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Mortality and its Causes in a German Cohort with Diabetes Mellitus Type 1 after 20 Years of Follow-Up: The JEVIN Trial
Abstract
Background The JEVIN trial started as a cross-sectional study in 1989/90 in Jena. After a follow-up of more than 20 years, the mortality incidence of JEVIN participants with type 1 diabetes was surveyed.
Methods 103 (78.6%) of the 131 JEVIN patients participating at baseline could be examined. 38 persons (36.9%) had deceased. All JEVIN survey data and routine examinations documented in the electronic patient record EMIL® of surviving and deceased participants were used for analyses. We compared the data of the surviving with the deceased participants (follow-up time: 2,166 person-years).
Results The incidence rate of death was 1.75/100 person-years. Median observation time for all patients was 23.1 years (range 0.61–26.6 years). Mean age at death was 58.5 years (34.2–78.4 years), and diabetes duration 35 years (3.5–68.5 years). Most frequent causes of death were: cardiovascular diseases (48.2%, n=13) and infections (25.9%, n=7). There were no differences in age (p=0.302), diabetes duration (p=0.371), BMI (p=0.535), blood pressure (p=0.622/0.820), gender (p=0.566), and smoking status (p=0.709) between surviving and deceased persons. The mean HbA1c of the last year before death or last visit was higher in the deceased than surviving persons (7.5% vs. 7.0%; p=0.010). 57.4% of the surviving and 87.0% of the deceased participants had nephropathy (p=0.012), 79.7% vs. 89.7% retinopathy (p=0.241) and 61.4% vs. 63.3% neuropathy (p=0.860), but only nephropathy was significantly associated with increased mortality risk (HR=4.208, CI:1.226-14.440; HR=2.360, CI:0.696-8.004; HR=0.944, CI:0.436-2.043).
Conclusions In the JEVIN population with diabetes mellitus type 1 only, diabetic nephropathy was associated with higher mortality risk.
... We are able to show that the increased mortality risk in individuals with type 1 diabetes certainly depends on the age of the individual and the duration of diabetes, while it only marginally depends on the duration of each of the diabetes- The mortality risk in individuals with more than one complication is simply the product of the risk estimates from each separate complication; no evidence was found of additional risk from having more than one complication. Large clinical trials have shown that intensive control of blood glucose lowers mortality risk in individuals with type 1 diabetes [6,7,20]. However, even with glycaemic levels near those recommended, an increased mortality risk remains [8,9]. ...
... We showed a clear association between diabetic neuropathy and mortality in type 1 diabetes. Few other studies have reported on mortality rates in individuals with type 1 diabetes and peripheral neuropathy [10,20] and those that do show discrepant results. The explanation for these differences remains elusive, but it could be related to the diversity in the criteria for the definition of neuropathy. ...
Aims/hypothesis
The role of burden and duration of multiple microvascular complications on mortality rate has not been explored in detail in type 1 diabetes. Taking complication burden and time-updated duration into account we aimed to quantify mortality rate in individuals with and without microvascular complications.
Methods
This observational clinical cohort included 3828 individuals with type 1 diabetes attending the Steno Diabetes Center Copenhagen in 2001–2013. We used information on mortality and detailed clinical measures of microvascular complications from electronic patient records. Poisson models were used to model mortality rates according to complication burden.
Results
During 26,665 person-years of follow-up, 503 deaths occurred. Compared with individuals without microvascular complications, the mortality rate ratio was 2.20 (95% CI 1.79, 2.69) for individuals with diabetic kidney disease, 1.72 (95% CI 1.39, 2.12) for individuals with neuropathy and 1.02 (95% CI 0.77, 1.37) for individuals with retinopathy, all adjusted for calendar time (year/month/day), age, duration of diabetes, sex, HbA1c, LDL-cholesterol, BMI, smoking status, systolic blood pressure, use of antihypertensive and lipid-lowering medication, and cardiovascular disease status. In individuals with two complications or more, the risk of mortality did not exceed the combined risk from each individual complication. Mortality rate ratios increased immediately after diagnosis of neuropathy and diabetic kidney disease. Mortality rate ratios were independent of the duration of neuropathy and retinopathy, while the mortality rate associated with diabetic kidney disease reached a stable level after approximately 3 years.
Conclusions/interpretation
Neuropathy and diabetic kidney disease are strong and independent risk markers of mortality in type 1 diabetes, whereas no evidence of higher mortality rate was found for retinopathy. We found no indication that the mortality risk with multiple complications exceeds the risk conferred by each complication separately. The duration spent with microvascular complications had only a marginal effect on mortality.
... However, the introduction of insulin has significantly increased people's life expectancy. Today, children and adolescents with T1DM have a life expectancy of around 65 to 69 years [4]. ...
Introduction: Type 1 diabetes mellitus (T1DM), in which the pancreas is no longer able to produce insulin to naturally control blood sugar, can be a major problem for the patient in terms of disease management. Closed-loop hybrid systems are designed to automate insulin delivery to improve T1DM outcomes and reduce the burden and distress for the user. The hybrid closed-loop makes an important contribution to reducing the difficulties of disease, also its control and management. Research goal: The goal is to examine how the closed hybrid loop system has contributed to the management of T1DM and improved the quality of life of patients. Participants and Methods: The survey was based on a non-experimental quantitative method with a questionnaire developed for the study. The surveys were distributed on Facebook in groups dedicated to patients with T1DM. The survey covered hybrid closed-loop users in Slovenia. Descriptive and inferential statistics were used for the statistical processing of the obtained data. IBM SPSS Statistics (version 20) was used. Results: The hybrid closed-loop system provides respondents with better management of T1DM and a better quality of life. 82.9% of respondents have fewer hypoglycaemic episodes than before using the hybrid system, 65.7% of respondents detect signs of hypoglycaemia earlier and fear of hypoglycaemia is reduced. 70.3% of respondents say they have less worries about diabetes. Conclusion: The study confirmed the prediction that respondents with T1DM are satisfied with the hybrid closed-loop system and notice fewer fluctuations in their blood sugar. The latest treatment method also helps to improve the quality of life. Because of its benefits, respondents recommend using a hybrid closed-loop system.
... However, this association disappears when retinopathy was adjusted for presence of macroalbuminuria. In addition, the 20-year mortality is calculated in a Germany cohort with T1DM, and the results also detect no association of DR and mortality [32]. Therefore, further studies are needed and various confounding factors should be taken into account. ...
Background: The prognostic significance of diabetic retinopathy (DR) for cardiovascular diseases (CVD) remained unclear. Therefore, we performed this meta-analysis to assess whether DR predicted CVD mortality in diabetic patients.
Methods: We searched PubMed, Embase, Web of Science and Cochrane Library for cohort studies reporting the association of DR and CVD mortality. Then we pooled the data for analysis.
Results: After screening the literature, 10 eligible studies with 11,239 diabetic subjects were finally included in quantitative synthesis. The pooled risk ratio (RR) of DR, mild DR, and severe DR for CVD mortality was 1.83 (95% confidence interval (CI): 1.42, 2.36; P < 0.001), 1.13 (95% CI: 0.81, 1.59; P = 0.46), and 2.26 (1.31, 3.91; P = 0.003), respectively, compared to those without DR. In type 2 DM, the patients with DR had a significantly higher CVD mortality (RR: 1.69; 95% CI: 1.27, 2.24; P < 0.001). Subgroup analysis also showed a significantly higher CVD mortality in DR according to various regions, study design, data source, and follow-up period (all RR > 1; all P values < 0.05). Data from 2 studies showed no significant correlation of DR and CVD mortality in diabetic patients receiving cardiovascular surgery (RR: 2.40; 95% CI: 0.63, 9.18; P = 0.200).
