Continued Reduction in the Prevalence of Retinopathy in Adolescents With Type 1 Diabetes

Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.
Diabetes care (Impact Factor: 8.42). 11/2011; 34(11):2368-73. DOI: 10.2337/dc11-0102
Source: PubMed


To examine trends in microvascular complications in adolescents with type 1 diabetes between 1990 and 2009 in Sydney, Australia.
We used analysis of complications in 1,604 adolescents (54% female, aged 12-20 years, median duration 8.6 years), stratified by four time periods using Generalized Estimation Equations as follows: T1 (1990-1994), T2 (1995-1999), T3 (2000-2004), and T4 (2005-2009). Early retinopathy was detected using seven-field fundal photography, albumin excretion rate (AER) using timed overnight urine collections, and albumin-to-creatinine ratio (ACR) and peripheral nerve function using thermal and vibration threshold.
Retinopathy declined (53, 38, 23, and 12%; P < 0.001), as did borderline elevation of AER/ACR (45, 30, 26, and 30%; P < 0.001) and microalbuminuria (8, 4, 3, and 3%; P = 0.006). Multiple daily injections (MDI)/continuous subcutaneous insulin infusion (CSII) use increased (17, 54, 75, and 88%; P < 0.001), median HbA(1c) decreased (9.1, 8.9, 8.5, and 8.5%; P < 0.001), and severe hypoglycemia was unchanged (6, 8, 10, and 7%; P = 0.272). Retinopathy was associated with diabetes duration (odds ratio [OR] 1.12 [95% CI 1.08-1.17]), age (1.13 [1.06-1.20]), HbA(1c) (1.16 [1.08-1.25]), systolic blood pressure (BP) SDS (1.31 [1.16-1.48]), socioeconomic disadvantage (1.42 [1.04-1.95]), and 1 to 2 injections per day (vs. MDI/CSII; 1.35 [1.05-1.73]); borderline AER/ACR with male sex (1.32 [1.02-1.70]), age (1.19 [1.12-1.26]), HbA(1c) (1.18 [1.08-1.29]), weight SDS (1.31 [1.21-1.53]), insulin dose per kilograms (1.64 [1.13-2.39]), 1 to 2 injections per day (1.41 [1.08-1.84]), and socioeconomic disadvantage (1.68 [1.23-2.31]); and microalbuminuria with age (1.14 [1.01-1.29]), HbA(1c) (1.20 [1.05-1.37]), diastolic BP SDS (1.76 [1.26-2.46]), and 1 to 2 injections per day (1.95 [1.11-3.41]).
The decline in retinopathy supports contemporary guidelines that recommend lower glycemic targets and use of MDI/CSII in children and adolescents with type 1 diabetes.

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Available from: Albert K F Chan, Apr 04, 2014
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    • "Identified prevalence rates of retinopathy in this young adult population were elevated compared to recent data for adolescents with type 1 diabetes. Downie et al. [47] reported a prevalence of 12% between 2005–2009, compared to up to 40% and 57.6% in the literature reviewed here [38, 40]. The review rate was not dissimilar to rates provided for older cohorts of people with type 1 diabetes (within a decade outside the review age criteria). "
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    ABSTRACT: Background: Vascular complications curtail life expectancy and quality of life in type 1 diabetes and development at younger ages is particularly detrimental. To date no review has summarised the prevalence or factors predicting their development in young adults. Methods: A quantitative epidemiological systematic review was conducted to identify the prevalence and predictive factors for development of retinopathy, nephropathy and hypertension in young adults (sample age mean [plus 1SD] 18-30 years) with type 1 diabetes, using processes adapted from established review methods set out by the Centre for Reviews and Dissemination.MEDLINE (Ovid), Scopus (Elsevier), CINAHL, Science Direct (Elsevier), Google Scholar and Cochrane databases were searched to identify relevant articles published between 1993 and June 2014. From this eleven papers were retrieved, appraised and results summarised by three reviewers using established methods. Results: Some form of retinopathy occurred in up to almost half of participants; more severe forms affected up to one in ten. One in six was reported with microalbuminuria; one in 14 had macroalbuminuria. Hypertension occurred in almost one in two participants. Applying out-dated high thresholds this decreased to approximately one in ten participants. Glycaemic control was a consistent predictor of vascular disease in this age group. Conclusion: Prevalence rates of retinopathy, nephropathy and hypertension in young adults with type 1 diabetes emphasise the importance of regular complication screening for early detection and treatment. The predictive effect of glycaemic control reinforces its importance for prevention of vascular complications.
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    • "Where assessed, one in six cohort members had at least one recorded episode of microalbuminuria and as many as one in three had a mean recorded systolic or diastolic BP equal to or above 130 mmHg and/or 80 mmHg, respectively; almost one in two were affected when medication for hypertension was included. One in nine had documented retinopathy; less than demonstrated for young adults in NSW between 1990–2000 [25], but consistent with more recent NSW adolescents’ data from 2005–2009 [26]. Whilst a reduction in retinopathy prevalence over time may have been related to changes in diabetes management following the definitive Diabetes Control and Complications Trial [22] which made glycaemic control central, low levels of screening potentially under-estimates the true level of retinopathy in this cohort; also hypertension and nephropathy. "
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    • "Although insulin regimens have become more intensive during the past 15 years, there has been minimal improvement to metabolic control (HbA1c). However, an Australian longitudinal study showed a decreased risk of diabetes complications with intensified treatment despite very small change in HbA1c (Downie et al. 2011). The lack of a clear association between intensity of treatment and long-term outcome highlights the complexity of diabetes management, and indicates that control of the disease is above all dependent on the disease management skills and motivation of the child and family. "
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