Discordant Trends in Microvascular Complications in Adolescents With Type 1 Diabetes From 1990 to 2002

Abstract

OBJECTIVE -Since the Diabetes Control and Complications Trial, diabetes management goals have changed. The aims of the present study were to assess complication rates, including nerve abnormalities, in adolescents from 1990 to 2002 and to investigate associated risk factors. RESEARCH DESIGN AND METHODS-Cross-sectional analysis of complications was assessed in three study periods (1990 -1994 [T1], 1995-1998 [T2], and 1999 -2002 [T3]) in adolescents matched for age and diabetes duration (n ϭ 878, median age 14.6 years, median duration 7.5 years). Retinopathy was assessed by seven-field stereoscopic fundal photography, albumin excretion rate (AER) from three consecutive timed overnight urine collections, peripheral nerve function by thermal and vibration thresholds, and autonomic nerve function by cardiovascular reflexes.RESULTS -Retinopathy declined significantly (T1, 49%; T2, 31%; and T3, 24%; P Ͻ 0.0001), early elevation of AER (Ն7.5 g/min) declined (38, 30, and 25%, respectively, P ϭ 0.022), and microalbuminuria (AER Ն20 g/min) declined (7, 3, and 3%, respectively; P ϭ 0.017, T1 vs. T2 and T3). Autonomic nerve abnormalities were unchanged (18, 21, and 18%, respectively; P ϭ 0.60), but peripheral nerve abnormalities increased (12, 19, and 24%, respectively; P ϭ 0.0017). More patients were treated with three or more injections per day (12, 46, and 67%, respectively; P Ͻ 0.0001) and insulin dose increased (1.08, 1.17, and 1.22 units ⅐ kg Ϫ1 ⅐ day Ϫ1 , respectively; P Ͻ 0.0001), but median HbA 1c (A1C) was unchanged (8.5, 8.5, and 8.4%, respectively). BMI and height SD score increased: BMI 0.46, 0.67, and 0.79, respectively (P Ͻ 0.0001), and height Ϫ0.09, 0.05, and 0.27, respectively (P Ͻ 0.0001).CONCLUSIONS -Retinopathy and microalbuminuria declined over time in this cohort, but the increased rate of peripheral nerve abnormalities is of concern. Despite intensified management (higher insulin dose and more injections), A1C has not changed and remains well above the recommended targets for adolescents. Recognition that screening is important to identify individuals who will benefit from interventions has led to screening programs for adolescents (2,3). Prevention of long-term chronic complications has now become one of the main goals of modern type 1 diabetes treatment in children and adolescents.In Australia, we initially reported a retinopathy rate of 42% in adolescents (4) and microalbuminuria has been found in 4 -20% of children, mostly after the age of 12-15 years (5-7). Although symptomatic neuropathy is uncommon in children with diabetes, previous studies have found a high prevalence of subclinical neurological abnormalities: nerve conduction abnormalities in 51% (8), cardiac autonomic abnormalities in 31% (9), and reduced sensory sensibility in 16% (10). A decline in the cumulative incidence of nephropathy was reported in Linkoping, Sweden, in 1994 in individuals diagnosed as children during 1961-1980 (11). This finding was considered by some to apply to only that geographical area because a similar study in...

Plantar Fascia Thickness, a Measure of Tissue Glycation, Predicts the Development of Complications in Adolescents With Type 1 Diabetes

“…This result is likely to be due to the low prevalence of microalbuminuria in this cohort (4%) and in other recent reports (12,13). Early elevation of AER precedes the development of microalbuminuria (24); therefore, a possible interpretation of our findings is that augmented collagen deposition within the extracellular matrix of the glomeruli parallels collagen glycation in connective tissues including the plantar aponeurosis.…”

“…The photographs were graded by the same ophthalmologist (S.H.) according to the Early Treatment Diabetic Retinopathy Study (ETDRS) adaptation of the modified Airlie House classification of diabetic retinopathy as described previously (12,13) .…”

Retinal Arteriolar Dilation Predicts Retinopathy in Adolescents With Type 1 Diabetes

“…Detailed characteristics of this cohort have been reported in previous publications (11)(12)(13)(14)(15). Children and adolescents with type 1 diabetes, referred by their physicians, were assessed for complications in our clinics.…”

Kontrola glikemii i jej zmienność głównymi czynnikami ryzyka mikroalbuminurii u dzieci chorych na cukrzycę typu 1

“…Such natural course of the disease brings into question the necessity of pharmacological treatment implementation, especially in diabetic children and adolescents. There is no consensus on the frequency of diabetic nephropathy and microalbuminuria, as some reports evidence decreasing prevalence, while others show no improvement despite the intensification of diabetes control and pharmacological therapy [14][15][16][17]. Another important conclusion suggested on the basis of recent studies is that microalbuminuria is reversible even without any intervention.…”