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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EAs many as half of all diabetes patients also have some form of chronic kidney disease (CKD) [\u003Ca href=\u0022http:\/\/www.kidney.org\u0022\u003Ewww.kidney.org\u003C\/a\u003E]. A global population of diabetes patients of about 350 million means that there are approximately 150 to 200 million type 2 diabetes patients with CKD\u0027a problem of immense proportions. The combination of diabetes and CKD is characteristic of a specific population of diabetics (eg, those that are older, overweight\/obese, hypertensive).\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes Mellitus\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ERenal Disease\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EDiabetes \u0026amp; Kidney Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EAs many as half of all diabetes patients also have some form of chronic kidney disease (CKD) [\u003Ca href=\u0022http:\/\/www.kidney.org\u0022\u003Ewww.kidney.org\u003C\/a\u003E]. A global population of diabetes patients of about 350 million means that there are approximately 150 to 200 million type 2 diabetes patients with CKD\u2014a problem of immense proportions. Merlin Thomas, MD, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia, explained that the combination of diabetes and CKD is characteristic of a specific population of diabetics (eg, those that are older, overweight\/obese, hypertensive). Although diabetes increases the incidence of a low estimated glomerular filtration rate (eGFR; \u0026lt;60 mL\/min), the most common reason for low eGFR is aging, not type 2 diabetes.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EDr. Thomas said he believes that CKD in diabetic patients is mislabeled. Diabetic patients with CKD would be better categorized as having chronic disease, since they are at an increased risk of heart failure, anemia, hypertension, fluid retention, dyslipidemia, malaise\/inactivity, treatment side effects, and, in particular, cardiovascular disease (CVD) and premature death. One study that compared the rates of atherosclerotic vascular disease, congestive heart failure, renal replacement therapy, and death in patients with diabetes and\/or CKD reported that whereas patients with CKD were at a much greater risk for renal replacement therapy on a relative basis, in absolute terms, the high death rate in this population may reflect accelerated rates of atherosclerotic vascular disease and congestive heart failure (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E) [Foley RN et al. \u003Cem\u003EJASN\u003C\/em\u003E 2005].\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/12509\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/12509\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12509\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EAdjusted Hazard Ratio by Disease Load.\u003C\/p\u003E\n         \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-6\u0022\u003EThe effect of CKD in diabetic patients complicates treatment in a variety of ways\u2014in particular, through its effect on glucose control. As eGFR decreases, insulin half-life is prolonged, thus leading to hypoglycemia. In addition, almost one-third of the glucose that is released in response to hypoglycemia comes from the kidney\u2014if the kidneys are not functioning properly, this response is lost. HbA1C is also lower in patients with CKD, even at the same mean glucose control; so, clinicians need to be careful in equating low HbA1C levels in these patients with good glucose control, as this may not necessarily be the case. Finally, CKD is a sign of other pending problems. A patient with an eGFR \u0026lt;60 mL\/min\/1.73 m\u003Csup\u003E2\u003C\/sup\u003E is at increased risk of a heart attack or stroke and has poorer outcomes from these events, an increased risk of injury-induced fractures, medication-induced adverse events, and poor blood pressure control.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EAlthough the mortality rate that is associated with type 1 diabetes is 5 times higher than that of the general population, it is improving (a decrease of \u223c30% over the last 2 decades). In some cases, these improvements exceed gains that are seen in the general population. Presenting data from two large registry studies, Trevor J. Orchard, MD, University of Pittsburgh, Pennsylvania, USA, discussed the factors that are relevant to mortality in patients with type 1 diabetes.