Predictors of mortality and end‐stage diabetic complications in patients with Type 1 diabetes mellitus on intensified insulin therapy

Mühlhauser, Ingrid; Overmann, H.; Bender, Ralf; Jörgens, Viktor; Berger, Michael

doi:10.1046/j.1464-5491.2000.00372.x

Cited by 73 publications

(57 citation statements)

References 32 publications

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“…However, the changes experienced by these patients add to the evidence currently available with respect to patients on IIT for more than 10 years in a European outpatient healthcare setting. One large-scale cohort trial investigated prognostic factors related to diabetic late complications and mortality after 10 years [15,16]. In a recently repeated cross-sectional survey of Type 1 diabetic outpatients in Sweden, HbA 1 c levels improved only marginally from 7.6% to 7.4% over 14 years with increasing use of intensified therapy, but the prevalence of severe hypoglycaemia increased from 17% to 27% [17], which is consistent with previous findings [2,4,18].…”

Section: Discussionsupporting

confidence: 84%

Long-term evaluation of a structured outpatient education programme for intensified insulin therapy in patients with Type 1 diabetes: a 12-year follow-up

et al. 2004

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Aims/hypothesis. This study was conducted to evaluate the long-term outcome of a structured outpatient diabetes teaching and treatment programme (DTTP) for intensified insulin therapy in patients with Type 1 diabetes, which aims to improve metabolic control without increasing the risk of severe hypoglycaemia. Methods. All 123 diabetic outpatients (age 41±14 years; 64 women; BMI 23.5±3.1; diabetes duration 17± 11 years; HbA 1 c 7.9±1.6%; 32 patients with a history of severe hypoglycaemia; 18 with overt nephropathy; 22 with proliferative retinopathy) who participated in the DTTP between June 1989 and June 1990 were invited for follow-up visits after 3, 6 and 12 years. Results. Out of the 123 patients, 11 died during the follow-up period, two were lost for follow-up, and one was not willing to participate in re-evaluation after 12 years. Mean HbA 1 c levels decreased from 7.9± 1.6% to 7.1±1.2% (p<0.01) after 3 years, and were 7.8±1.5% (NS) and 7.8±1.2% (NS) after 6 and 12 years respectively. Frequency of hypoglycaemia decreased from 0.49 episodes per patient per year to 0.14 after 3 years (p<0.01), 0.19 after 6 years (p<0.01) and 0.16 after 12 years (p<0.01). Of the participants, 41% were able to lower HbA 1 c levels without episodes of severe hypoglycaemia and to maintain this improvement at all follow-up visits over the 12-year period. At follow-up, intensified insulin therapy was carried out by 94% of the patients. Conclusions/interpretation. A sustained reduction of the incidence of severe hypoglycaemia was observed in patients with Type 1 diabetes after participation in a structured outpatient DTTP over a 12-year period.

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Section: Discussionsupporting

confidence: 84%

Long-term evaluation of a structured outpatient education programme for intensified insulin therapy in patients with Type 1 diabetes: a 12-year follow-up

et al. 2004

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“…In our cohort, ESRD was by far the most likely outcome (Figure 2A), with 36% of patients developing ESRD during follow-up (n ϭ 210). This equates to an incidence of 5.1 per 100 person-years (95% CI 4.44, 5.85), and is comparable to that observed in German patients with macroalbuminuria (35%) 20 and in line with some more contemporary data from the Joslin Diabetes Center, where the incidence of ESRD was 5.3 per 100 personyears in patients with proteinuria. 21 These data suggest that our ability to slow down overt nephropathy is limited at best, and has not improved substantially since the advent of the reninangiotensin system blockade.…”

Section: Clinical Epidemiology Wwwjasnorgsupporting

confidence: 86%

Competing-Risk Analysis of ESRD and Death among Patients with Type 1 Diabetes and Macroalbuminuria

