The changing epidemiology of diabetic microangiopathy in type 1 diabetes

Abstract

Diabetic microvascular complications in the kidney and the eye are a major burden for diabetic patients due to increased morbidity and mortality. Furthermore, diabetic nephropathy is the leading cause of end-stage renal disease and diabetic retinopathy is the leading cause of blindness in younger patients, representing a major public health concern. During the past two decades beneficial effects of, in particular, aggressive antihypertensive control and strict glycaemic control have been demonstrated in randomised controlled clinical trials. Technological improvements in diabetes care have made good metabolic control easier to achieve. Has this led to an improved prognosis? In observational studies from dedicated centres, a decrease from 47 to 13% has been reported in the incidence of proliferative diabetic retinopathy after 20-25 years of diabetes, and the incidence of overt diabetic nephropathy after 20 years has decreased from 28 to 5.8%. Even functional and morphological remission of diabetic nephropathy has been reported. Despite this, recent population-based studies have failed to demonstrate a decrease in the incidence of blindness caused by diabetes, and the incidence of end-stage renal disease has progressively increased. This may, in part, be the result of a combination of increasing numbers of diabetic patients and a lag phase between improvement in management and a decline in end-stage complications. It is of concern, however, that the results from specialised centres may not apply to routine diabetes care. It is, therefore, mandatory that the beneficial effects of pharmacological and non-pharmacological interventions demonstrated in clinical trials and recommended by treatment guidelines are translated into clinical practice to ensure a widespread improvement in prognosis.

Bases moleculares da glomerulopatia diabética

“…Nesta fase, a progressão inexorável à insuficiência renal crônica e necessidade de diálise e/ou transplante renal eram a regra, mas o controle metabólico intensivo (6), tratamento rigoroso da hipertensão arterial e o uso de drogas com efeito bloqueador do sistema renina-angiotensina-aldosterona (7) têm sido estratégias eficazes na redução da incidência e desaceleração da progressão da doença (8). No entanto, ainda um número considerável de pacientes desenvolve esta complicação e suas mais graves conseqüências, sendo necessária a identificação dos mecanismos envolvidos na sua gênese para se obter prevenção e tratamento mais eficientes.…”

Redusert forekomst av proliferativ retinopati ved type 1-diabetes?

“…I en dansk studie med personer som fikk type 1-diabetes i årene 1965-84, var det gradvis synkende forekomst av proliferativ retinopati etter 20 år med diabetes -fra 31,2 % hos dem som fikk diabetes i årenene 1965-69 til 12,5 % hos dem som fikk sykdommen i perioden 1979-84 (4). Bedre blodsukkerkontroll og blodtrykksbehandling, mindre røyking og regelmessig øyebunnsundersøkelse er sannsynligvis viktige årsaker til dette (6)(7)(8).…”

How to survive diabetes

“…Mercifully, the prognosis of diabetic nephropathy has been transformed since then, and developments at the primary, secondary and tertiary levels of intervention have been responsible. At the primary level, the proportion of children and young adults developing proteinuria within 20-25 years of diagnosis has dropped from about 30% to about 10% within the past two decades, at least in studies from centres of excellence in Scandinavia [21,22], and improved glucose control and ACE inhibitors for microalbuminuria are likely to have contributed to this. It must, however, be emphasised that these optimistic findings have yet to be replicated elsewhere [1].…”