Sustained effect of intensive treatment of type 1 diabetes mellitus on development and progression of diabetic nephropathy: the Epidemiology of Diabetes Interventions and Complications (EDIC) study - PubMed (original) (raw)

Multicenter Study

Sustained effect of intensive treatment of type 1 diabetes mellitus on development and progression of diabetic nephropathy: the Epidemiology of Diabetes Interventions and Complications (EDIC) study

Writing Team for the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. JAMA. 2003.

Abstract

Context: The Diabetes Control and Complications Trial (DCCT) demonstrated the benefits of intensive treatment of diabetes in reducing glycemic levels and slowing the progression of diabetic nephropathy. The DCCT cohort has been examined annually for another 8 years as part of the follow-up Epidemiology of Diabetes Interventions and Complications (EDIC) study. During the EDIC study, glycemic levels no longer differed substantially between the 2 original treatment groups.

Objective: To determine the long-term effects of intensive vs conventional diabetes treatment during the DCCT on kidney function during the EDIC study.

Design, setting, and participants: Observational study begun in 1993 (following DCCT closeout) in 28 medical centers in the United States and Canada. Participants were 1349 (of 1375) EDIC volunteers who had kidney evaluation at years 7 or 8.

Main outcome measures: Development of microalbuminuria, clinical-grade albuminuria, hypertension, or increase in serum creatinine level.

Results: Results were analyzed by intention-to-treat analyses, comparing the 2 original DCCT treatment groups. New cases of microalbuminuria occurred during the EDIC study in 39 (6.8%) of the participants originally assigned to the intensive-treatment group vs 87 (15.8%) of those assigned to the conventional-treatment group, for a 59% (95% confidence interval [CI], 39%-73%) reduction in odds, adjusted for baseline values, compared with a 59% (95% CI, 36%-74%) reduction at the end of the DCCT (P<.001 for both comparisons). New cases of clinical albuminuria occurred in 9 (1.4%) of the participants in the original intensive-treatment group vs 59 (9.4%) of those in the original conventional-treatment group, representing an 84% reduction in odds (95% CI, 67%-92%), compared with a reduction of 57% (95% CI, -1% to +81%) at the end of the DCCT. Fewer cases of hypertension (prevalence at year 8, 29.9% vs 40.3%; P<.001) developed in the original intensive-treatment group. Significantly fewer participants reached a serum creatinine level of 2 mg/dL or greater in the intensive-treatment vs the conventional-treatment group (5 vs 19, P =.004), but there were no differences in mean log clearance values. Although small numbers of patients required dialysis and/or transplantation, fewer patients experienced either of these outcomes in the intensive group (4 vs 7, P =.36).

Conclusions: The persistent beneficial effects on albumin excretion and the reduced incidence of hypertension 7 to 8 years after the end of the DCCT suggest that previous intensive treatment of diabetes with near-normal glycemia during the DCCT has an extended benefit in delaying progression of diabetic nephropathy.

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Figures

Figure 1

Figure 1

Distribution of HbA1c Concentration by Randomized Treatment Group at the End of the DCCT and in Each Year of the EDlC Study DCCT indicates Diabetes Control and Complications Trial; EDIC, Epidemiology of Diabetes Interventions and Complications; HbA1c, glycosylated hemoglobin. Boxes indicate 25th and 75th percentiles of HbA1c, level; whiskers, 5th and 95th percentiles; heavy horizontal lines, medians; thin horizontal lines, means.

Figure 2

Figure 2

Prevalence and Cumulative Incidence of Microalbuminuria Microalbuminuria defined as albumin excretion rate ≥28 μg/min, equivalent to 40 mg/24 h. A, Prevalence at the end of the Diabetes Control and Complications Trial (DCCT) and during the Epidemiology of Diabetes Interventions and Complications (EDIC) study. The differences between the 2 treatment groups are significant at each time point after DCCT closeout (P<.001). B, Cumulative incidence of new cases in the EDIC study for those participants in the intensive- and conventional-treatment groups with normal albuminuria at the beginning and end of the DCCT. The difference in cumulative incidences is significant by the log-rank test (P<.001).

Figure 3

Figure 3

Prevalence and Incidence of Albuminuria Albuminuria defined as albumin excretion rate ≥208 μg/min, equivalent to 300 mg/24 h. A, Prevalence of clinical albuminuria at the end of the Diabetes Control and Complications Trial (DCCT) and during the Epidemiology of Diabetes Interventions and Complications (EDIC) study. The differences between the treatment groups are significant at each time point after DCCT close-out (P<.01). B, Cumulative incidence of new cases in the EDIC study for those participants in the intensive- and conventional-treatment groups with either normoalburninuria or microalbuminuria at the end of the DCCT. The difference in cumulative incidences is significant by the tog-rank-test. (P<.001).

Figure 4

Figure 4

Prevalence of Hypertension at Each Year of the EDlC Study Prevalence of hypertension (defined as blood pressure >140/90 mm Hg) at the end of the Diabetes Control and Complications Trial (DCCT) and during the Epidemiology of Diabetes Interventions and Comptications (EDIC) study for participants in the intensive- vs conventional-treatment groups. The aggregate odds reduction with intensive vs conventional therapy of emergent hypertension during the EDIC study, adjusted for DCCT mean arterial pressure, was 40.4% (95% confidence interval, 33.7%-46.5%; P<.001).

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