Improved prognosis of diabetic nephropathy in type 1 diabetes

Abstract

The natural history of diabetic nephropathy offered an average survival of only 5-7 years. During the past decades, multiple changes in therapy and lifestyle have occurred. The prognosis of diabetic nephropathy after implementing stricter control of blood pressure (including increased use of long-term renin-angiotensin system inhibition), lipids, and glycemia, along with less smoking and other lifestyle and treatment advancements, is inadequately analyzed. To clarify this, we studied 497 patients with type 1 diabetes and diabetic nephropathy at the Steno Diabetes Center and compared them with previous data, obtained using identical criteria at our hospital. The glomerular filtration rate, measured yearly by 51Cr-EDTA plasma clearance, was a mean of 71 ml/min per 1.73 m2 at baseline. The mean glomerular filtration rate decline was significantly reduced by 19% (95% confidence interval 5-34) from previously 4.0 to 3.3 ml/min per 1.73 m2/year. During a median follow-up of 9.1 years, 29% of participants doubled their plasma creatinine or developed end-stage renal disease. Mortality risk was similar to our prior study (hazard ratio 1.05 (0.76-1.43). However, after age adjustment, as both diabetes and nephropathy onset occurred later in life, mortality was reduced by 30%. Risk factors for decline in glomerular filtration rate, death, and other renal end points were generally in agreement with prior studies. Thus, with current treatment of nephropathy in type 1 diabetes, the prognosis and loss of renal function has improved along with better control of modifiable risk factors.

Obstetric and perinatal outcome in type 1 diabetes patients with diabetic nephropathy during 1988–2011

“…Despite the improving prognosis of diabetic nephropathy [15], premature deaths among our patients were still common. The obesity epidemic has not affected women with diabetic nephropathy, whose median BMI has remained in the normal range.…”

“…Poor maternal glycaemic control in late pregnancy predisposes to fetal chronic hypoxia [45], which is in agreement with our observation of the association between the last HbA 1c level before delivery and umbilical artery pH <7. 15.…”

“…Optimisation of glycaemic control and reduction of BP, especially using renin-angiotensin system (RAS) inhibitors, slows the progression and improves the prognosis of diabetic nephropathy [15]. Suboptimal control of BP in early pregnancy is associated with an increased risk of preterm delivery in women with diabetic nephropathy, independent of glycaemic control and duration of diabetes [16].…”

Dual Renin-Angiotensin-Aldosterone System Inhibition for the Treatment of Diabetic Kidney Disease: Adverse Effects and Unfulfilled Promise

“…Despite increases in the prevalence of DM in the last decade, it is reassuring that the incidence of DN has been declining since 2006 [5]. The recent decline in the incidence of DN has been attributed to better glycemic management, blood pressure control, and widespread use of renin-angiotensin-aldosterone system (RAAS) blockade [4,6]. Given the underlying pathophysiology, there was hope that dual RAAS blockade could reduce progression even further.…”

“…Diabetic nephropathy (DN) is a major complication of DM affecting individuals with type 1 or type 2 DM and is the leading cause of chronic kidney disease and end-stage kidney disease (ESKD) in the USA [3]. Those diagnosed with DN are faced with a mean survival of 5-7 years, with excess mortality mainly attributed to cardiovascular complications [4]. Approximately 39 % of patients with chronic kidney disease have DM and 41-44 % of all new cases of ESKD are due to DN.…”