Variation and trends in incidence of childhood diabetes in Europe. EURODIAB ACE Study Group

Occurrence of celiac disease after onset of type 1 diabetes: a 6-year prospective longitudinal study

OBJECTIVE

To investigate the prevalence of celiac disease in a large cohort of children and adolescents at the onset of type 1 diabetes and the occurrence of new cases during a 6-year follow-up.

METHODS

We prospectively studied, by repeated serologic screening, 274 consecutive patients at the onset of type 1 diabetes (age [mean +/- standard deviation]: 8.28 +/- 4.65 years) for 6 subsequent years. One patient had a diagnosis of celiac disease before the onset of diabetes. The immunoglobulin A-antiendomysium antibody test was selected as the screening test; patients with positive results (++ or +++) or with 2 consecutive weak positive tests (+) were considered appropriate for the jejunal biopsy.

RESULTS

At diabetes onset, 15 (5.5%) of 273 patients tested positive with the antiendomysium test; jejunal biopsy was performed in 10, and celiac disease was diagnosed in 9. The prevalence of biopsy-confirmed celiac disease at the manifestation of diabetes was 3.6% (10 of 274 patients). Twelve more patients with a negative antiendomysium antibody test at diabetes onset tested positive during the follow-up within 4 years; 10 of them had biopsies performed, and 7 had celiac disease. Therefore, the overall prevalence of biopsy-confirmed celiac disease in the entire cohort of patients was 6.2%. The age at diabetes onset in patients with and without celiac disease was not different (7.88 +/- 5.69 vs 8.3 +/- 4.58 years). The majority of cases of celiac disease were asymptomatic in their presentation, and no signs of overt malnutrition were documented.

CONCLUSIONS

The prevalence of celiac disease in patients with type 1 diabetes is approximately 20 times higher than in the general population. Sixty percent of cases are already present at diabetes onset, mostly undetected, but an additional 40% of patients develop celiac disease a few years after diabetes onset. Extending screening programs for celiac disease after the onset of type 1 diabetes is recommended, even in the absence of clinical symptoms.

The incidence of type 1 diabetes in the age group 0-39 years has not increased in Antwerp (Belgium) between 1989 and 2000: evidence for earlier disease manifestation

OBJECTIVE

A worldwide increase in the incidence of childhood type 1 diabetes has been observed. Because in various countries the majority of new type 1 diabetic patients are diagnosed in adulthood, we investigated whether the rising incidence of this disorder in children reflects a global increase in the incidence of diabetes or a shift toward earlier clinical presentation.

RESEARCH DESIGN AND METHODS

The incidence of type 1 diabetes presenting before age 40 years was prospectively measured in the Antwerp district over a 12-year period (1989-2000). The completeness of ascertainment was evaluated by the capture-recapture method. Trends in incidence during the study period were analyzed by Poisson regression.

RESULTS

The incidence of type 1 diabetes diagnosed before age 40 years remained constant over the 12-year period, averaging 9.9 cases per 100,000 individuals per year. The incidence was similar in both sexes under age 15 years, but a marked male excess was noted for adult-onset disease, in particular after age 20 years, resulting in a male-to-female ratio of 0.9 under age 15 years vs. 1.6 thereafter (P = 0.001). During the 12-year observation period, there was a significant tendency toward increasing incidence under age 15 years at the expense of a decreasing incidence between ages 15 and 40 years (P = 0.025). The annual increase in incidence averaged 1.8% under age 15 years and 5.0% under age 5 years (P = 0.06).

CONCLUSIONS

Our results indicate that in Belgium, the increasing incidence of childhood type 1 diabetes-especially for children under age 5 years-is not attributable to a global increase in disease incidence, but rather to earlier clinical manifestation. The results suggest that an environmental factor may preferentially accelerate the subclinical disease process in young diabetes-prone subjects.

Trends in the incidence of childhood diabetes in south Asians and other children in Bradford, UK

AIMS

To investigate incidence rates and time trends, over 21 years, of Type 1 diabetes in a migrant population of south Asian children in Bradford, UK.

METHODS

Children (0-14 years) living in the city of Bradford and diagnosed with Type 1 diabetes were selected from a population-based region-wide register. Between 1978 and 1998, 289 new-onset cases were registered and classified as south Asian (Indian, Pakistani, Bangladeshi) or not, based on their full name using two different computer algorithms and visual inspection.