Forsblom

Harjutsalo

Thorn

et al. 2011

Journal of the American Society of Nephrology

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Patients with both type 1 diabetes and CKD have an increased risk of adverse outcomes. The competing risks of death and ESRD may confound the estimates of risk for each outcome. Here, we sought to determine the major predictors of the cumulative incidence of ESRD and pre-ESRD mortality in patients with type 1 diabetes and macroalbuminuria while incorporating the competing risk for the alternate outcome into a Fine-Gray competing-risks analysis. We followed 592 patients with macroalbuminuria for a median of 9.9 years. During this time, 56 (9.5%) patients died and 210 (35.5%) patients developed ESRD. Predictors of incident ESRD, taking baseline renal function and the competing risk for death into account, included an elevated HbA 1c , elevated LDL cholesterol, male sex, weight-adjusted insulin dose, and a shorter duration of diabetes. By contrast, predictors of pre-ESRD death, taking baseline renal function and the competing risk for ESRD into account, included only age, the presence of established macrovascular disease, and elevated cholesterol levels. This competing-risks approach has potential to highlight the appropriate targets and strategies for preventing premature mortality in patients with type 1 diabetes. 22: 537-544, 201122: 537-544, . doi: 10.1681 The presence of overt nephropathy in patients with type 1 diabetes from Finland is associated with an increased risk of premature mortality that is over nine times that observed in the age-gender matched general population. 1 A number of different factors potentially contribute to this risk, including poor glycemic control and dyslipidemia. Epidemiologic understanding of the role different factors may play in these adverse outcomes has potentially been limited by cause-specific analyses that fail to take into account competing risks. 2 In particular, in individuals with macroalbuminuria, the outcomes of death and ESRD have important competing effects. For example, analysis of the predictors of ESRD needs to take into account the risk of dying before ESRD. Equally, the consequence of analyzing the predictors of death while taking into account the (proximal) risk of ESRD effectively limits exposure time to the pre-ESRD milieu and "hastens" exposure to the different risks associated with renal replacement therapy. This kind of analysis may be best performed within the paradigm of a formal competing-risks (Fine-Gray) proportional-hazards regression model, which estimates the cumulative incidence of an outcome while accounting for the competing risks of an J Am Soc Nephrol

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“…Following the selection criteria of the reviews, 16 publications [28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43] referring to our three reference programmes should have been identified. In practice, a total of 11 were identified [5,28,30,32,34,38,39,[43][44][45][46], and seven [28,32,34,35,38,39,46] were included in at least one of the reviews. In six reviews the main controlled trials of our reference programmes [28, 30-32, 38, 44] were included in data synthesis [10,11,16,18,19,25].…”

Section: Resultsmentioning

confidence: 99%

Meta-analysis does not allow appraisal of complex interventions in diabetes and hypertension self-management: a methodological review

Lenz¹,

Steckelberg²,

Richter

et al. 2007

Diabetologia

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Common methodologies used in systematic reviews do not allow adequate appraisal of complex interventions. The aim of the present study was to describe and critically appraise current methods of systematic reviews on complex interventions, using diabetes and hypertension patient education as examples. PubMed, the Cumulative Index to Nursing and Allied Health (CINAHL), the Cochrane Library and Health Technology Assessment databases were searched. Systematic reviews focusing on diabetes or hypertension patient education were included. Authors were contacted. Two investigators independently evaluated the reviews. The available evidence of three patient education programmes of diabetes and hypertension self-management implemented in Germany was used as a reference. We included 14 reviews; 12 reviews mentioned that the included education programmes were multidimensional. Reviews on comparable topics identified different publications of the same programme. Identical programmes were classified differently within and between reviews.Education programmes were dissected to analyse effects of single components. Different components of identical programmes were used. Interdependencies between components were not explored. Six reviews performed metaanalysis across programmes with heterogeneous educational or organisational approaches. The complexity of efficacy measures was disregarded: e.g. HbA 1c was used as an isolated outcome variable without considering treatment goals, effects on hypoglycaemia, body weight or quality of life. Our results indicate that methods of current systematic reviews are not fully equipped to appraise patient education and self-management programmes. Since these are complex and heterogeneous interventions, consideration of aggregated evidence is necessary.

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Predictors of mortality and end‐stage diabetic complications in patients with Type 1 diabetes mellitus on intensified insulin therapy

Cited by 73 publications

References 32 publications

Long-term evaluation of a structured outpatient education programme for intensified insulin therapy in patients with Type 1 diabetes: a 12-year follow-up

Long-term evaluation of a structured outpatient education programme for intensified insulin therapy in patients with Type 1 diabetes: a 12-year follow-up

Competing-Risk Analysis of ESRD and Death among Patients with Type 1 Diabetes and Macroalbuminuria

Meta-analysis does not allow appraisal of complex interventions in diabetes and hypertension self-management: a methodological review

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