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EDr. Orchard discussed the results of a recently published 30-year mortality study from the Allegheny County Type 1 Diabetes Registry, which includes data for 1075 diabetes patients (48% women, 7% black) who were diagnosed between January 1, 1965 and December 31, 1979 [Secrest A et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2010]. The 30-year overall mortality rate was 19% (202 deaths). Mortality rates among blacks were significantly higher than for whites overall and at the 30-year follow-up time point (40.5% vs 17.1%; p\u0026lt;0.001). Thirty-year mortality rates were also higher in women than in men, but the difference was not significant. To determine the trend in mortality over time for patients with diabetes, mortality was analyzed in 3 cohorts, based on year of diagnosis (1965 to 1969, 1970 to 1974, and 1975 to 1979). There was a stepwise decrease in mortality, with the 1965-to-1969 group having significantly higher mortality than the 1975-to-1979 group overall (RR, 1.86: p\u0026lt;0.001) and at 30-years follow-up (RR, 1.51; p=0.02). The study also examined factors that are associated with mortality and found that during the first 10 years of diabetes, acute complications constituted the largest cause of mortality. Renal and CVD were not factors until the second decade, but they predominated thereafter, with renal and CVD contributing to more than 70% of deaths (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/11\/27\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Factors Associated with Mortality.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-937103415\u0022 data-figure-caption=\u0022Factors Associated with Mortality.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/11\/27\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/11\/27\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/11\/27\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12506\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-9\u0022 class=\u0022first-child\u0022\u003EFactors Associated with Mortality.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from the American Diabetes Association. Cause-Specific Mortality Trends in a Large Population-Based Cohort With Long-Standing Childhood-Onset Type 1 Diabetes. Secrest AM et al. \u003Cem\u003EDiabetes Care\u003C\/em\u003E 2010; 59(12):3216\u20133222.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-10\u0022\u003EThe impact of renal disease was also shown in the Finnish Diabetic Nephropathy (FinnDiane) study, a national, multicenter, 7-year follow-up study of 4201 adults with type 1 diabetes that showed a clear association between the presence and severity of CKD and all-cause mortality. At baseline, mean age and duration of diabetes ranged from 36 to 44 years and 20 to 32 years, respectively, depending on renal status. A total of 12% of participants had microalbuminuria, 14% had macroalbuminuria, and 7% had end-stage renal disease (ESRD). Over the 7-year period, there were 291 deaths. Standardized mortality rates were 0.8 for participants with normal albuminuria, 2.8 for those with microalbuminuria, 9.2 for those with macroalbuminuria, and 18.3 for those with ESRD [Groop PH et al. \u003Cem\u003EDiabetes\u003C\/em\u003E 2009].\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EDr. Orchard discussed a recent study that further examined cause of death by renal status using data from the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study, which included 658 subjects with childhood-onset type 1 diabetes (age \u0026lt;17 years). Participants in the EDC study had a mean age of 28 years with a mean duration of diabetes of 19 years. Renal disease was defined as an albumin excretion rate \u226520 \u03bcg\/min from multiple samples and grouped as microalbuminuria (20\u2013200 \u03bcg\/min), overt nephropathy (\u0026gt;200 \u03bcg\/min), or ESRD (dialysis or renal transplantation). At baseline, 311 (47.3%) individuals had renal disease (microalbuminuria 21.3%, overt nephropathy 22.2%, and ESRD 3.8%). Over a median follow-up of 20 years, there were 152 deaths (23.1%). Mortality was 6.2 (95% CI, 5.2 to 7.2) times higher than expected. Standardized mortality ratios were 2.0 (1.2 to 2.8) for participants with normoalbuminuria; 6.4 (4.4 to 8.4) for those with microalbuminuria; 12.5 (9.5 to 15.4) in the presence of overt nephropathy; and 29.8 (16.8 to 42.9) for participants with ESRD. Excluding those (n=64) with normoalbuminuria who later progressed to renal disease, there was no excess mortality among the subjects in the remaining normoalbuminuria group (1.2; 0.5 to 1.9), whose deaths were largely unrelated to diabetes. These results support the FinnDiane findings and extend them up to 20 years, showing that type 1 diabetes patients without renal disease can achieve long-term survival that is comparable with the general population [Orchard TJ et al. \u003Cem\u003EDiabetologia\u003C\/em\u003E 2010].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EMicroalbuminuria not only represents the early stage of diabetic nephropathy but also reflects widespread vascular damage and is a marker of insulin resistance in type 1 diabetes, as well as a predictor of CVD, irrespective of diabetes status. In the HOPE study, the relative risk for major cardiovascular events was 1.97 and 1.61 in those with and without diabetes, respectively [HOPE Study Investigators. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2000]. Thus, as microalbuminuria is also associated with numerous other risk factors\/markers and with general vascular damage, the total concordance between microalbuminuria and the excess mortality of type 1 diabetes probably reflects much more than early renal disease alone.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/11\/11\/27.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmyb2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmyb2\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzmyb2\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}