Modern-day clinical course of type 1 diabetes mellitus after 30 years' duration: the diabetes control and complications trial/epidemiology of diabetes interventions and complications and Pittsburgh epidemiology of diabetes complications experience (1983-2005).
BACKGROUND
Clinical treatment goals of type 1 diabetes mellitus (T1DM) have changed since the Diabetes Control and Complications Trial (DCCT) demonstrated reduced long-term complications with intensive diabetes therapy. There have been few longitudinal studies to describe the clinical course of T1DM in the age of intensive therapy. Our objective was to describe the current-day clinical course of T1DM.


METHODS
An analysis of the cumulative incidence of long-term complications was performed. The DCCT (1983-1993) assigned patients to conventional or intensive therapy. Since 1993, the DCCT has been observational, and intensive therapy was recommended for all patients. The Pittsburgh Epidemiology of Diabetes Complications (EDC) study is an observational study of patients with T1DM from Allegheny County, Pennsylvania. The study population comprised the DCCT T1DM cohort (N = 1441) and a subset of the EDC cohort (n = 161) selected to match DCCT entry criteria. In the DCCT, intensive therapy aimed for a near-normal glycemic level with 3 or more daily insulin injections or an insulin pump. Conventional therapy, with 1 to 2 daily insulin injections, was not designed to achieve specific glycemic targets. Main outcome measures included the incidences of proliferative retinopathy, nephropathy (albumin excretion rate >300 mg/24 h, creatinine level >or=2 mg/dL [to convert to micromoles per liter, multiply by 88.4], or renal replacement), and cardiovascular disease.


RESULTS
After 30 years of diabetes, the cumulative incidences of proliferative retinopathy, nephropathy, and cardiovascular disease were 50%, 25%, and 14%, respectively, in the DCCT conventional treatment group, and 47%, 17%, and 14%, respectively, in the EDC cohort. The DCCT intensive therapy group had substantially lower cumulative incidences (21%, 9%, and 9%) and fewer than 1% became blind, required kidney replacement, or had an amputation because of diabetes during that time.


CONCLUSIONS
The frequencies of serious complications in patients with T1DM, especially when treated intensively, are lower than that reported historically.
Diabetes Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114-2698, USA. dnathan@partners.org
Nathan
David M
DM
Zinman
Bernard
B
Cleary
Patricia A
PA
Backlund
Jye-Yu C
JY
Genuth
Saul
S
Miller
Rachel
R
Orchard
Trevor J
TJ
D000293:Adolescent; D000328:Adult; D001786:Blood Glucose; D002170:Canada / Q000453:epidemiology; D048909:Diabetes Complications / Q000453:epidemiology*; D003922:Diabetes Mellitus, Type 1 / Q000150:complications / Q000453:epidemiology* / Q000628:therapy; D016883:Diabetic Ketoacidosis / Q000139:chemically induced; D006801:Humans; D007003:Hypoglycemia / Q000139:chemically induced; D007328:Insulin / Q000008:administration & dosage / Q000009:adverse effects; D008137:Longitudinal Studies; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D014481:United States / Q000453:epidemiology; D015430:Weight Gain; D055815:Young Adult
D001786:Blood Glucose; D007328:Insulin