Impact on mortality and incidence of end-stage renal disease of education and treatment at a diabetes center among patients with type 1 diabetes: comparison of two subgroups in the Japanese DERI cohort

Rapid increase in the incidence of end-stage renal disease in patients with type 1 diabetes having HbA1c 10% or higher for 15 years

The incidence of end-stage renal disease (ESRD) in Japanese patients with type 1 diabetes mellitus (T1DM) was investigated regarding the association between mean HbA1c values during follow-up and the duration of follow-up/illness. The study includes 988 patients diagnosed at ages younger than 30 yr. These patients were initially examined between 1962 and 1999, and HbA1 and/or HbA1c measurements were taken for at least 3 yr after 1980. The follow-up period was from the date of the first HbA1 or HbA1c measurement to the final measurement day, or HbA1c measurement day immediately before the development of ESRD. The condition progressed to ESRD in 63 patients (mean duration of illness: 23.6 yr). Cox regression analysis revealed that patients with HbA1c of ≥ 10% had a significantly increased higher risk than those with HbA1c under 8% (P < 0.0001). The HbA1c cut-off point was 10.0%. The HbA1c value was ≥ 10% at baseline and during follow-up in 128 patients. Assuming that HbA1c of ≥ 10% persisted since the time of diagnosis in these patients, the cumulative incidence of ESRD abruptly increased after 15 yr of illness. Thus, the incidence of ESRD increased after the persistence of HbA1c of ≥ 10% for 15 yr.

Clinical background of Japanese patients with type 1 diabetes mellitus who have received insulin therapy for 50 years or longer

AIMS

We clarified the clinical background of Japanese patients with type 1 diabetes mellitus (T1DM) who have received insulin therapy for 50 years or longer.

METHODS

Of 1,412 patients diagnosed with T1DM at an age younger than 30 years old between 1962 and 2000, 29 had a 50-year or longer history of diabetes. We investigated the mean values of HbA1c and systolic blood pressure (SBP) during follow-up, as well as diabetic retinopathy, diabetic nephropathy, and macroangiopathy.

RESULTS

The mean age of the subjects at the time of diagnosis was 10 years and that at the completion of this survey was 66 years. The mean follow-up period was 43 years. The mean HbA1c value and SBP during the follow-up period were 8.2% and 130 mmHg, respectively. Seventeen percent of patients did not have diabetic retinopathy, 59% had proliferative retinopathy, and 66% had undergone photocoagulation. Fifty-four percent of patients did not have microalbuminuria and 11% had end-stage renal disease. Macroangiopathy was observed in 46%, cardiovascular disease (CVD) in 25%, and ischemic stroke in 18%.

CONCLUSIONS

It became possible for patients with T1DM to live more than 50 years in Japan.

The Incidence of End-Stage Renal Disease in the Diabetic (Compared to the Non-Diabetic) Population: A Systematic Review

End-stage renal disease (ESRD) in diabetes is a life threatening complication resulting in a poor prognosis for patients as well as high medical costs. The aims of this systematic review were (1) to evaluate the incidence of ESRD due to all causes and due to diabetic nephropathy in the diabetic population and differences between incidences of ESRD with respect to sex, ethnicity, age and regions, (2) to compare incidence rates in the diabetic and non-diabetic population, and (3) to investigate time trends. The systematic review was conducted according to the PRISMA group guidelines by performing systematic literature searches in the biomedical databases until January 3rd 2015; thirty-two studies were included. Among patients with incident type 1 diabetes the 30-year cumulative incidence ranged from 3.3% to 7.8%. Among patients with prevalent diabetes, incidence rates of ESRD due to all causes ranged from 132.0 to 167.0 per 100,000 person-years, whereas incidence rates of ESRD due to diabetic nephropathy varied from 38.4 to 804.0 per 100,000 person-years. The incidence of ESRD in the diabetic population was higher compared to the non-diabetic population, and relative risks varied from 6.2 in the white population to 62.0 among Native Americans. The results regarding time trends were inconsistent. The review conducted demonstrates the considerable variation of incidences of ESRD among the diabetic population. Consistent findings included an excess risk when comparing the diabetic to the non-diabetic population and ethnic differences. We recommend that newly designed studies should use standardized methods for the determination of ESRD and population at risk.

Improved incidence of end-stage renal disease of type 1 diabetes in Japan, from a hospital-based survey

OBJECTIVE

To explore whether the incidence of end-stage renal disease (ESRD) in type 1 diabetes (T1DM) was lowered over time, and how the baseline characteristics and risk factor management during follow-up were associated with the incident ESRD.