Conclusions: DR is a risk marker of cardiovascular death, and severe DR predicts a doubled mortality of CVD in diabetes. These findings indicate the importance of early identification and management of diabetic patients with DR to reduce the risk of death.
... However, this association disappears when retinopathy was adjusted for presence of macroalbuminuria. In addition, the 20-year mortality is calculated in a Germany cohort with T1DM, and the results also detect no association of DR and mortality [32]. Therefore, further studies are needed and various confounding factors should be taken into account. ...
Background
The prognostic significance of diabetic retinopathy (DR) for cardiovascular diseases (CVD) remained unclear. Therefore, we performed this meta-analysis to assess whether DR predicted CVD mortality in diabetic patients.
Methods
We searched PubMed, Embase, Web of Science and Cochrane Library for cohort studies reporting the association of DR and CVD mortality. Then we pooled the data for analysis.
Results
After screening the literature, 10 eligible studies with 11,239 diabetic subjects were finally included in quantitative synthesis. The pooled risk ratio (RR) of DR, mild DR, and severe DR for CVD mortality was 1.83 (95% confidence interval (CI): 1.42, 2.36; p < 0.001), 1.13 (95% CI 0.81, 1.59; p = 0.46), and 2.26 (1.31, 3.91; p = 0.003), respectively, compared to those without DR. In type 2 DM, the patients with DR had a significantly higher CVD mortality (RR: 1.69; 95% CI 1.27, 2.24; p < 0.001). Subgroup analysis also showed a significantly higher CVD mortality in DR according to various regions, study design, data source, and follow-up period (all RR > 1; all P values < 0.05). Data from 2 studies showed no significant correlation of DR and CVD mortality in diabetic patients receiving cardiovascular surgery (RR: 2.40; 95% CI 0.63, 9.18; P = 0.200).
Conclusions
DR is a risk marker of cardiovascular death, and severe DR predicts a doubled mortality of CVD in diabetes. These findings indicate the importance of early identification and management of diabetic patients with DR to reduce the risk of death.
... However, this association disappears when retinopathy was adjusted for presence of macroalbuminuria. In addition, the 20-year mortality is calculated in a Germany cohort with T1DM, and the results also detect no association of DR and mortality [32]. Therefore, further studies are needed and various confounding factors should be taken into account. ...
Background: The prognostic significance of diabetic retinopathy (DR) for cardiovascular diseases (CVD) remained unclear. Therefore, we performed this meta-analysis to assess whether DR predicted CVD mortality in diabetic patients.
Methods: We searched PubMed, Embase, Web of Science and Cochrane Library for cohort studies reporting the association of DR and CVD mortality. Then we pooled the data for analysis.
Results: After screening the literature, 10 eligible studies with 11,239 diabetic subjects were finally included in quantitative synthesis. The pooled risk ratio (RR) of DR, mild DR, and severe DR for CVD mortality was 1.83 (95% confidence interval (CI): 1.42, 2.36; P < 0.001), 1.13 (95% CI: 0.81, 1.59; P = 0.46), and 2.26 (1.31, 3.91; P = 0.003), respectively, compared to those without DR. In type 2 DM, the patients with DR had a significantly higher CVD mortality (RR: 1.69; 95% CI: 1.27, 2.24; P < 0.001). Subgroup analysis also showed a significantly higher CVD mortality in DR according to various regions, study design, data source, and follow-up period (all RR > 1; all P values < 0.05). Data from 2 studies showed no significant correlation of DR and CVD mortality in diabetic patients receiving cardiovascular surgery (RR: 2.40; 95% CI: 0.63, 9.18; P = 0.200).
Conclusions: DR is a risk marker of cardiovascular death, and severe DR predicts a doubled mortality of CVD in diabetes. These findings indicate the importance of early identification and management of diabetic patients with DR to reduce the risk of death.
... However, this association disappears when retinopathy was adjusted for presence of macroalbuminuria. In addition, the 20-year mortality is calculated in a Germany cohort with T1DM, and the results also detect no association of DR and mortality [32]. Therefore, further studies are needed and various confounding factors should be taken into account. ...
Background: The prognostic significance of diabetic retinopathy (DR) for cardiovascular diseases (CVD) remained unclear. Therefore, we performed this meta-analysis to assess whether DR predicted CVD mortality in diabetic patients.
Methods: We searched PubMed, Embase, Web of Science and Cochrane Library for cohort studies reporting the association of DR and CVD mortality. Then we pooled the data for analysis.
Results: After screening the literature, 10 eligible studies with 11,239 diabetic subjects were finally included in quantitative synthesis. The pooled risk ratio (RR) of DR, mild DR, and severe DR for CVD mortality was 1.83 (95% confidence interval (CI): 1.42, 2.36; P < 0.001), 1.13 (95% CI: 0.81, 1.59; P = 0.46), and 2.26 (1.31, 3.91; P = 0.003), respectively, compared to those without DR. In type 2 DM, the patients with DR had a significantly higher CVD mortality (RR: 1.69; 95% CI: 1.27, 2.24; P < 0.001). Subgroup analysis also showed a significantly higher CVD mortality in DR according to various regions, study design, data source, and follow-up period (all RR > 1; all P values < 0.05). Data from 2 studies showed no significant correlation of DR and CVD mortality in diabetic patients receiving cardiovascular surgery (RR: 2.40; 95% CI: 0.63, 9.18; P = 0.200).
Conclusions: DR is a risk marker of cardiovascular death, and severe DR predicts a doubled mortality of CVD in diabetes. These findings indicate the importance of early identification and management of diabetic patients with DR to reduce the risk of death.
... In the Joslin 50-year Medalist Study and in the Finnish Diabetic Nephropathy Study (FinnDiane) the coexistence of proliferative diabetic retinopathy (PDR) and stage ≥ 3b diabetic kidney disease (DKD) was associated with higher prevalence of CV disease in patients with longstanding type 1 diabetes [14]. Nonetheless, till recently [15], cross-sectional [14,16] and prospective data [17] assessing the impact of cumulative microvascular disease burden on CV disease and overall mortality in type 1 diabetes have been scanty. Therefore, we have investigated to which extent the cumulative burden of retinopathy, nephropathy, and peripheral neuropathy is associated with the incidence of all-cause mortality, major CV disease and coronary heart disease (CHD) irrespective of conventional CV risk factors in individuals with type 1 diabetes. ...
Abstract Background Microvascular complications (MC) have been claimed to increase the risk for cardiovascular disease in diabetic subjects. However, the effect of MC burden on the risk of major vascular outcomes and all-cause mortality in type 1 diabetes is still poorly explored. We evaluated the relationship between microvascular complications burden and incidence of major cardiovascular events and all-cause mortality in subjects with type 1 diabetes. Methods We recruited 774 participants with type 1 diabetes in a single-center observational study over a follow-up of 10.8 ± 2.5 years. Hazard ratios (HR) for cardiovascular outcomes and all-cause death associated with microvascular complications were determined by unadjusted and adjusted Cox regression analysis. Results Out of 774 individuals, 54.9% had no-MC, 32.3% 1 MC, 9.7% 2 MC and 3.1% 3 MC. A total of 54 deaths (7.0%) occurred. Death rate increased from no-MC 2.1% (Ref) to 1 MC 7.2% (HR 3.54 [95% CI 1.59–7.87]), 2 MC 14.7% (HR 6.41 [95% CI 2.65–15.49]) and 3 MC 66.7% (HR 41.73 [95% CI 18.42–94.57], p
... Empirical data from countries with comparable health care systems indicate that R is approximately 3 [17,18]. In case of patients with severe late complications, R reaches a value of about 4 [19]. Figure 4 shows the age-specific incidence rate of type 1 diabetes in German women in 2010. ...