RESULTS

Sixty-six children (22.8%) were designated as south Asian with 223 (77.2%) remaining. The overall age-sex standardized incidence for south Asian and non-south Asian children was 13.0 per 100,000 person years (95% confidence interval 9.9-16.2) and 12.9 (11.2-14.6), respectively. Rates were similar for south Asians at all ages, whereas for the mainly Caucasian children incidence differed significantly by age group (P < 0.001). An average annual increase in incidence of 4.3% (P = 0.001) was seen for all children compared with 6.5% in south Asians (P = 0.002) and 2.4% (P = 0.128) in non-south Asians.

CONCLUSIONS

Children in south Asia have a low incidence of Type 1 diabetes but migrants to the UK have similar overall rates to the indigenous population. However, a more steeply rising incidence is seen in the south Asian population, and our data suggest that incidence in this group may eventually outstrip that of the non-south Asians. Genetic factors are unlikely to explain such a rapid change, implying an influence of environmental factors in disease aetiology. The similarity in rates by age group in the south Asian population is notable.

Terbinafine (Lamisil) treatment of toenail onychomycosis in patients with insulin-dependent and non-insulin-dependent diabetes mellitus: a multicentre trial

BACKGROUND

Diabetes mellitus (DM) affects an estimated 175 million people world-wide. Approximately one-third of patients with DM have toenail onychomycosis.

OBJECTIVES

To determine the efficacy and safety of terbinafine treatment of toenail onychomycosis in patients with DM receiving insulin and/or oral antidiabetic agents. Special interest was focused on potential drug interactions with oral hypoglycaemic substances.

METHODS

In a multicentre trial, patients suffering from insulin-dependent DM (IDDM) or non- insulin-dependent DM (NIDDM) with toenail onychomycosis were treated for 12 weeks with oral terbinafine 250 mg daily and followed up to 48 weeks. In addition to clinical, mycological and laboratory investigations, blood glucose levels were monitored.

RESULTS

At the end of the trial (week 48), a mycological cure rate of 73% was achieved. The rates of clinical cure and complete cure (mycological cure plus clinical cure) were 57% and 48%, respectively. There was no statistically significant difference between the NIDDM and IDDM groups with respect to the cure rates (P > 0.05). No hypoglycaemic episode was reported and none of the patients had hypoglycaemia during the treatment phase.

CONCLUSIONS

With excellent cure rates and a good tolerability profile, terbinafine should continue to be a drug of choice for the treatment of toenail onychomycosis in the rising number of NIDDM patients receiving multiple medication.

The study of CTLA-4 and vitamin D receptor polymorphisms in the Romanian type 1 diabetes population

Several studies suggested that part of the genetic susceptibility for Type 1 diabetes (T1DM) is encoded by some polymorphisms of CTLA-4 gene (2q33) and of Vitamin D Receptor gene (VDR; 12q12-14). Our aim was to assess their contribution to T1DM genetic susceptibility in the Romanian population. We typed CTLA-4 49 A/G and VDR FokI (F/f), ApaI (A/a) and TaqI (T/t) polymorphisms by Sequence Specific Primer PCR (SSP-PCR) in 204 Romanian diabetic families (756 individuals: 212 T1DM probands and 544 unaffected parents and siblings). We studied alleles transmission using the Transmission Disequilibrium Test (TDT). We found an increased transmission of CTLA-4 49G allele to diabetics (54.8%, p=0.11). The transmission of F (56.1%, p=0.063), a (55.7%, p=0.061) and T (51.8%, p=0.37) alleles of VDR gene to diabetics was increased but did not reach statistical significance. In conclusion we found the same increased transmission of CTLA-4 49 G allele to diabetics as previously reported. VDR FoqI F allele seems to be predisposing while TaqI T allele seems to be protective.

