Long-term Mortality and End-Stage Renal Disease in a Type 1 Diabetes Population Diagnosed at Age 15–29 Years in Norway

Abstract

OBJECTIVETo study long-term mortality, causes of death, and end-stage renal disease (ESRD) in people diagnosed with type 1 diabetes at age 15-29 years. RESEARCH DESIGN AND METHODSThis nationwide, population-based cohort with type 1 diabetes diagnosed during 1978-1982 (n = 719) was followed from diagnosis until death, emigration, or September 2013. Linkages to the Norwegian Cause of Death Registry and the Norwegian Renal Registry provided information on causes of death and whether ESRD was present. A clinical committee reviewed the causes of death. We calculated standardized mortality ratios (SMRs) for comparison with the background population. RESULTSDuring 30 years' follow-up, 4.6% of participants developed ESRD and 20.6% (n = 148; 106 men and 42 women) died. Cumulative mortality by years since diagnosis was 6.0% (95% CI 4.5-8.0) at 10 years, 12.2% (10.0-14.8) at 20 years, and 18.4% (15.8-21.5) at 30 years. The SMR was 4.4 (95% CI 3.7-5.1). Mean time from diagnosis of diabetes to ESRD was 23.6 years (range 14.2-33.5). Death was caused by chronic complications (32.2%), acute complications (20.5%), violent death (19.9%), or any other cause (27.4%). Death was related to alcohol in 15% of cases. SMR for alcohol-related death was 6.8 (95% CI 4.5-10.3), for cardiovascular death was 7.3 (5.4-10.0), and for violent death was 3.6 (2.3-5.3). CONCLUSIONSThe cumulative incidence of ESRD was low in this cohort with type 1 diabetes followed for 30 years. Mortality was 4.4 times that of the general population, and more than 50% of all deaths were caused by acute or chronic complications. A relatively high proportion of deaths were related to alcohol.Studies assessing causes of death in type 1 diabetes are most frequently conducted in individuals diagnosed during childhood (1-7) or without evaluating the effect of age at diagnosis (8,9). Reports on causes of death in cohorts of patients diagnosed during late adolescence or young adulthood, with long-term follow-up, are less frequent (10). This period in life is often referred to as "emerging adulthood" and is represented by several changes in life, increasing risk behaviors, and exploration of possible life directions (11). Young people move away from the care provided by their families. Transition from

Response to Comment on Gagnum et al. Long-term Mortality and End-Stage Renal Disease in a Type 1 Diabetes Population Diagnosed at Age 15–29 Years in Norway. Diabetes Care 2017;40:38–45

“…We thank Sun et al (1) for their comments on our article on mortality, causes of death, and end-stage renal disease in patients with type 1 diabetes (T1D) (2). We reported that deaths related to alcohol, suicide, and violence (intoxications or accidents) occurred at higher rates in people with T1D compared with the general population in Norway.…”

Risk of end‐stage renal disease from chronic kidney disease defined by decreased glomerular filtration rate in type 1 diabetes: A comparison with type 2 diabetes and the effect of metabolic syndrome

“…Patients with T1D had a fourfold risk of mortality compared with the general population when a cohort with type 1 diabetes was assessed using the standardized mortality ratio and followed for 30 years; this risk increased further by eight to nine‐folds with the co‐presence of ESRD . Despite advances in care for T1D patients with impaired kidney function—including tools for glycemic control, blood pressure management, and the renin‐angiotensin system blockers—the incidence of ESRD caused by T1D has not decreased during the past 20 years in the United States .…”

Continuous Glucose Monitoring with Multiple Daily Insulin Treatment: Outcome Studies

“…17,19,20 Reports from Scotland, Australia, and Norway show that both acute and chronic complications of diabetes contribute to the excess mortality in persons with type 1 diabetes. [21][22][23] Sudden death, including those discovered dead-in-bed accounted for 22% of the deaths in persons dying under age 40 with type 1 diabetes in the Australian study and 5% of those dying before age 30 in the Norwegian cohort. 21,24 One case report confirmed hypoglycemia as the cause of deadin-bed syndrome, and a recent report by Novodvorsky et al confirms that cardiac arrhythmias and repolarization occur during asymptomatic nocturnal hypoglycemia more commonly than daytime hypoglycemia.…”

“…[21][22][23] Sudden death, including those discovered dead-in-bed accounted for 22% of the deaths in persons dying under age 40 with type 1 diabetes in the Australian study and 5% of those dying before age 30 in the Norwegian cohort. 21,24 One case report confirmed hypoglycemia as the cause of deadin-bed syndrome, and a recent report by Novodvorsky et al confirms that cardiac arrhythmias and repolarization occur during asymptomatic nocturnal hypoglycemia more commonly than daytime hypoglycemia. [25][26][27] Hypoglycemia is a well-described deterrent to the achievement of normal glycemia and impacts patients at all levels of glucose control.…”