RESEARCH DESIGN AND METHODS

An observational cohort study was performed in 1014 patients with T1DM diagnosed from 1961 to 1999, who were admitted to the diabetes center. The incidence of ESRD up to 2010 and the effect of risk factors, including annual mean glycated haemoglobin (HbA1c) and blood pressure, were investigated.

RESULTS

During a mean follow-up of 19.3 years, with 88.3% follow-up rate, the incidence of ESRD was significantly lower in T1DM diagnosed in 1985-1999 than in 1961-1984 (0.8 vs 5.0 per 1000 person-years, p<0.0001), which was not precluded by preceding death. Multivariate Cox regression analysis indicated that the former group (vs the latter) was associated with a significantly reduced risk of ESRD independent of baseline variables of age, duration and gender (p<0.01). The continuous variable of year of T1DM diagnosis remained significant after adjustment for the above variables plus baseline proteinuria and retinopathy (p=0.02). Time-dependent Cox regression analysis indicated that ESRD was associated with annual mean HbA1c (p<0.01), systolic blood pressure (p<0.001) and baseline proteinuria (p<0.001), followed by continuous variable of year of T1DM diagnosis (p=0.09).

CONCLUSIONS

Our data indicate that incidence of ESRD is decreasing over time, coinciding with enhanced glycemic and blood pressure controls. The incidence of ESRD in recently diagnosed T1DM appears to be much lower than previously reported ESRD incidence.

Changes in the prognosis of Japanese patients who developed type 1 diabetes before the age of 30 years

AIMS

We investigated changes in vital prognosis according to the year at diagnosis of type 1 diabetes mellitus (T1DM) in a hospital-based survey.

METHODS

Of 1054 Japanese subjects diagnosed as T1DM between 1952 and 1999 before the age of 30 and consulted the diabetes center between 1962 and 1999, the survival status up to 2010 or 20 years of follow-up was investigated. Subjects were divided by the year at diagnosis of T1DM: before 1979 (Group A: n = 359), 1980 to 1989 (Group B: n = 400), and 1990 to 1999 (Group C: n = 295). The mortality (/100,000 person years) and standardized mortality ratio (SMR) were calculated, and the effect of year at diagnosis of T1DM was explored by the Cox proportional hazard model.

RESULTS

The survival status was confirmed in 90.0%. The mortality rate (95%CI) and age and sex adjusted SMR (95%CI) were 457 (288-627) and 3.0 (1.9-4.2) in Group A, 265 (143-387) and 2.2 (1.2-3.2) in Group B, and 144 (29-259) and 1.6 (0.3-2.9) in Group C, respectively. The cumulative survival rate was significantly different according to the year at diagnosis of T1DM (p = 0.0239). Cox's proportional hazard model revealed that Groups B and C had significantly lower risks of death than Group A after adjustment for gender and age at diagnosis of T1DM (HR 0.48 [95%CI 0.26-0.87] for Group B and HR 0.25 [95%CI 0.09-0.60] for Group C).

CONCLUSION

This study indicated that vital prognosis is improving according to the year at diagnosis of T1DM and suggested the need of a nationwide survey.

Comparison of the adherence to the american diabetes association guidelines of diabetes care in primary care and subspecialty clinics

Background

Diabetes mellitus is a major public health problem with significant morbidity and mortality. Evidence based guidelines have been proposed to reduce the micro and macrovascular complications, but studies have shown that these goals are not being met. We sought to compare the adherence to the American Diabetes Association guidelines for measurement and control of glycohemoglobin (A1c), blood pressure (BP), lipids (LDL) and microalbuminuria (MA) by subspecialty and primary care clinics in an academic medical center.

Methods

390 random charts of patients with diabetes from Family Practice (FP), Internal Medicine (IM) and Diabetes (DM) clinics at Michigan State University were reviewed.