High familial risk and genetic susceptibility in early onset childhood diabetes

Early onset type 1 diabetes is associated with rapid beta-cell failure and high levels of HLA-mediated genetic susceptibility. We examined familial risk of disease in relation to age at onset in 1,299 families participating in the Bart's Oxford population-based family study of type 1 diabetes. Risk of diabetes was estimated by survival analysis in 1,430 siblings and 2,419 parents and related to age at onset in the proband. Unaffected relatives at high risk were identified by measurement of islet autoantibodies, and HLA class II genotyping was performed in probands where DNA was available (573 children). The cumulative risk of diabetes by age 20 years was 11.7% in siblings of probands diagnosed before age 5 years, compared with 3.6% for ages 5-9 years and 2.3% for ages 10-14 years (P < 0.0001). In parents, the cumulative risk by age 40 years was 5.9% if the proband was diagnosed before age 5 years, compared with 3.7% for ages 5-9 years and 3.7% for ages 10-14 years (P = 0.04). Of 1,169 unaffected siblings tested at study entry, 7.3% had two or more autoantibody markers if the proband was diagnosed before age 5 years, compared with 2.2 and 2.4%, respectively, for ages 5-9 and 10-14 years (P = 0.002). The frequency of the highest risk genotype decreased with increasing age at onset. Of children diagnosed before age 5 years, 52% were heterozygous for HLA DRB1*03-DQA1*0501-DQB1*02/DRB1*04-DQA1*0301-DQB1*0302 compared with 32% and 33%, respectively, for children diagnosed at ages 5-9 and 10-14 years (P < 0.001). Diabetes with onset before age 5 years is therefore a marker of high familial risk.

Incidence of childhood type 1 diabetes mellitus in Gomel, Belarus

BACKGROUND

The importance of genetic and environmental factors in causing type 1 diabetes mellitus (DM1) in many European countries is unknown. We studied this question by assessing the incidence of the disease in children in Gomel, Belarus, in the years subsequent to the Chernobyl disaster, comparing it to the antecedent period.

METHODS

We identified all new patients with DM1 under 15 years at onset who presented between 1976 and 1999; we used as denominator the number of children aged 0-14 born in Gomel, to calculate the incidence. All data were validated by using the capture-recapture method. We compared the incidence rate between the periods before and after 1986; we also calculated the average increment of incidence in the latter period (1987-1999).

RESULTS

In the whole period, 438 new patients presented, with an average crude rate of incidence of 4.6/100,000 but with a net difference between the former (before 1986) and latter (after 1986) periods. The average standard incidence in the latter period was 5.7 (C.I. 4.5-7.0), with a significant increase in the 10-14 year age group. The average yearly increase of incidence in the same period was 8.9%, highly significant (p < 0.001).

CONCLUSIONS

The results seem to confirm the hypothesis of the influence of environmental pollution subsequent to the Chernobyl accident.

Varying clinical presentations at onset of type 1 diabetes mellitus in children--epidemiological evidence for different subtypes of the disease?

OBJECTIVE

On the basis of 2121 case observations between 1987 and 1997, we describe the clinical and laboratory characteristics of diabetes mellitus type 1 at its onset. Our objective is to analyze whether clinical presentation follows a uniform pattern or whether there is evidence for different subtypes.

RESEARCH DESIGN AND METHODS

Thirty-one pediatric hospitals and one diabetes center in Baden-Wuerttemberg (BW), Germany, participated in this study. The hospital records of 2121 children below 15 yr of age were examined retrospectively. Statistical analysis was done after logarithmic transformation into a normal distribution.

RESULTS

The average duration of symptoms was found to be 15.2 d (95% CI (Confidence Intervals) = 14.3-16.1) ranging between 2.0 and 180 d (95% central range). The most frequent symptoms were polyuria and polydipsia; 7.2% presented with altered level of consciousness. The mean blood glucose value was 407.9 mg/dL (95% CI = 400.0-416.0), corresponding to 23.3 mmol/L (95% CI = 22.8-23.8). The median pH value was 7.35 (95% CI = 7.34-7.36), and the median base excess was -5 mmol/L (95% CI =-5 to -4). The younger patients had a shorter duration of symptoms and suffered most frequently from ketoacidosis.

CONCLUSIONS

Although the symptoms of diabetes at its onset follow a uniform pattern, the clinical presentation and duration of symptoms indicate that there may be various forms of type 1 diabetes.

