title: Cardiac autonomic neuropathy predicts cardiovascular morbidity and mortality in type 1 diabetic patients with diabetic nephropathy.
abstract: OBJECTIVE
  Cardiac autonomic neuropathy (CAN) has been associated with a poor prognosis in patients with diabetes. Because CAN is common in patients with diabetic nephropathy, we evaluated the predictive value of CAN in type 1 diabetic patients with and without diabetic nephropathy.
  
  
  METHODS
  In a prospective observational follow-up study, 197 type 1 diabetic patients with diabetic nephropathy and a matched group of 191 patients with long-standing type 1 diabetes and normoalbuminuria were followed for 10.1 years (range 0.0-10.3 years). At baseline, CAN was assessed by heart rate variation (HRV) during deep breathing. HRV was evaluated as a predictor of the primary end point: cardiovascular morbidity and mortality. As secondary end points, all-cause mortality and the influence of HRV on progression of diabetic nephropathy (decline in glomerular filtration rate [GFR]) was evaluated.
  
  
  RESULTS
  During the follow-up, 79 patients (40%) with nephropathy reached the combined primary end point vs. 19 patients (10%) with normoalbuminuria (log-rank test, P < 0.0001). The unadjusted hazard ratio (HR) for reaching the primary end point when having an abnormal HRV (< or =10 bpm) measured at baseline compared with a normal HRV was 7.7 (range 1.9-31.5; P = 0.004) in patients with nephropathy. Similarly in the normoalbuminuric patients, the unadjusted HR was 4.4 (1.4-13.6; P = 0.009). In patients with nephropathy, abnormal HRV was significantly associated with fatal and nonfatal cardiovascular disease after adjustment for cardiovascular risk factors. The adjusted HR for reaching the primary end point in a patient with nephropathy and an abnormal HRV was 6.4 (1.5-26.3, P = 0.010), as compared with a normal HRV. The unadjusted HR for dying when having an abnormal HRV compared with a normal HRV was 3.3 (95% CI 1.0-10.7; P = 0.043) in patients with diabetic nephropathy. After adjustment for confounding factors, the impact of HRV on all-cause mortality in patients with nephropathy was no longer significant (P = 0.293). There was no relationship between abnormal HRV and rate of decline in GFR.
  
  
  CONCLUSIONS
  HRV is an independent risk factor for cardiovascular morbidity and mortality in type 1 diabetic patients with nephropathy.
authors.affiliation: Steno Diabetes Center, Niels Steensensvej 2, 2820 Gentofte, Denmark. ansa@steno.dk
authors.forename: Anne Sofie
authors.initials: AS
authors.lastname: Astrup
authors.forename: Lise
authors.initials: L
authors.lastname: Tarnow
authors.forename: Peter
authors.initials: P
authors.lastname: Rossing
authors.forename: Birgitte V
authors.initials: BV
authors.lastname: Hansen
authors.forename: Jannik
authors.initials: J
authors.lastname: Hilsted
authors.forename: Hans-Henrik
authors.initials: HH
authors.lastname: Parving
mesh_terms: D000328:Adult; D001342:Autonomic Nervous System Diseases / Q000503:physiopathology*; D003922:Diabetes Mellitus, Type 1 / Q000150:complications*; D003928:Diabetic Nephropathies / Q000401:mortality*; D003929:Diabetic Neuropathies / Q000150:complications / Q000503:physiopathology*; D005260:Female; D005500:Follow-Up Studies; D006331:Heart Diseases / Q000209:etiology* / Q000401:mortality; D006339:Heart Rate / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012044:Regression Analysis; D012307:Risk Factors