Results

We reviewed 131, 134 and 125 charts from the FP, IM and DM clinics, respectively. DM clinic had a higher percentage of patients with type 1 diabetes 43/125 (34.4%) compared with 7/131 (5.3%) in FP and 7/134 (5.2%) in IM clinics. A1c was measured in 99%, 97.8% and 100% subjects in FP, IM and DM clinics respectively. B.P. was measured in all subjects in all three clinics. Lipids were checked in 97.7%, 95.5% and 92% patients in FP, IM and DM clinics respectively. MA was measured at least once during the year preceding the office visit in 85.5%, 82.8% and 76.8% patients in FP, IM and DM clinics respectively. A1C was controlled (<7%) in 38.9, 43.3, 28.8% of patients in the FP, IM and DM clinics, respectively (p = 0.034). LDL was controlled (<100 mg/dl or 2.586 mmol/l) in 71.8, 64.9, 64% of patients in the FP, IM and DM clinics, respectively. MA was controlled (<30 mg/gm creatinine) in 60.3%, 51.5% and 60% patients in FP, IM and DM clinics respectively (P = 0.032). BP was controlled (<130/80) in 59.5, 67.2 and 52.8% patients in the FP, IM and DM clinics, respectively.

Conclusion

Testing rates for A1C, LDL, and MA were high, in both subspecialty and primary care clinics. However, the degree of control was not optimal. Significantly fewer patients in the DM clinic had A1c <7%, the cause of which may be multifactorial.

Urinary type IV collagen as a predictor for the incidence of microalbuminuria in young patients with Type 1 diabetes

AIMS

To clarify whether urinary type IV collagen-to-creatinine ratio is a predictor for the incidence of microalbuminuria in patients with Type 1 diabetes.

METHODS

A longitudinal observational cohort study was conducted; the subjects included normoalbuminuric patients diagnosed with Type 1 diabetes before the age of 30 years and who were less than 40 years old at the start of the observation. In total, 225 patients were enrolled (age, mean ± SD: 25 ± 5 years; male: 32.9%). The endpoint was the incidence of microalbuminuria, defined as 30 mg/g Cr ≤ urinary albumin-to-creatinine ratio < 300 mg/g Cr. Patients were divided into two groups based on the median of urinary type IV collagen-to-creatinine ratio levels.

RESULTS

During the median follow-up period of 8.8 years (range 1.0-12.8 years), 13 patients with high urinary type IV collagen-to-creatinine ratio progressed to microalbuminuria. Meanwhile, only one patient with low urinary type IV collagen-to-creatinine ratio reached the endpoint. Kaplan-Meier estimates for the time to reach the endpoint were significantly faster for patients with a high ratio than for those with a low ratio (log-rank test, P < 0.001). In the multivariate Cox hazard analysis, the hazard ratio for patients with high vs. low urinary type IV collagen-to-creatinine ratio was 13.51 (95% CI 1.59-115.02, P = 0.017). When urinary type IV collagen-to-creatinine ratio was treated as a continuous variable, logarithmically transformed urinary type IV collagen-to-creatinine ratio, but not baseline albumin-to-creatinine ratio, was independently associated with reaching the endpoint (hazard ratio 19.23, 95% CI 1.53-242.30, P = 0.022).

CONCLUSIONS

Urinary type IV collagen may be an important predictor for the incidence of microalbuminuria in young patients with Type 1 diabetes.

Follow-up survey of all participants at the first and second juvenile diabetes summer camp in Japan in 1963 and 1964

This report documents the status of all 10 participants in the first (1963) and second (1964) summer camp in Japan as of 31 December 2008. The eight living participants continue to function as adults in society without hemodialysis.

Incidence and development of diabetic microangiopathy of fulminant type 1 diabetes--comparison with non-fulminant type 1 diabetes

OBJECTIVE

The data from the Fulminant Type 1 Diabetes Committee suggested that patients with fulminant type 1 diabetes are a subgroup at high risk for diabetic microangiopathy in the first 5 years after diagnosis associated with the lack of endogenous insulin secretion from the onset of diabetes. The aim of this study was to assess the development of microangiopathy in patients with fulminant type 1 diabetes followed in our diabetes center.

METHODS

Sixteen patients with fulminant type 1 diabetes and 60 age-matched patients with non-fulminant type 1 diabetes were recruited as subjects. The existence or lack of diabetic retinopathy and nephropathy, average HbA(1C) level, serum C-peptide level, average blood pressure, insulin level, whether or not they were taking antihypertensive agents, and smoking history were investigated retrospectively based on medical records.

RESULTS

The 5-year incidence of microangiopathy was lower in fulminant than in non-fulminant type 1 diabetes patients; retinopathy cases occurred in 0% vs. 8.3% of patients, and nephropathy occurred in 0% vs. 1.7% of patients. The 10-year incidence of retinopathy was 0% vs. 24.1%, and that of nephropathy was 11.1% vs. 3.4%. The cumulative incidence of microangiopathy did not differ between the fulminant and non-fulminant type 1 diabetes patients. Mean HbA(1C) levels and systolic blood pressure were significantly lower in fulminant type 1 diabetes patients.