Clinical application of NKT cell assays to the prediction of type 1 diabetes

Type 1 diabetes is a disease characterised by disturbed glucose homeostasis, which results from autoimmune destruction of the insulin-producing beta cells in the pancreas. The autoimmune attack, while not yet fully characterised, exhibits components of both mis-targeting and failed tolerance induction. The involvement of non-classical lymphocytes in the induction and maintenance of peripheral tolerance has recently been recognised and natural killer T (NKT) cells appear to play such a role. NKT cells are a subset of T cells that are distinct in being able to produce cytokines such as IL-4 and IFN-gamma extremely rapidly following activation. These lymphocytes also express some surface receptors, and the lytic activity, characteristic of NK cells. Deficiencies in NKT cells have been identified in animal models of type 1 diabetes, and a causal association has been demonstrated by adoptive transfer experiments in diabetes-prone NOD mice. Preliminary work suggests that a similar relationship may exist between deficiencies in NKT cells and type 1 diabetes in humans, although the techniques reported to date would be difficult to translate to clinical use. Here, we describe methods appropriate to the clinical assessment of NKT cells and discuss the steps required in the assessment and validation of NKT cell assays as a predictor of type 1 diabetes.

HLA class II genetic association of type 1 diabetes mellitus in Czech children

To examine human leukocyte antigen (HLA) class II association of type 1 diabetes mellitus (DM) in Czech children, we performed a case-control study of 261 patients diagnosed before the age of 15 and 289 non-diabetic control children. Complete HLA-DQA1, DQB1 genotyping and DRB1*04 subtyping were carried out by polymerase chain reactions with sequence-specific primers. The effect of the DRB1*04 subtypes was studied in DRB1*04 alleles carried on DQB1*0302-DQA1*03 haplotypes. The risk was statistically evaluated by testing 2 x 2 tables, considering corrected p-values < 0.05 significant. The DQB1*0302 (odds ratio, OR = 9.0), DQB1*0201 (OR = 3.4) and DQA1*03 (OR = 7.5) alleles were significantly associated with diabetes risk, while the DQB1*0602 (OR = 0.02), DQB1*0301 (OR = 0.08), DQB1*0503 (OR = 0.13), DQB1*0603 (OR = 0.20), DQA1*01 (OR = 0.28) and DQA1*02 (OR = 0.26) alleles were significantly protective. Of the DQA1-DQB1 genotypes, we point out the extremely high risk of OR = 116 conferred by HLA-DQA1*05-DQB1*0201/DQA1*03-DQB1*0302. Among DRB1*04 subtypes, DRB1*0403 was significantly protective (OR = 0.05, CI 95% 0.01-0.45). Since none of the remaining DRB1*04 subtypes was associated with type 1 DM, our study may present another piece of evidence that the DRB1*0401 and DRB1*0404 alleles do not modify type 1 diabetes risk generally in European populations.

Prospects for predicting and stopping the development of type 1 of diabetes

The prevention of diabetes and its devastating complications is the prime goal of diabetes care. In immune-mediated type 1 diabetes, beta cell destruction can be predicted with increasing confidence both before and after diagnosis, thus allowing the development of preventative strategies. Multicentre clinical trials with the natural products insulin and nicotinamide have been launched, but the results will only be available in a few years time. Meanwhile, observational studies in large representative risk groups can help to refine the selection of subjects with a more homogenous risk for beta cell destruction, thereby reducing the need for large sample sizes. The comparison between biological markers and disease progression will help to define surrogate disease end-points that can be monitored before the hard clinical end-points of hyperglycaemia or remission. These advances will facilitate the start of new pilot trials to identify relatively safe candidate interventions adapted to disease stage.

The effect of day care exposure on the risk of developing type 1 diabetes: a meta-analysis of case-control studies

OBJECTIVE

Exposure to infections in infancy or childhood may be important in the pathogenesis of type 1 diabetes, but a protective role has also been suggested. We tested the hypothesis that increased early contact with infectious agents, measured by day care exposure, would decrease the risk of type 1 diabetes in childhood.

RESEARCH DESIGN AND METHODS

We conducted a systematic review of case-control studies. Meta-analysis was performed to combine results, assess for heterogeneity, and explore variation in study design.

RESULTS

Several generally well-designed case-control studies show a statistically significant protective effect of day care on type 1 diabetes. However, meta-analysis revealed too much heterogeneity to accept the overall synthesis results and none of the studies used prerecorded data. Day care does seem to have a protective effect in the subgroup of children who will be diagnosed with type 1 diabetes before the age of 5 years (odds ratio = 0.6, 95% CI 0.5-0.8); however, this result is based on only two studies.

