Mortality and incidence of renal replacement therapy in people with type 1 diabetes mellitus--a three decade long prospective observational study in the Lainz T1DM cohort.

CONTEXT AND OBJECTIVE: We investigated long term mortality, requirement for renal replacement therapy (RRT), and incidence of other late diabetic complications in an observational cohort study of 641 people with type 1 diabetes (T1DM). DESIGN: Prospective observational cohort study. SETTING: The study was conducted at a Tertiary Diabetes Centre in Vienna, Austria. PATIENTS: A cohort with all people with T1DM (n = 641, 47% females, 30 ± 11 years) attending their annual diabetes review was created in 1983-1984. Biomedical data were collected. MAIN OUTCOME MEASURES: In 2013 we investigated mortality rates and incidence rates of RRT by record linkage with national registries and incidence of other major diabetes complications by questionnaire. RESULTS: 156 (24%) patients died [mortality rate: 922 (95%CI: 778-1066) per 100 000 person years]. Fifty-five (8.6%) received RRT [incidence rate: 335 (95%CI: 246-423) per 100 000 person years]. The 380 questionnaires (78% return rate) recorded cardiac events, strokes, limb amputations, and/or blindness, affecting 21.8% of survivors. Mortality and incidence of RRT increased in each quartile of baseline HbA1c, with the lowest rates in the quartile with HbA1c ≤ 6.5% (48 mmol/mol) (P < .05). CONCLUSIONS: In people with established type 1 diabetes who were observed for almost three decades, the overall mortality was 24% and the incidence of renal replacement therapy was 8.6%, with a 21.8% combined incidence rate of the other hard endpoints in the surviving people. A clear linear relationship between early glycemic control and the later development of end stage renal disease and mortality has been found.

PAI-1 4G/5G insertion/deletion promoter polymorphism and microvascular complications in type 2 diabetes mellitus.

BACKGROUND: Plasminogen activator inhibitor-1 (PAI-1) plays an important role in the regulation of fibrinolysis and extracellular matrix turnover. PAI-1 4G/5G insertion/deletion polymorphism in the PAI-1 promoter region has been shown to modulate PAI-1 plasma levels. We investigated the relationship between this polymorphism and the prevalence of diabetic nephropathy and retinopathy in patients with type 2 diabetes in the Austrian population. PATIENTS AND METHODS: 147 consecutive patients with type 2 diabetes mellitus (96 men, 51 women; median age, 65 years; IQR, 59-71) were analyzed for the PAI-1 4G/5G genotype. RESULTS: The genotype distribution in the individuals tested was as follows: 17% (n = 25) 5G/5G, 54% (n = 80) 4G/5G, and 29% (n = 42) 4G/4G. Patients homozygous for allele 4G had a significantly higher risk of diabetic proliferative retinopathy than patients without signs of diabetic retinopathy or nonproliferative retinopathy (OR, 7.3; 95% CI, 1.4-38.8; P = 0.02). No significant associations were observed between the PAI-1 genotype and the presence of albuminuria. CONCLUSION: According to our results, diabetic proliferative retinopathy might be associated with the prevalence of PAI-1 genotype 4G/4G.

[Diabetic foot syndrome]. / Das diabetische Fusssyndrom.

The diabetic foot syndrome (DFS) is an important diabetic complication. The typical lesion is a neuropathic plantar foot ulcer which heals well when treated properly. However, complications resulting from deep infections of soft tissue or bone, together with a reduced peripheral blood flow, may necessitate amputation of the lower limbs. In general, diabetic patients have a 10-fold higher risk for amputation than non-diabetic subjects and also a poorer long-time prognosis than the latter. The target of a 50% reduction of lower limb amputations in diabetic patients, given by the St. Vincent Declaration for Europe in 1990, has not been achieved. The prevention as well as treatment of DFS have to be improved in order to achieve this target. The feet of diabetic patients must be inspected regularly and the patients must be educated appropriately. Detailed information on avoidable risk factors and the availability of protective footwear are essential for the prevention of DFS. An increasing number of ischemic diabetic subjects undergo vascular reconstruction, which yields good results. On account of the multifactorial etiology of DFS, a multidisciplinary approach is required to resolve the problem. In addition to a diabetologist, the team should include a plastic and vascular surgeon, a neurologist, a radiologist and an orthopedist.

Transfer of knowledge from the specialist to the generalist by videoconferencing: effect on diabetes care.

We conducted a 12-month prospective interventional study of videoconferencing between primary and secondary care. A treatment network consisting of a diabetes specialist and four general practitioners was established. The communications medium was PC-based videoconferencing via ISDN at 128 kbit/s. A total of 154 type 2 diabetic patients entered the study. The specialist was contacted 94 times via videoconferencing. Metabolic and haemodynamic parameters were significantly improved over the course of the study: the mean HbA1c level fell from 8.1% to 7.8%, systolic blood pressure from 156 to 148 mmHg and diastolic blood pressure from 88 to 83 mmHg. The study demonstrated that therapeutic counselling by videoconferencing is feasible in diabetes care and suggests that it reduces hospital admissions and improves the quality of care.