Section on Genetics & Epidemiology, Research and Clinic Divisions, Joslin Diabetes Center, One Joslin Place, Boston, MA 02215, USA.
J Am Soc Nephrol. 2011 Mar;22(3):545-53. doi: 10.1681/ASN.2010040354. Epub 2011 Feb 25.
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.
从历史上看，患有 1 型糖尿病和大量白蛋白尿的患者存在较高的竞争风险：心血管死亡或肾衰竭。在这里，我们评估了在过去 30 年中接受治疗的患者的这些风险。在 1991 年至 2004 年间，我们招募了 423 名患有 1 型糖尿病且出现大量白蛋白尿（尿白蛋白排泄率≥300μg/min）的白人患者。在 2008 年之前，通过 98%的随访，有 172 名患者出现终末期肾病（发病率为 5.8/100 人年），29 名患者在未出现终末期肾病的情况下死亡（死亡率为 1/100 人年）。这些结果中的大多数发生在 36 岁至 52 岁之间，糖尿病病程为 21 至 37 年。15 年的累积风险为 ESRD 52%，pre-ESRD 死亡 11%。在 15 年的随访期间，肾保护治疗的使用率从 56%增加到 82%，血压和血脂水平显著改善；然而，在分析的几年中，ESRD 和 pre-ESRD 死亡的风险并未发生变化。发生 70 例 post-ESRD 死亡，20 世纪 90 年代和 21 世纪 00 年代的死亡率非常相似（分别为 11/100 人年和 12/100 人年）。接受预防性肾移植的患者死亡率较低（1/100 人年），尽管这些患者与透析患者在透析前 eGFR、性别、ESRD 发病年龄或糖尿病病程方面没有差异。总之，尽管广泛采用了肾保护治疗，但患有 1 型糖尿病和大量白蛋白尿的患者仍面临较高的 ESRD 风险，这表明迫切需要更有效的治疗方法。