CONCLUSIONS

Recall bias is one alternate explanation for these data; confirmation using prerecorded data is required. Such data could be prospectively measured in cohort studies of children at risk. We also suggest that information about day care attendance be measured in randomized trials of agents for the prevention of type 1 diabetes, as day care exposure could potentially modify the effect of the preventive agent.

Autoimmune diabetes not requiring insulin at diagnosis (latent autoimmune diabetes of the adult): definition, characterization, and potential prevention

Type 1 diabetes is caused by the immune-mediated destruction of islet insulin-secreting beta-cells. This chronic destructive process is associated with both cellular and humoral immune changes in the peripheral blood that can be detected months or even years before the onset of clinical diabetes. Throughout this prediabetic period, metabolic changes, including altered glucose tolerance and reduced insulin secretion, deteriorate at variable rates and eventually result in clinical diabetes. A fraction of individuals with humoral immunological changes have clinical diabetes that initially is not insulin-requiring. The onset of diabetes in these patients is usually in adult life, and because their diabetes is at least initially not insulin-requiring, they appear clinically to be affected by type 2 diabetes. Such patients probably have the same disease process as patients with type 1 diabetes in that they have similar HLA genetic susceptibility as well as autoantibodies to islet antigens, low insulin secretion, and a higher rate of progression to insulin dependency. These patients are defined as being affected by an autoimmune type of diabetes not requiring insulin at diagnosis, which is also named latent autoimmune diabetes of the adult (LADA). Special attention should be paid to diagnose such patients because therapy may influence the speed of progression toward insulin dependency, and in this respect, efforts should be made to protect residual C-peptide secretion. LADA can serve as a model for designing new strategies for prevention of type 1 diabetes but also as a target group for prevention in its own right.

Type 1 diabetes: new perspectives on disease pathogenesis and treatment

As our knowledge of type 1 (insulin-dependent) diabetes increases, so does our appreciation for the pathogenic complexity of this disease and the challenges associated with its treatment. Many new concepts about the pathogenesis of this disorder have arisen. The role of genetics versus environment in disease formation has been questioned, and the basis on which type 1 diabetes is characterised and diagnosed is the subject of much debate. Additionally, the care and treatment of patients with type 1 diabetes has seen a rapid evolution; with genetically engineered insulins, glucose monitoring devices, and algorithms all contributing to a decrease in disease-related complications. We focus this seminar on these changing views, and offer a new perspective on our understanding of the pathogenesis of type 1 diabetes and on principles for therapeutic management of patients with this disorder.

Protective role of infections and vaccinations on autoimmune diseases

Infectious agents may induce autoimmune disease through several mechanisms, notably antigen mimicry and inflammation of the target organ; conversely, infections may protect from autoimmune diseases. This paradoxical effect has been demonstrated for a number of bacteria, viruses and parasites on a variety of spontaneous or experimentally induced animal models of autoimmune diseases (e.g. experimental allergic encephalomyelitis, lupus mice, non-obese diabetic mice). The mechanisms of the protection are still ill-defined, and probably vary according to models. Stimulation of immunoregulatory CD4 T cells has been shown to play a central role in several major models. The role of superantigens is also important, like that of Toll-like receptors. Antigen competition is another major mechanism, itself open to several interpretations. Epidemiological data support a protective role of infections on human allergic and autoimmune diseases. These diseases are much more common in countries with high socio-economic development (typically Northern countries in Europe). The reason for this cannot be fully explained by genetic differences because migrating populations develop these diseases with the same incidence of the adoptive country rather than that of the country of origin. It is interesting that the frequency of these diseases has been increasing in developed countries over the last 20 years but not in undeveloped ones.