Chronic diseases impose a huge burden for mankind. Recently, a mathematical relation between the incidence and prevalence of a chronic disease in terms of a differential equation has been described. In this article, we study the characteristics of this differential equation. Furthermore, we prove the ill-posedness of a related inverse problem arising in chronic disease epidemiology. An example application for the inverse problem about type 1 diabetes in German women aged up to 35 years is given.
... A concurrent infection and the subsequent mounting of an immune along with existing inflammation in diabetics can further activate additional proinflammatory pathways. These can potentially further disturb the homeostatic balance in the eyes (Joshi et al., 1999;Casqueiro et al., 2012;Kitagaki et al., 2016;Heller et al., 2017). This heightened immune reaction, in the long run, plays havoc with the host's cellular functions. ...
Diabetic patients suffer from a host of physiological abnormalities beyond just those of glucose metabolism. These abnormalities often lead to systemic inflammation via modulation of several inflammation-related genes, their respective gene products, homocysteine metabolism, and pyroptosis. The very nature of this homeostatic disruption re-sets the overall physiology of diabetics via upregulation of immune responses, enhanced retinal neovascularization, upregulation of epigenetic events, and disturbances in cells’ redox regulatory system. This altered pathophysiological milieu can lead to the development of diabetic retinopathy (DR), a debilitating vision-threatening eye condition with microvascular complications. DR is the most prevalent cause of irreversible blindness in the working-age adults throughout the world as it can lead to severe structural and functional remodeling of the retina, decreasing vision and thus diminishing the quality of life. In this manuscript, we attempt to summarize recent developments and new insights to explore the very nature of this intertwined crosstalk between components of the immune system and their metabolic orchestrations to elucidate the pathophysiology of DR. Understanding the multifaceted nature of the cellular and molecular factors that are involved in DR could reveal new targets for effective diagnostics, therapeutics, prognostics, preventive tools, and finally strategies to combat the development and progression of DR in susceptible subjects.
The excess risk of death from any cause and of death from cardiovascular causes is unknown among patients with type 1 diabetes and various levels of glycemic control. We conducted a registry-based observational study to determine the excess risk of death according to the level of glycemic control in a Swedish population of patients with diabetes.
We included in our study patients with type 1 diabetes registered in the Swedish National Diabetes Register after January 1, 1998. For each patient, five controls were randomly selected from the general population and matched according to age, sex, and county. Patients and controls were followed until December 31, 2011, through the Swedish Register for Cause-Specific Mortality.
The mean age of the patients with diabetes and the controls at baseline was 35.8 and 35.7 years, respectively, and 45.1% of the participants in each group were women. The mean follow-up in the diabetes and control groups was 8.0 and 8.3 years, respectively. Overall, 2701 of 33,915 patients with diabetes (8.0%) died, as compared with 4835 of 169,249 controls (2.9%) (adjusted hazard ratio, 3.52; 95% confidence interval [CI], 3.06 to 4.04); the corresponding rates of death from cardiovascular causes were 2.7% and 0.9% (adjusted hazard ratio, 4.60; 95% CI, 3.47 to 6.10). The multivariable-adjusted hazard ratios for death from any cause according to the glycated hemoglobin level for patients with diabetes as compared with controls were 2.36 (95% CI, 1.97 to 2.83) for a glycated hemoglobin level of 6.9% or lower (≤52 mmol per mole), 2.38 (95% CI, 2.02 to 2.80) for a level of 7.0 to 7.8% (53 to 62 mmol per mole), 3.11 (95% CI, 2.66 to 3.62) for a level of 7.9 to 8.7% (63 to 72 mmol per mole), 3.65 (95% CI, 3.11 to 4.30) for a level of 8.8 to 9.6% (73 to 82 mmol per mole), and 8.51 (95% CI, 7.24 to 10.01) for a level of 9.7% or higher (≥83 mmol per mole). Corresponding hazard ratios for death from cardiovascular causes were 2.92 (95% CI, 2.07 to 4.13), 3.39 (95% CI, 2.49 to 4.61), 4.44 (95% CI, 3.32 to 5.96), 5.35 (95% CI, 3.94 to 7.26), and 10.46 (95% CI, 7.62 to 14.37).
In our registry-based observational study, patients with type 1 diabetes and a glycated hemoglobin level of 6.9% or lower had a risk of death from any cause or from cardiovascular causes that was twice as high as the risk for matched controls. (Funded by the Swedish Society of Medicine and others.).
Survival in type 1 diabetes has improved, but the impact on life expectancy in the U.S. type 1 diabetes population is not well established. Our objective was to estimate the life expectancy of the Pittsburgh Epidemiology of Diabetes Complications (EDC) study cohort and quantify improvements by comparing two subcohorts based on year of diabetes diagnosis (1950-1964 [n = 390] vs. 1965-1980 [n = 543]). The EDC study is a prospective cohort study of 933 participants with childhood-onset (aged <17 years) type 1 diabetes diagnosed at Children's Hospital of Pittsburgh from 1950 to 1980. Mortality ascertainment was censored 31 December 2009. Abridged cohort life tables were constructed to calculate life expectancy. Death occurred in 237 (60.8%) of the 1950-1964 subcohort compared with 88 (16.2%) of the 1965-1980 subcohort. The life expectancy at birth for those diagnosed 1965-1980 was ∼15 years greater than participants diagnosed 1950-1964 (68.8 [95% CI 64.7-72.8] vs. 53.4 [50.8-56.0] years, respectively) (P < 0.0001); this difference persisted regardless of sex or pubertal status at diagnosis. This improvement in life expectancy emphasizes the need for insurance companies to update analysis of the life expectancy of those with childhood-onset type 1 diabetes because weighting of insurance premiums is based on outdated estimates.
To clarify whether the increase in childhood type 1 diabetes is mirrored by a decrease in older age-groups, resulting in younger age at diagnosis.
We used data from two prospective research registers, the Swedish Childhood Diabetes Register, which included case subjects aged 0-14.9 years at diagnosis, and the Diabetes in Sweden Study, which included case subjects aged 15-34.9 years at diagnosis, covering birth cohorts between 1948 and 2007. The total database included 20,249 individuals with diabetes diagnosed between 1983 and 2007. Incidence rates over time were analyzed using Poisson regression models.
The overall yearly incidence rose to a peak of 42.3 per 100,000 person-years in male subjects aged 10-14 years and to a peak of 37.1 per 100,000 person-years in female subjects aged 5-9 years and decreased thereafter. There was a significant increase by calendar year in both sexes in the three age-groups <15 years; however, there were significant decreases in the older age-groups (25- to 29-years and 30- to 34-years age-groups). Poisson regression analyses showed that a cohort effect seemed to dominate over a time-period effect.
