The 30-Year Natural History of Type 1 Diabetes Complications

Abstract

Declining incidences in Europe of overt nephropathy, proliferative retinopathy, and mortality in type 1 diabetes have recently been reported. However, comparable data for the U.S. and trend data for neuropathy and macrovascular complications are lacking. These issues are addressed using the prospective observational Pittsburgh Epidemiology of Childhood-Onset Diabetes Complications Study. Participants were stratified into five cohorts by diagnosis year: 1950 -1959, 1960 -1964, 1965-1969, 1970 -1974, and 1975-1980. Mortality, renal failure, and coronary artery disease (CAD) status were determined on the complete cohort (n ‫؍‬ 906) at 20, 25, and 30 years. Overt nephropathy, proliferative retinopathy, and neuropathy were assessed at 20 and 25 years on the subset of participants with a clinical examination. There was a decreasing trend by diagnosis year for mortality, renal failure, and neuropathy across all time intervals (P < 0.05), with the 1950 -1959 cohort having a fivefold higher mortality at 25 years than the 1970s' cohorts. Proliferative retinopathy and overt nephropathy showed nonsignificant declines at 20 years (P < 0.16 and P < 0.13, respectively) and no change at 25 years. CAD event rates, which were lower than the other complications, also showed no trend. Although some type 1 diabetes complications (mortality, renal failure, and neuropathy) are declining, others (CAD, overt nephropathy, and proliferative retinopathy) show less favorable changes by 30 years.

School performance in children with type 1 diabetes—a population-based register study

“…Over the past few years, the efforts to improve metabolic control in childhood diabetes have probably contributed to the decreasing prevalence of diabetic complications [1][2][3]. Particularly since the strong proof provided by the Diabetes Control and Complications Trial (DCCT) [4], attempts to keep HbA 1c below the proposed threshold value have been adopted by most clinicians, including those in paediatric clinics, especially as it has been shown that, as early as in the first years of type 1 diabetes, metabolic control has an impact on markers of late complications [5,6].…”

How to survive diabetes

“…If this interpretation is correct, we may need to reconsider the widespread clinical assumption that improved glucose control and antihypertensive therapy have converted the malignant angiopathy of early-onset diabetes into something more benign. They may simply have shifted the survival curve to the right, as suggested by at least one study [25].…”

“…Nor could proteinuria ever be considered benign, for its mortality was 100% by 24 years, and uraemia developed to an equal extent in those who died before or after 10 years of proteinuria [20]. Furthermore, the bell-shaped pattern of incidence reported from Denmark [20] may not be universal, and the Pittsburgh Study showed a sustained increase in the incidence of nephropathy over the first 35 years of diabetes [25].…”

“…Coronary artery disease is greatly accelerated in those with nephropathy [25,28], to the extent that the excess coronary risk associated with type 1 diabetes is much reduced, although still well above baseline, when nephropathy is absent [29]. Long-term survivors are typically lean and normotensive, with raised HDL-cholesterol and relatively low insulin requirements, implying sensitivity to its actions (Table 1).…”

Retinal vascular fractals predict long-term microvascular complications in type 1 diabetes mellitus: the Danish Cohort of Pediatric Diabetes 1987 (DCPD1987)

“…Microvascular complications remain common in type 1 diabetes [1,2]. Identifying early biomarkers of diabetic peripheral neuropathy (DPN), diabetic nephropathy (DN) and diabetic retinopathy (DR) will allow the earlier implementation of treatment and support the development of new treatment modalities.…”