CONCLUSION

No difference between the patients visiting the center with fulminant type 1 diabetes and those with non-fulminant type 1 diabetes was observed in the development of microangiopathy complications.

The geoepidemiology of type 1 diabetes

Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by absolute insulin deficiency resulting from the progressive immune-mediated destruction of pancreatic islet beta cells. It is thought to be triggered by as yet unidentified environmental factors in genetically susceptible individuals, the major genetic contribution coming from loci within the HLA complex, in particular HLA class II. The worldwide incidence of T1D varies by at least 100-fold, being highest in Finland and Sardinia (Italy) and lowest in Venezuela and China. The incidence has been increasing worldwide at an annual rate of approximately 3%. While genetic factors are thought to explain some of the geographic variability in T1D occurrence, they cannot account for its rapidly increasing frequency. Instead, the declining proportion of newly diagnosed children with high-risk genotypes suggests that environmental pressures are now able to trigger T1D in genotypes that previously would not have developed the disease during childhood. Although comparisons between countries and regions with low and high-incidence rates have suggested that higher socioeconomic status and degree of urbanization are among the environmental factors that play a role in the rising incidence of T1D, the findings are too inconsistent to allow firm conclusions. Morbidity and mortality as well as causes of death also show considerable geographic variation. While glycemic control has been identified as a major predictor of the micro- and macrovascular complications of T1D and shows considerable geographical variability, it does not appear to be the only factor involved in the regional differences in complication rates. The role of genetics in susceptibility to nephropathy, retinopathy and other diabetic complications largely remains to be explored.

Do specialized centers and specialists produce better outcomes for patients with chronic diseases than primary care generalists? A systematic review

PURPOSE

Although specialized centers are generally accepted for treatment of relatively uncommon diseases, such as cystic fibrosis, statements regarding the amount of expertise or minimum number of patients treated are increasingly included in guidelines for the treatment of other chronic diseases such as rheumatoid arthritis and diabetes mellitus.

DATA SOURCES

Medline and Embase from 1987 through March 2008 were searched.

STUDY SELECTION

Studies reporting the effect of treatment in a specialized or high-volume center or by subspecialists on a clinically relevant outcome. Data extraction Two reviewers extracted the data independently and assessed the methodological quality.

RESULTS OF DATA SYNTHESIS

We included 22 articles. Two randomized-controlled trials and a quasi-experimental study compared the effect of outpatient team care with traditional outpatient care for patients with rheumatoid arthritis. These studies showed no difference or were inconsistent. Studies on the outcomes of care for diabetic patients (5 prospective or historical cohort studies and 10 retrospective cohort studies) were generally of poor quality. Studies comparing the subspecialist care with the care provided by general internists or primary care providers produced inconsistent results. Similar inconsistency and poor quality were found for three observational studies on cystic fibrosis.

CONCLUSION

The available literature suggests that among patients with rheumatoid arthritis, diabetes mellitus or cystic fibrosis, outcomes are not superior in specialized centers or with subspecialists compared with other forms of chronic illness care.

Time-course changes in clinical features of early-onset Japanese type 1 and type 2 diabetes: TWMU hospital-based study

Using a database of patients with type 1 (n=1675) and type 2 (n=2259) diabetes diagnosed before the age of 30 years at the Diabetes Center, Tokyo Women's Medical University (TWMU), in which such Japanese patients have been registered at the time of first visit since the 1960s, we performed a hospital-based study over the last 40 years to clarify time-course changes in clinical features of type 1 and type 2 diabetes diagnosed before the age of 30 years. Type 2 diabetes had a male dominancy, while there has been a female dominancy in patients with type 1 diabetes as in previous reports of Japanese childhood-onset type 1 diabetes. Such dominances had been continued over the last 40 years. The number of patients with type 2 diabetes and with a past history of obesity increased with time. The age at which type 2 diabetes was diagnosed was suggested to have been getting lower with time, whereas that of type 1 diabetes has been higher with time. There was no marked difference in family history of diabetes in the first-degree relatives of patients with type 2 diabetes, regardless of the presence or absence of a past history of obesity. More female patients with type 2 diabetes diagnosed before the age of 15 years had mothers with type 2 diabetes compared to corresponding male patients.