Twenty-five years of prospective nationwide incidence registration demonstrates a clear shift to younger age at onset rather than a uniform increase in incidence rates across all age-groups. The dominance of cohort effects over period effects suggests that exposures affecting young children may be responsible for the increasing incidence in the younger age-groups.
The FinnDiane Study has reported that mortality in type 1 diabetes is not increased over a 7 year follow-up in the absence of renal disease (RD). Using the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study population (n = 658) of childhood-onset type 1 diabetes (age <17 years), the present study sought to replicate and expand these findings to a 20 year follow-up (as of 1 January 2008) and examine cause of death by renal status.
At baseline (1986-1988), mean age and duration of diabetes were 28 and 19 years, respectively. RD was defined as an albumin excretion rate ≥20 μg/min from multiple samples and grouped as microalbuminuria (MA; 20-200 μg/min), overt nephropathy (ON; >200 μg/min), or end stage renal disease (ESRD; dialysis or renal transplantation).
At baseline, 311 (47.3%) individuals had RD (MA 21.3%, ON 22.2% and ESRD 3.8%). During a median 20 year follow-up, there were 152 deaths (23.1%). Mortality was 6.2 (95% CI 5.2-7.2) times higher than expected, with standardised mortality ratios of 2.0 (1.2-2.8) for normoalbuminuria (NA); 6.4 (4.4-8.4) for MA; 12.5 (9.5-15.4) for ON; and 29.8 (16.8-42.9) for ESRD. Excluding those (n = 64) with NA who later progressed to RD, no significant excess mortality was observed in the remaining NA group (1.2, 0.5-1.9), whose deaths were largely unrelated to diabetes.
These data confirm the importance of RD, including persistent microalbuminuria, as a marker of mortality risk and suggest that type 1 diabetes patients without renal disease achieve long-term survival comparable to the general population.
Clinical treatment goals of type 1 diabetes mellitus (T1DM) have changed since the Diabetes Control and Complications Trial (DCCT) demonstrated reduced long-term complications with intensive diabetes therapy. There have been few longitudinal studies to describe the clinical course of T1DM in the age of intensive therapy. Our objective was to describe the current-day clinical course of T1DM.
An analysis of the cumulative incidence of long-term complications was performed. The DCCT (1983-1993) assigned patients to conventional or intensive therapy. Since 1993, the DCCT has been observational, and intensive therapy was recommended for all patients. The Pittsburgh Epidemiology of Diabetes Complications (EDC) study is an observational study of patients with T1DM from Allegheny County, Pennsylvania. The study population comprised the DCCT T1DM cohort (N = 1441) and a subset of the EDC cohort (n = 161) selected to match DCCT entry criteria. In the DCCT, intensive therapy aimed for a near-normal glycemic level with 3 or more daily insulin injections or an insulin pump. Conventional therapy, with 1 to 2 daily insulin injections, was not designed to achieve specific glycemic targets. Main outcome measures included the incidences of proliferative retinopathy, nephropathy (albumin excretion rate >300 mg/24 h, creatinine level >or=2 mg/dL [to convert to micromoles per liter, multiply by 88.4], or renal replacement), and cardiovascular disease.
After 30 years of diabetes, the cumulative incidences of proliferative retinopathy, nephropathy, and cardiovascular disease were 50%, 25%, and 14%, respectively, in the DCCT conventional treatment group, and 47%, 17%, and 14%, respectively, in the EDC cohort. The DCCT intensive therapy group had substantially lower cumulative incidences (21%, 9%, and 9%) and fewer than 1% became blind, required kidney replacement, or had an amputation because of diabetes during that time.
The frequencies of serious complications in patients with T1DM, especially when treated intensively, are lower than that reported historically.
This study aimed to identify clinical features associated with premature mortality in a large contemporary cohort of adults with type 1 diabetes.
The Finnish Diabetic Nephropathy (FinnDiane) study is a national multicenter prospective follow-up study of 4,201 adults with type 1 diabetes from 21 university and central hospitals, 33 district hospitals, and 26 primary health care centers across Finland.
During a median 7 years of follow-up, there were 291 deaths (7%), 3.6-fold (95% CI 3.2-4.0) more than that observed in the age- and sex-matched general population. Excess mortality was only observed in individuals with chronic kidney disease. Individuals with normoalbuminuria showed no excess mortality beyond the general population (standardized mortality ratio [SMR] 0.8, 95% CI 0.5-1.1), independent of the duration of diabetes. The presence of microalbuminuria, macroalbuminuria, and end-stage kidney disease was associated with 2.8, 9.2, and 18.3 times higher SMR, respectively. The increase in mortality across each stage of albuminuria was equivalent to the risk conferred by preexisting macrovascular disease. In addition, the glomerular filtration rate was independently associated with mortality, such that individuals with impaired kidney function, as well as those demonstrating hyperfiltration, had an increased risk of death.
An independent graded association was observed between the presence and severity of kidney disease and mortality in a large contemporary cohort of individuals with type 1 diabetes. These findings highlight the clinical and public health importance of chronic kidney disease and its prevention in the management of type 1 diabetes.
Since 1990 in most Eastern European countries health care systems have been decentralized or are undergoing the processes of decentralization. Increasingly, diabetic patients are no longer treated by diabetologists but by non-specialized physicians. During the same period structured treatment and teaching programmes have been introduced and health care is increasingly influenced by the St. Vincent declaration. To show the effect of these changes on the quality of diabetes care 90% (n = 244) of all insulin-treated diabetic patients aged 16 to 60 years and living in the city of Jena (100247 inhabitants) were studied in 1994/1995. The results were compared with the baseline examination of 1989/1990 (n = 190). HbA1c (HbA1c/mean normal) in IDDM patients under specialized care was similar in 1994/1995 (1.54 +/- 0.27, n = 47) to 1989/1990 (1.52 +/- 0.31, n = 131, p = 0.0018), but higher under non-specialized care (1.71 +/- 0.38, n = 80, p = 0.0087). In the total group of NIDDM patients there was no significant change in HbA1c (1994/1995: 1.75 +/- 0.4, n = 117, vs 1989/1990: 1.78 +/- 0.4, n = 59, p = 0.67), but with a tendency to higher HbA1c under non-specialized (1.81 +/- 0.4, n = 79) compared to specialized care (1.66 +/- 0.39, n = 38, p = 0.06). Incidence of severe hypoglycaemia (IDDM 0.13; NIDDM 0.04), ketoacidosis (0.02; 0.01) and the prevalence of nephropathy (21%; 35%) and neuropathy (24%; 38%) remained unchanged in comparison to 1989/1990, whereas there was an increase in the prevalence of diabetic retinopathy. Specialized care is mandatory for patients with IDDM.
To establish all-cause death rates and life expectancies of and risk factors for mortality in insulin-treated diabetic individuals living in Canterbury, New Zealand.
Insulin-treated diabetic subjects (n = 1,008) on the Canterbury Diabetes Registry were tracked over 9 years, and their vital status was determined. Death rates were standardized using direct and indirect methods. Cox proportional hazard regression was used to model the effects of demographic and clinical covariates on survival time.