The epidemiology of childhood-onset type 1 diabetes mellitus in Romania. ONROCAD Study Group. National Romanian Organisation for the Care of Diabetic Children and Adolescents

The ONROCAD Study group was established to provide descriptive epidemiological information on type 1 diabetes mellitus (DM) in Romania. Data on all new patients with type 1 DM with onset before age 15 years during the four-year period 1992-1995 in Romania were submitted from all members of the ONROCAD Study Group, representing all doctors and clinics that manage children with DM in Romania. Age- and sex-specific incidence rates were estimated, using available demographic data. A total of 706 new patients with type 1 DM and onset 0-14 years was registered. The overall completeness of ascertainment was estimated at 93.5%. For all Romania, the incidence of childhood-onset type 1 DM was estimated at 3.57/100,000/year. The incidence in the three regions was statistically significantly different (p = 0.002), with high rates in Transylvania and low rates in Muntenia. Girls had a significantly higher incidence than boys for each of the age groups 0-4, 5-9 and 10-14 years. Between these age groups, the incidence increased significantly with age. The incidence of childhood-onset type 1 DM is among the lowest recorded in Europe. Significant, but unexplained, geographical variation exists within Romania. Searches for factors to explain this heterogeneity may provide clues to the etiology of childhood-onset type 1 DM.

Hospitalization among diabetic children and adolescents and the general population in Germany. German Working Group for Pediatric Diabetology

OBJECTIVE

To compare hospitalization in a multicenter-based cohort of diabetic children and adolescents (aged 1-19 years) in Germany with that of the general population.

RESEARCH DESIGN AND METHODS

Based on standardized documentation, hospital stays after manifestation were ascertained in diabetic subjects 1-19 years of age in 1997. Hospitalization data in the general German population were derived from official statistics. Incidence rates and numbers of hospital days were estimated. Ratios of hospitalization incidences and numbers of hospital days between the diabetic and the general population were calculated. Costs for hospital care in the German diabetic population in 1997 were determined.

RESULTS

A total of 5,874 patients came from 61 pediatric centers (52% male, age [mean +/- SD] 12.2 +/- 4.3 years, diabetes duration 4.6 +/- 4.4 years). Hospitalization incidence rates and hospital days per person-year (95% CI) were 0.27 (0.25-0.29) and 1.80 (1.75-1.84) in the diabetic population and 0.0948 (0.0946-0.0949) and 0.6416 (0.6412-0.6420) in the general population. The standardized ratio of hospital incidences was 3.1 (2.9-3.2), and the ratio of numbers of hospital days was 2.8 (2.7-2.9). Costs for hospital care after manifestation were estimated to be $506 (U.S. dollars) per person-year and $12.4 million in the whole German diabetic population aged 1-19 years in 1997; including hospital stays at diabetes onset, total annual costs were $24 million ($970 per person-year).

CONCLUSIONS

Diabetic children and adolescents in Germany had an approximately three times higher hospitalization risk and three times more hospital days than the age-matched general population. Including hospitalization at diabetes onset, the annual costs of hospital care for the German diabetic population aged 1-19 years amounted to approximately 1% of all costs for hospital care in this age-group. Thus, costs were largely overproportional (diabetes prevalence 0.1%).

Relation between occurrence of type 1 diabetes and asthma

A negative association has been observed between type 1 diabetes and atopic diseases in individuals, a finding that supports the Th1/Th2 paradigm. By using published data on disease occurrence in different countries, we show a strong positive association between the occurrence of type 1 diabetes and symptoms of asthma at the population level in Europe and elsewhere. Our finding suggests that there may be common factors influencing susceptibility to the two disorders at the country level. Our observation must be accommodated in explanations of the epidemiology of type 1 diabetes or atopic diseases.

Diabetic nephropathy and end-stage renal failure: the Norwegian story

Diabetic nephropathy is the most common single cause of end-stage renal failure (ESRF) in the Western world, recorded as the cause of renal failure in up to 40% to 45% of those entering renal replacement therapy (RRT) programs. However, marked differences exist between countries; the percentage of patients entering RRT in Norway because of diabetic nephropathy is 10% of the incident RRT population. The percentage in the United States is approximately 40%; therefore, the purpose of the present study was to compare data from Norway with data from the United States in an attempt to detect factors that might explain some of the differences. To make the comparisons as valid as possible, an attempt has been made to focus on populations of similar genetic make-up. The incidence of type 1 diabetes is a little higher in Norway than in the United States, whereas the prevalence of type 2 diabetes may be twice as high in the United States as in Norway; marked differences in the prevalence of obesity is probably a significant causative factor. There seems to be no striking difference in the prevalence of microalbuminuria in people with diabetes in the two populations, whereas there are insufficient data to compare the prevalence of overt proteinuria. The incidence of patients with a diagnosis of diabetic nephropathy as the cause of ESRF entering RRT in the two study populations showed marked differences; the incidence for 1997 was 8.9/million population in Norway and 113/million population in the United States. The proportion of type 2 diabetes was 46% in Norway and 64% in the US (1997). It is unlikely that the marked difference in incidence of RRT can be explained by differences in type 2 diabetes prevalence alone. The populations may not be directly comparable, and differences in the size of study populations and in the choice of renal diagnosis in patients with diabetes as a comorbid factor at the beginning of RRT may introduce uncertainties. Further, data on other factors--such as incidence of death before RRT is indicated, quality of care, and health care delivery, expressed as degree of blood pressure and metabolic control--were not available. Differences in acceptance of diabetes patients into RRT programs are not believed to contribute significantly. Norway is seeing a development toward increasing body weight and a change toward a more sedentary lifestyle, together with an increasing prevalence of type 2 diabetes earlier in life than has previously been the case. An increase in diabetic nephropathy and need for RRT because of type 2 diabetes must therefore be expected in Norway. To understand differences and to best design preventive programs, further comparative studies of the two populations seem warranted.

