Risk for ESRD in type 1 diabetes remains high despite renoprotection

Abstract

Historically, patients with type 1 diabetes and macroalbuminuria had high competing risks: cardiovascular death or renal failure. Here, we assessed these risks in patients receiving therapies implemented during the last 30 years. Between 1991 and 2004, we enrolled 423 white patients with type 1 diabetes who developed macroalbuminuria (albumin excretion rate, ≥300 μg/min). With follow-up for 98% through 2008, ESRD developed in 172 patients (incidence rate, 5.8/100 person-years), and 29 died without ESRD (mortality rate, 1/100 person-years). The majority of these outcomes occurred between ages 36 and 52 years with durations of diabetes of 21 to 37 years. The 15-year cumulative risks were 52% for ESRD and 11% for pre-ESRD death. During the 15 years of follow-up, the use of renoprotective treatment increased from 56 to 82%, and BP and lipid levels improved significantly; however, the risks for both ESRD and pre-ESRD death did not change over the years analyzed. There were 70 post-ESRD deaths, and the mortality rate was very similar during the 1990s and the 2000s (11/100 person-years versus 12/100 person-years, respectively). Mortality was low in patients who received a pre-emptive kidney transplant (1/100 person-years), although these patients did not differ from dialyzed patients with regard to predialysis eGFR, sex, age at onset of ESRD, or duration of diabetes. In conclusion, despite the widespread adoption of renoprotective treatment, patients with type 1 diabetes and macroalbuminuria remain at high risk for ESRD, suggesting that more effective therapies are desperately needed.

Figure 1.

Cumulative incidence of ESRD in patients with T1D and macroalbuminuria rises with increased baseline CKD stages.

Figure 2.

Number of incident cases of ESRD attributable to diabetes according to calendar time increases in 40- to 49-year-olds and decreases in 20- to 39-year-olds. Total number of incident cases among 20- to 49-year-olds in 1990 was 3359; in 1995, it was 3972; in 2000, it was 4287; and in 2006, it was 4600. We obtained from the U.S. Renal Data System (http://www.usrds.org/) the number of incident cases of ESRD attributed to diabetes between 1990 and 2006 that occurred in the white U.S. population. In these patients, T1DM is the predominant diabetes type and almost the exclusive type in those with sufficient diabetes duration to develop diabetes associated ESRD.