At study entry, age ranged from 2.9 to 92.7 years, with mean 48.7 +/- 20.4 years; age at diagnosis was 0.2-88.9 years, mean 34.5 +/- 20.0 years; and duration of diabetes was 0.1-58.5 years, mean 14.0 +/- 10.6 years. There were 303 deaths in 7,372 person-years of follow-up with a standardized mortality ratio (SMR) of 2.6 (95% CI 2.4-3.0). Relative mortality was greatest for those aged 30-39 years (SMR 9.2 [4.8-16.2]). The death rate for the diabetic cohort standardized against the Segi world standard population was 16.2 per 1,000. Attained age, sex, and clinical subtype were significant predictors of mortality The SMR for subjects with type 1 diabetes and age at onset <30 years was 3.7 (CI 2.7-5.0), 2.2 (1.8-2.6) for those with onset > or =30 years, and 3.1 (2.5-3.7) for subjects suspected of having latent autoimmune diabetes in adulthood or insulin-treated type 2 diabetes. Life expectancy was reduced for both sexes at all ages.
Mortality rates for insulin-treated diabetic individuals remain high, resulting in shortened life spans relative to the general population. Marked differences in mortality exist between clinical groups of subjects. Further research is needed to improve diabetes classification and to clarify differences in health outcomes.
To compare the risk of cardiovascular disease (CVD) death and the impact of hyperglycemia on the risk of CVD mortality associated with type 1 diabetes to that associated with type 2 diabetes.
The study comprised 173 participants with type 1 diabetes, 834 participants with type 2 diabetes, and 1,294 nondiabetic participants, aged 45-64 years at baseline and free of CVD. The age of onset of diabetes was >30 years in both diabetic groups.
During an 18-year follow-up, 86 participants with type 1 diabetes, 567 participants with type 2 diabetes, and 252 nondiabetic participants died. CVD mortality rates per 1,000 person-years were 23.1 (95% CI 16.9-31.9) in type 1 diabetic, 35.3 (30.8-40.4) in type 2 diabetic, and 4.6 (3.8-5.7) in nondiabetic participants. Adjusted hazard ratios for CVD mortality in participants with type 1 diabetes versus no diabetes was 3.6 (95% CI 2.2-5.7) in men and 13.3 (6.9-22.5) in women and in participants with type 2 diabetes versus no diabetes 3.3 (2.5-4.5) in men and 10.1 (6.7-17.4) in women. An increment of 1 unit (%) of GHb increased CVD mortality by 52.5% (95% CI 28.4-81.3) in type 1 diabetic subjects and by 7.5% (4.3-10.8) in type 2 diabetic participants.
The impact of type 1 and type 2 diabetes on CVD mortality was similar. The effect of increasing hyperglycemia on the risk of CVD mortality was more profound in type 1 than in type 2 diabetic subjects.
Background: The JEVIN trial started as a cross-sectional study in 1989/90 in Jena, a city of the former German Democratic Republic. At that time, the centralized diabetes care system was broken down and restarted 10 years later; structured treatment and teaching programs were implemented, blood glucose self-monitoring, insulin pump-systems and analogue insulin were introduced. We surveyed people with type-1-diabetes of the baseline JEVIN trial in a 20-year follow-up.
Methods: 131 patients with type-1-diabetes were analyzed in 1989/90. Of the living population in 2009/10 (n=104), 83 persons were identified and 75 persons with a mean diabetes duration of 35 years were reexamined regarding HbA1c, self-monitoring, diabetes therapy, severe hypoglycemia, diabetic late complications and compared with the results of the same persons in 1989/90.
Results: HbA1c decreased from 57.1 mmol/mol in 1989/90 to 52.7 mmol/mol in 2009/10 (7.4 –7.0%; p=0.049). Self-monitoring of blood glucose increased from 2 to 35 tests/week (p<0.001). 100%-use of animal insulin changed to human and analogue insulin therapy. The incidence of severe hypoglycemia increased from 0.1 to 0.16/patient-year. Retinopathy increased from 29 to 69% (p<0.001), nephropathy from 5 to 27% (p<0.001) and neuropathy from 13 to 43% (p<0.001). 17% had no diabetic late complications.
Conclusions: The JEVIN trial shows a significant improve in HbA1c in the past 20 years. Severe hypoglycemia occurred rarely and 17% were still free of any diabetic late complication after 35 years of diabetes. This indicates a good quality of diabetes care in a German setting.
Objective:
To study long-term mortality, causes of death, and end-stage renal disease (ESRD) in people diagnosed with type 1 diabetes at age 15-29 years.
Research design and methods:
This nationwide, population-based cohort with type 1 diabetes diagnosed during 1978-1982 (n = 719) was followed from diagnosis until death, emigration, or September 2013. Linkages to the Norwegian Cause of Death Registry and the Norwegian Renal Registry provided information on causes of death and whether ESRD was present. A clinical committee reviewed the causes of death. We calculated standardized mortality ratios (SMRs) for comparison with the background population.
Results:
During 30 years' follow-up, 4.6% of participants developed ESRD and 20.6% (n = 148; 106 men and 42 women) died. Cumulative mortality by years since diagnosis was 6.0% (95% CI 4.5-8.0) at 10 years, 12.2% (10.0-14.8) at 20 years, and 18.4% (15.8-21.5) at 30 years. The SMR was 4.4 (95% CI 3.7-5.1). Mean time from diagnosis of diabetes to ESRD was 23.6 years (range 14.2-33.5). Death was caused by chronic complications (32.2%), acute complications (20.5%), violent death (19.9%), or any other cause (27.4%). Death was related to alcohol in 15% of cases. SMR for alcohol-related death was 6.8 (95% CI 4.5-10.3), for cardiovascular death was 7.3 (5.4-10.0), and for violent death was 3.6 (2.3-5.3).
Conclusions:
The cumulative incidence of ESRD was low in this cohort with type 1 diabetes followed for 30 years. Mortality was 4.4 times that of the general population, and more than 50% of all deaths were caused by acute or chronic complications. A relatively high proportion of deaths were related to alcohol.
Whether mortality in type 1 diabetes mellitus is affected following intensive glycemic therapy has not been established.
To determine whether mortality differed between the original intensive and conventional treatment groups in the long-term follow-up of the Diabetes Control and Complications Trial (DCCT) cohort.
After the DCCT (1983-1993) ended, participants were followed up in a multisite (27 US and Canadian academic clinical centers) observational study (Epidemiology of Diabetes Control and Complications [EDIC]) until December 31, 2012. Participants were 1441 healthy volunteers with diabetes mellitus who, at baseline, were 13 to 39 years of age with 1 to 15 years of diabetes duration and no or early microvascular complications, and without hypertension, preexisting cardiovascular disease, or other potentially life-threatening disease.
During the clinical trial, participants were randomly assigned to receive intensive therapy (n = 711) aimed at achieving glycemia as close to the nondiabetic range as safely possible, or conventional therapy (n = 730) with the goal of avoiding symptomatic hypoglycemia and hyperglycemia. At the end of the DCCT, after a mean of 6.5 years, intensive therapy was taught and recommended to all participants and diabetes care was returned to personal physicians.
Total and cause-specific mortality was assessed through annual contact with family and friends and through records over 27 years' mean follow-up.
Vital status was ascertained for 1429 (99.2%) participants. There were 107 deaths, 64 in the conventional and 43 in the intensive group. The absolute risk difference was -109 per 100,000 patient-years (95% CI, -218 to -1), with lower all-cause mortality risk in the intensive therapy group (hazard ratio [HR] = 0.67 [95% CI, 0.46-0.99]; P = .045). Primary causes of death were cardiovascular disease (24 deaths; 22.4%), cancer (21 deaths; 19.6%), acute diabetes complications (19 deaths; 17.8%), and accidents or suicide (18 deaths; 16.8%). Higher levels of glycated hemoglobin (HbA1c) were associated with all-cause mortality (HR = 1.56 [95% CI, 1.35-1.81 per 10% relative increase in HbA1c]; P < .001), as well as the development of albuminuria (HR = 2.20 [95% CI, 1.46-3.31]; P < .001).