Diabetes mellitus in Tassin, France: remarkable transformation in incidence and outcome of ESRD in diabetes

The incidence and prevalence of diabetes mellitus (DM) in the dialysis population in Europe, and more especially in France, have been lagging behind the impressive United States and Japanese rates. For a decade, things have been changing, and the incidence of DM in hemodialysis (HD) reached almost 40 in Tassin, France in 1999. The prevalence has followed the same trend but increased more slowly. The increase in incidence and prevalence is almost totally accounted for by type 2 DM explosive outbreak and development. The morbidity on dialysis (hypotensive episodes, hospitalization number, and duration) was significantly worse in diabetic patients (without difference between type 1 and 2) than in nondiabetic patients. The mortality rate was higher in diabetic patients than in nondiabetic patients (mean half-life 3 and 13 years, respectively), even after adjustment for age and comorbidity. The mortality rate was higher in type 2 than in type 1 (mean half-life 2.7 and 5.2 years, respectively), a difference which disappears when adjusting for age and comorbidity. Specific causes of death were different in diabetic and nondiabetic HD patients; in diabetics there was a six-fold higher cardiovascular (CV) and three-fold higher infectious mortality, but there was the same mortality from cancer. A strong difference was observed between type 1 and type 2 DM: in type 1 there was no increased infectious mortality and a moderately increased CV mortality compared with nondiabetic patients. Type 2 diabetic patients had a four-fold increased infectious and an eight-fold increased CV mortality. Altogether, the eruption of DM in our unit over the last decade has drastically increased the crude mortality, but the standardized mortality ratio using the USRDS mortality table remained unchanged, about 45 of expected mortality.

Racial disparities in access to simultaneous pancreas-kidney transplantation in the United States

The purpose of our study is to assess the extent of racial differences in the access to simultaneous pancreas-kidney (SPK) transplantation and evaluate the potential influence of socioeconomic factors on access to transplantation. We performed a retrospective analysis of the US Renal Data System and United Network for Organ Sharing data on all patients with end-stage renal disease (ESRD) due to diabetes mellitus from 1988 to 1996 (n = 562, 814), including all dialysis, wait list, and transplant patients. Racial differences in incidence, prevalence, insurance coverage, employment status, and transplantation rates were calculated. Caucasians had the highest prevalence of ESRD caused by type 1 diabetes (73%), followed by blacks (22%), Hispanics (3%), Native Americans (2%), and others (<1%). Both blacks and Native Americans increased their annual incidence of ESRD caused by insulin-dependent diabetes mellitus by 10% compared with only a 3.5% increase in Caucasians, whereas incidence rates increased annually by almost 8% for both blacks and Native Americans compared with a 3% increase for Caucasians. However, Caucasians received 92% of all SPK transplants, whereas all other racial groups combined received a disproportionate minority of the remaining transplants. Lack of private insurance and unemployment status were associated with annual changes in both incidence of ESRD caused by type 1 diabetes and SPK transplant rates. In conclusion, we observed striking racial disparities for access to SPK transplantation in the United States today, which may be related to employment status, access to private insurance, and subsequent health care. Our preliminary data support current efforts to encourage Medicare and Medicaid coverage for all patients requiring SPK transplantation regardless of racial or financial status.