After a mean of 27 years' follow-up of patients with type 1 diabetes, 6.5 years of initial intensive diabetes therapy was associated with a modestly lower all-cause mortality rate when compared with conventional therapy.
clinicaltrials.gov Identifiers: NCT00360815 and NCT00360893.
BACKGROUND
Long-term microvascular and neurologic complications cause major morbidity and mortality in patients with insulin-dependent diabetes mellitus (IDDM). We examined whether intensive treatment with the goal of maintaining blood glucose concentrations close to the normal range could decrease the frequency and severity of these complications.
METHODS
A total of 1441 patients with IDDM -- 726 with no retinopathy at base line (the primary-prevention cohort) and 715 with mild retinopathy (the secondary-intervention cohort) were randomly assigned to intensive therapy administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood glucose monitoring or to conventional therapy with one or two daily insulin injections. The patients were followed for a mean of 6.5 years, and the appearance and progression of retinopathy and other complications were assessed regularly.
RESULTS
In the primary-prevention cohort, intensive therapy reduced the adjusted mean risk for the development of retinopathy by 76 percent (95 percent confidence interval, 62 to 85 percent), as compared with conventional therapy. In the secondary-intervention cohort, intensive therapy slowed the progression of retinopathy by 54 percent (95 percent confidence interval, 39 to 66 percent) and reduced the development of proliferative or severe nonproliferative retinopathy by 47 percent (95 percent confidence interval, 14 to 67 percent). In the two cohorts combined, intensive therapy reduced the occurrence of microalbuminuria (urinary albumin excretion of ≥ 40 mg per 24 hours) by 39 percent (95 percent confidence interval, 21 to 52 percent), that of albuminuria (urinary albumin excretion of ≥ 300 mg per 24 hours) by 54 percent (95 percent confidence interval, 19 to 74 percent), and that of clinical neuropathy by 60 percent (95 percent confidence interval, 38 to 74 percent). The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia.
CONCLUSIONS
Intensive therapy effectively delays the onset and slows the progression of diabetic retinopathy, nephropathy, and neuropathy in patients with IDDM.
Unlabelled:
AIMS AND HYPOTHESES: JEVIN ( Jena's St. Vincent Trial) is a prospective, 10-year follow-up, population-based survey of all insulin-treated patients with type 1 and type 2 diabetes mellitus aged 16-60 years and living in the city of Jena (100,000 inhabitants), Thuringia. It aims to show the effects of recent changes in the health care system and new treatment strategies. During the period from 1989/90 to 1994/95, the health care system was decentralized. There has been an broad implementation of postgraduate educational courses for primary care physicians, of structured treatment and teaching programs (TTP), of intensified insulin therapy, and blood glucose self-monitoring for all patients.
Patients and methods:
190 patients (83% of the target population), 244 patients (90%) and 261 patients (90%) were studied in 1989/90, 1994/95 and 1999/2000, respectively.
Results:
Up to 1994/95, the relative HbA(1c) (HbA(1c)/mean normal) of patients with type 1 diabetes increased (1994/95: 1.65 +/- 0.35 vs. 1989/90: 1.52 +/- 0.31; p = 0.002). For patients with type 2 diabetes mellitus it remained constant (1.75 +/- 0.4 vs. 1.78 +/- 0.31; p = 0.669). During the period from 1994/95 to 1999/2000, there was a substantial improvement in the relative HbA(1c) of both, patients with type 1 (1.48 +/- 0.3; p < 0.0001), and type 2 diabetes (1.47 +/- 0.25; p < 0.0001). Up to 1999/2000, 87.7% of the patients with type 1 (1989/90: 0%, 1994/95: 73.2%) and 96.6% of the patients with type 2 diabetes (1989/90: 0%, 1994/95: 89.7%) participated in TTPs. Similarly, the percentage of patients with intensified insulin therapy (type 1/2: 1989/90: 5.3%/3.4%, 1994/95: 80.3%/30.8%, 1999/2000: 94.7%/48.3%) and the frequency of weekly blood glucose self-monitoring (type 1/2: 1989/90: 1 [0-28]/0 [0-21], 1994/95: 25 [0-49]/14 [0-35], 1999/2000: 28 [0-70]/21 [0-46]) increased. Moreover, there was a drastic improvement in private health care: up to 1999/2000, about 90% of all the patients studied were treated by primary care physicians who took part in postgraduate educational courses.
Conclusions:
During the past decade, there has been a substantial improvement in the quality of diabetes control. The broad implementation of structured TTPs, intensified insulin therapy, and blood glucose self-monitoring for patients with type 1 and 2 diabetes mellitus seem to be the major cornerstones for the improved quality of diabetes care. However, the impressive improvement in the quality of diabetes care in patients with type 2 diabetes mellitus seems not to be related mainly to an increase (about 10% vs. 20% in type 1 diabetes) in the number of patients under specialist care, but rather to an improvement in the quality of diabetes therapy administered by private health care physicians.
ACCURACYGFR estimating equations are derived from regression analysis in which the level of measured GFR is related to the serum concentration of an endogenous filtration marker and to observed clinical and demographic variables that serve as surrogates for the non-GFR determinants of the serum concentration. Age, sex, race, and body weight are surrogates for creatinine generation from muscle, which affects serum creatinine concentration independently from GFR. In principle, GFR estimating equations provide a more accurate estimate of measured GFR than the serum level of the filtration marker alone. In addition, GFR estimates are provided in the same units as measured GFR, thereby simplifying clinical decisions based on the level of kidney function. Inaccuracy of GFR estimates may be due to bias, defined as systematic deviation of estimated GFR compared with measured GFR using the reference (or “gold”) standard, or may be due to imprecision, defined as random variation (or “spread”) of estimated GFR values centered around the measured values.7Variation in creatinine assays is a major source of bias. More accurate creatinine assays, traceable to gold-standard creatinine measurements, have now replaced less accurate methods, and a creatinine standardization program has been implemented in all clinical laboratories throughout the United States.8 The effect of standardizing creatinine assays will vary among clinical laboratories, but on average will lead to lower values for serum creatinine and higher values for estimated GFR compared with measurements before standardization. The MDRD Study and CKD-EPI equations can be used with standardized creatinine.3,9 The Cockcroft-Gault equation cannot be re-expressed for standardized serum creatinine; thus, older studies that used nonstandardized creatinine assays to examine the performance of the Cockcroft-Gault equation are no longer relevant.Bias may also reflect systematic differences between development datasets and populations in which the equation will be used. These differences likely reflect differences in non-GFR determinants that are not captured by the variables used in the estimating equations. The systematic underestimation of measured GFR at higher estimated GFR by the MDRD Study equation is well known,10–12 and may reflect higher creatinine generation in healthy individuals compared with individuals with CKD in whom the MDRD Study equation was derived. This bias is reduced substantially, but not completely, by the CKD-EPI equation, which was derived from studies including people without CKD.3,13,14 In addition, the variable of black versus white or other does not capture all of the variation in creatinine generation among all racial and ethnic groups. This may be overcome in part by modifications using other race-ethnicity variables, as has been reported for use of the MDRD Study equation.15–17 A forthcoming article in AJKD introduces a modification of the CKD-EPI equation for use in Japan.18 However, even with these modifications, no equation will be free of bias in all settings and populations. Thus, knowledge of the effect of clinical conditions on non-GFR determinants of filtration markers is essential for interpretation of GFR estimates.Imprecision may reflect GFR measurement error or random variation in surrogates of non-GFR determinants. Accuracy may be improved by developing GFR estimating equations using more precise GFR measurement methods or multiple filtration markers with noncorrelated non-GFR determinants, such as cystatin C in addition to creatinine.19
The incidence of type 1 diabetes in children younger than 15 years is increasing. Prediction of future incidence of this disease will enable adequate fund allocation for delivery of care to be planned. We aimed to establish 15-year incidence trends for childhood type 1 diabetes in European centres, and thereby predict the future burden of childhood diabetes in Europe.
20 population-based EURODIAB registers in 17 countries registered 29 311 new cases of type 1 diabetes, diagnosed in children before their 15th birthday during a 15-year period, 1989-2003. Age-specific log linear rates of increase were estimated in five geographical regions, and used in conjunction with published incidence rates and population projections to predict numbers of new cases throughout Europe in 2005, 2010, 2015, and 2020.
Ascertainment was better than 90% in most registers. All but two registers showed significant yearly increases in incidence, ranging from 0.6% to 9.3%. The overall annual increase was 3.9% (95% CI 3.6-4.2), and the increases in the age groups 0-4 years, 5-9 years, and 10-14 years were 5.4% (4.8-6.1), 4.3% (3.8-4.8), and 2.9% (2.5-3.3), respectively. The number of new cases in Europe in 2005 is estimated as 15 000, divided between the 0-4 year, 5-9 year, and 10-14 year age-groups in the ratio 24%, 35%, and 41%, respectively. In 2020, the predicted number of new cases is 24 400, with a doubling in numbers in children younger than 5 years and a more even distribution across age-groups than at present (29%, 37%, and 34%, respectively). Prevalence under age 15 years is predicted to rise from 94 000 in 2005, to 160 000 in 2020.
If present trends continue, doubling of new cases of type 1 diabetes in European children younger than 5 years is predicted between 2005 and 2020, and prevalent cases younger than 15 years will rise by 70%. Adequate health-care resources to meet these children's needs should be made available.
European Community Concerted Action Program.
The efficacy of care in the centralized diabetes care system in the former German Democratic Republic was evaluated on the basis of the recommendations of the St. Vincent Declaration. Eighty-three per cent (n = 190, 46% women) of all insulin-treated diabetic patients aged 16-60 years who were registered in one district diabetes care unit were examined. Of these, 131 patients had type 1 (insulin-dependent) diabetes (69%) and 59 type 2 (non-insulin-dependent) diabetes (31%). All patients were on animal insulin and 96% (n = 187) had conventional therapy consisting of fixed insulin dose and a fixed diet. Levels of glycosylated haemoglobin (normal 4.15%, SD 0.54) were 6.3 +/- 1.3% in type 1 and 7.4 +/- 1.7% in type 2 diabetics. Retinopathy was found in 35% of type 1 (proliferative 3.8%) and 23% of type 2 patients (proliferative 3.4%). No patient was blind. Screening for nephropathy identified 29% of type 1 and 47% of type 2 diabetics as having albuminuria > 20 mg/l in early-morning urine. The prevalence of hypertension was 31% and 69% for type 1 and type 2 patients respectively. Foot ulcers were found in 2.1% and lower limb amputations in 2.1%. The incidence of severe hypoglycaemia (except in pregnancy) was 0.07 per patient per year. This study shows that the diabetes care system was effective and the winding up of this system with the reunification of Germany was not a medical necessity. However, the system failed to establish an integrated regime with regional general practitioners for the effective treatment of hypertension.
A cross-sectional multicentre study of randomly selected diabetic patients was performed using a standardised questionnaire and examination, to establish the prevalence of peripheral neuropathy in patients attending 118 hospital diabetes clinics in the UK. Vibration perception threshold was performed in two centres to compare with the clinical scoring systems. A total of 6487 diabetic patients were studied. 53.9% male, median age 59 years (range 18-90 years). 37.4% Type 1 (insulin-dependent) diabetes mellitus, with a median duration of diabetes 8 years (0-62 years). The overall prevalence of neuropathy was 28.5% (27.4-29.6%) (95% confidence interval) in this population. The prevalence in Type 1 diabetic patients was 22.7% (21.0-24.4%) and in Type 2 (non-insulin-dependent) diabetic patients it was 32.1% (30.6-33.6%). The prevalence of diabetic peripheral neuropathy increased with age, from 5% (3.1-6.9%) in the 20-29 year age group to 44.2% (41.1-47.3%) in the 70-79 year age group. Neuropathy was associated with duration of diabetes, and was present in 20.8% (19.1-22.5%) of patients with diabetes duration less than 5 years and in 36.8% (34.9-38.7%) of those with diabetes duration greater than 10 years. Mean vibration perception threshold measured at the great toe was 21.1 +/- 13.5 SD volts and correlated with the neuropathy disability score, r = 0.8 p < 0.001. In conclusion, diabetic peripheral neuropathy is a common complication associated with diabetes. It increases with both age and duration of diabetes, until it is present in more than 50% of Type 2 diabetic patients aged over 60 years.(ABSTRACT TRUNCATED AT 250 WORDS)
Individuals with type 1 diabetes applying for insurance (life, health, accident, etc.) may either see their application being declined by the insurance company or find their premiums being substantially higher than the standard premium. During the last 40-50 years, the prognosis of patients with type 1 diabetes has improved dramatically, partly as a consequence of improved metabolic regulation and partly due to introduction of better treatment for late diabetic complications. The aim of the present study was to determine whether the increased premiums paid by diabetic patients for life insurance and accident insurance reflect the true risk of a diabetic individual.
Mortality: 3,000 type 1 diabetic patients were followed for 12-51 years. The impact of age, sex, year of diagnosis, and development of nephropathy on excess mortality was analyzed. Accidents: A cohort of nearly 7,000 members of the Danish Diabetes Association participating in group accident insurance was followed for 3 years. The risk and outcome of accidents in the diabetic group was compared with similar risks in a nondiabetic group.
Mortality: Over a 40-year period, the median life expectancy of type 1 diabetic patients increased by more than 15 years. The decrease was predominantly explained by a decreasing incidence of nephropathy, so that a simple model for estimating insurance premiums (including age of diagnosis, sex, and presence or absence of diabetic nephropathy) could be established. Accident insurance: Individuals with type 1 diabetes experienced a risk of accidents that was not in excess of that found in two control groups, and the outcome (degree of disability) after the accidents did not differ between the diabetic and the nondiabetic group.
Type 1 diabetic patients still have a mortality in excess of nondiabetic individuals. Life insurance premiums should, however, always reflect the changing prognosis of type 1 diabetes and thus, continuous monitoring and revisions are needed. For accident insurance, we found no increased risk of accidents; thus, diabetic individuals should be offered accident insurance on normal terms.
To investigate long-term mortality and its temporal trends as of 1 January 1999 among the 1,075 patients with type 1 diabetes (onset age <18 years, diagnosed between 1965 and 1979) who comprise the Allegheny County population-based registry.
Overall, sex- and race-specific mortality rates per person-year of follow-up were determined. Standardized mortality ratios were also calculated. Survival analyses and Cox proportional hazard model were also used. Temporal trends were examined by dividing the cohort into three groups by year of diagnosis (1965-1969, 1970-1974, and 1975-1979).
Living status of 972 cases was ascertained as of January 1, 1999 (ascertainment rate 90.4%). The mean duration of diabetes was 25.2 +/- 5.8 (SD) years. Overall, 170 deaths were observed. The crude mortality rate was 627 per 100,000 person-years (95% CI 532-728) and standardized mortality ratio was 519 (440-602). Life-table analyses by the Kaplan-Meier method indicated cumulative survival rates of 98.0% at 10 years, 92.1% at 20 years, and 79.6% at 30 years duration of diabetes. There was a significant improvement in the survival rate between the cohort diagnosed during 1965-1969 and that diagnosed during 1975-1979 by the log-rank test (P = 0.03). Mortality was higher in African-Americans than in Caucasians, but there were no differences seen by sex. The improvement in recent years was seen in both ethnic groups and sexes.
An improvement in long-term survival was observed in the more recently diagnosed cohort. This improvement is consistent with the introduction of HbA1 testing, home blood glucose monitoring, and improved blood pressure therapy in the 1980s.
Although ischaemic heart disease is the predominant cause of mortality in older people with diabetes, age-specific mortality rates have not been published for patients with Type 1 diabetes. The Diabetes UK cohort, essentially one of patients with Type 1 diabetes, now has sufficient follow-up to report all heart disease, and specifically ischaemic heart disease, mortality rates by age.
A cohort of 23,751 patients with insulin-treated diabetes, diagnosed under the age of 30 years and from throughout the United Kingdom, was identified during the period 1972 to 1993 and followed for mortality until December 2000. Age- and sex-specific heart disease mortality rates and standardised mortality ratios were calculated.
There were 1437 deaths during the follow-up, 536 from cardiovascular disease, and of those, 369 from ischaemic heart disease. At all ages the ischaemic heart disease mortality rates in the cohort were higher than in the general population. Mortality rates within the cohort were similar for men and women under the age of 40. The standardised mortality ratios were higher in women than men at all ages, and in women were 44.8 (95%CI 20.5-85.0) at ages 20-29 and 41.6 (26.7-61.9) at ages 30-39.
The risk of mortality from ischaemic heart disease is exceptionally high in young adult women with Type 1 diabetes, with rates similar to those in men with Type 1 diabetes under the age of 40. These observations emphasise the need to identify and treat coronary risk factors in these young patients.
Although diabetes mellitus is one of the most prevalent and costly chronic diseases in the United States, no estimates have been published of individuals' average lifetime risk of developing diabetes.
To estimate age-, sex-, and race/ethnicity-specific lifetime risk of diabetes in the cohort born in 2000 in the United States.
Data from the National Health Interview Survey (1984-2000) were used to estimate age-, sex-, and race/ethnicity-specific prevalence and incidence in 2000. US Census Bureau data and data from a previous study of diabetes as a cause of death were used to estimate age-, sex-, and race/ethnicity-specific mortality rates for diabetic and nondiabetic populations.
Residual (remaining) lifetime risk of diabetes (from birth to 80 years in 1-year intervals), duration with diabetes, and life-years and quality-adjusted life-years lost from diabetes.
The estimated lifetime risk of developing diabetes for individuals born in 2000 is 32.8% for males and 38.5% for females. Females have higher residual lifetime risks at all ages. The highest estimated lifetime risk for diabetes is among Hispanics (males, 45.4% and females, 52.5%). Individuals diagnosed as having diabetes have large reductions in life expectancy. For example, we estimate that if an individual is diagnosed at age 40 years, men will lose 11.6 life-years and 18.6 quality-adjusted life-years and women will lose 14.3 life-years and 22.0 quality-adjusted life-years.
For individuals born in the United States in 2000, the lifetime probability of being diagnosed with diabetes mellitus is substantial. Primary prevention of diabetes and its complications are important public health priorities.
Declining incidences in Europe of overt nephropathy, proliferative retinopathy, and mortality in type 1 diabetes have recently been reported. However, comparable data for the U.S. and trend data for neuropathy and macrovascular complications are lacking. These issues are addressed using the prospective observational Pittsburgh Epidemiology of Childhood-Onset Diabetes Complications Study. Participants were stratified into five cohorts by diagnosis year: 1950-1959, 1960-1964, 1965-1969, 1970-1974, and 1975-1980. Mortality, renal failure, and coronary artery disease (CAD) status were determined on the complete cohort (n = 906) at 20, 25, and 30 years. Overt nephropathy, proliferative retinopathy, and neuropathy were assessed at 20 and 25 years on the subset of participants with a clinical examination. There was a decreasing trend by diagnosis year for mortality, renal failure, and neuropathy across all time intervals (P < 0.05), with the 1950-1959 cohort having a fivefold higher mortality at 25 years than the 1970s' cohorts. Proliferative retinopathy and overt nephropathy showed nonsignificant declines at 20 years (P < 0.16 and P < 0.13, respectively) and no change at 25 years. CAD event rates, which were lower than the other complications, also showed no trend. Although some type 1 diabetes complications (mortality, renal failure, and neuropathy) are declining, others (CAD, overt nephropathy, and proliferative retinopathy) show less favorable changes by 30 years.
Hyperglycemia is implicated in the development and progression of microvascular complications in type 1 diabetes. In contrast, the association between hyperglycemia and macrovascular complications or mortality in type 1 diabetes is not clear. The authors studied a population-based cohort of 879 individuals with type 1 diabetes from Wisconsin, free of cardiovascular disease and end-stage renal disease at the baseline examination (1980-1982). The main outcome of interest was all-cause (n=201) and cardiovascular (n=132) mortality as of December 31, 2001. Elevated glycosylated hemoglobin levels were associated with all-cause and cardiovascular mortality, independent of duration of diabetes, smoking, hypertension, and proteinuria. The multivariable relative risks comparing the highest quartile of glycosylated hemoglobin (>or=12.1%) with the lowest quartile (<or=9.4%) were 2.42 (95% confidence interval: 1.54, 3.82; p-trend=0.0006) for all-cause mortality and 3.28 (95% confidence interval: 1.77, 6.08; p-trend<0.0001) for cardiovascular mortality. This association was present among both sexes and persisted in subgroup analyses by categories of diabetes duration, smoking, body mass index, proteinuria, and retinopathy. These data suggest that hyperglycemia is associated with all-cause and cardiovascular mortality among individuals with type 1 diabetes.
Incidence and trends of childhood Type 1 diabetes worldwide 1990-1999
DIAMOND Project Group. Incidence and trends of childhood Type 1
diabetes worldwide 1990-1999. Diabet Med 2006; 23: 857-866
For the Scottish Diabetes Research Network epidemiology group and the Scottish Renal Registry; Estimated life expectancy in a scottish cohort with type 1 diabetes
- S J Livingstone
- D Levin
- H C Looker
Livingstone SJ, Levin D, Looker HC et al. For the Scottish Diabetes
Research Network epidemiology group and the Scottish Renal
Registry; Estimated life expectancy in a scottish cohort with type 1
diabetes, 2008-2010. JAMA 2015; 313: 37-44
Diabetes Typ 1 und Typ 2
Deutscher Hausärzteverband/AOK (Hg). Diabetes Typ 1 und Typ 2.
Hausarzt Handbuch. München: Med.Komm; 2007