OBJECTIVETo evaluate long-term survival, development of renal end points, and decline in glomerular filtration rate (GFR) in patients with type 2 diabetes and diabetic nephropathy (DN) after renin-angiotensin system (RAS) inhibition and multifactorial treatment of cardiovascular risk factors have become standard of care. RESEARCH DESIGN AND METHODSAll patients with type 2 diabetes and DN (n = 543) at the Steno Diabetes Center were followed during 2000-2010. GFR was measured yearly with 51 Cr-EDTA plasma clearance. Annual decline in GFR was determined in patients with at least three measurements over a minimum of 3 years (ΔGFR cohort, n = 286). Results were compared with historical data, obtained using identical criteria at our hospital, before implementation of current treatment guidelines. RESULTSBaseline mean (SD) GFR was 74 (32) mL/min/1.73 m 2 . More than 93% received RAS inhibition. During median 7.8 (interquartile range 5.7-9.8) years, mean (SE) annual GFR decline was 4.4 (0.24) compared with previously 5.2 (0.27) mL/min/ 1.73 m 2 /year (P = 0.04). Doubling of plasma creatinine or end-stage renal disease (ESRD) developed in 19%, and 37% died during 5.7 (3.3-8.8) years. Mortality from onset of DN in the ΔGFR cohort was compared with that of our prior ΔGFR cohort from 1983 to 2003 (n = 227). Crude mortality risk was reduced by 42% and after age adjustment by 50% (P < 0.001 for both). In a multistate model accounting for competing risks of ESRD and death, prior cardiovascular disease and lower GFR were predictors of mortality, whereas albuminuria, HbA 1c , and low GFR predicted ESRD. CONCLUSIONSOverall prognosis has improved considerably with current multifactorial treatment of DN in type 2 diabetes, including long-term RAS inhibition.

The natural history of diabetic nephropathy offered an average survival of only 5-7 years. During the past decades, multiple changes in therapy and lifestyle have occurred. The prognosis of diabetic nephropathy after implementing stricter control of blood pressure (including increased use of long-term renin-angiotensin system inhibition), lipids, and glycemia, along with less smoking and other lifestyle and treatment advancements, is inadequately analyzed. To clarify this, we studied 497 patients with type 1 diabetes and diabetic nephropathy at the Steno Diabetes Center and compared them with previous data, obtained using identical criteria at our hospital. The glomerular filtration rate, measured yearly by 51Cr-EDTA plasma clearance, was a mean of 71 ml/min per 1.73 m2 at baseline. The mean glomerular filtration rate decline was significantly reduced by 19% (95% confidence interval 5-34) from previously 4.0 to 3.3 ml/min per 1.73 m2/year. During a median follow-up of 9.1 years, 29% of participants doubled their plasma creatinine or developed end-stage renal disease. Mortality risk was similar to our prior study (hazard ratio 1.05 (0.76-1.43). However, after age adjustment, as both diabetes and nephropathy onset occurred later in life, mortality was reduced by 30%. Risk factors for decline in glomerular filtration rate, death, and other renal end points were generally in agreement with prior studies. Thus, with current treatment of nephropathy in type 1 diabetes, the prognosis and loss of renal function has improved along with better control of modifiable risk factors.

PurposeTo explore the feasibility of a research-based program for patient-centered consultations to improve medical adherence and blood glucose control in patients with type 2 diabetes.Patients and methodsThe patient-centered empowerment, motivation, and medical adherence (EMMA) consultation program consisted of three individual consultations and one phone call with a single health care professional (HCP). Nineteen patients with type 2 diabetes completed the feasibility study. Feasibility was assessed by a questionnaire-based interview with patients 2 months after the final consultation and interviews with HCPs. Patient participation was measured by 10-second event coding based on digital recordings and observations of the consultations.ResultsHCPs reported that EMMA supported patient-centered consultations by facilitating dialogue, reflection, and patient activity. Patients reported that they experienced valuable learning during the consultations, felt understood, and listened to and felt a trusting relationship with HCPs. Consultations became more person-specific, which helped patients and HCPs to discover inadequate diabetes self-management through shared decision-making. Compared with routine consultations, HCPs talked less and patients talked more. Seven of ten dialogue tools were used by all patients. It was difficult to complete the EMMA consultations within the scheduled time.ConclusionThe EMMA program was feasible, usable, and acceptable to patients and HCPs. The use of tools elicited patients’ perspectives and facilitated patient participation and shared decision-making.

BackgroundNon-invasive measurements of 24 hour ambulatory central aortic systolic pressure (24 h-CASP) and central pulse pressure (24 h-CPP) are now feasible. We evaluate the relationship between 24 h central blood pressure and diabetes-related complications in patients with type 1 diabetes.MethodsThe study was cross-sectional, including 715 subjects: 86 controls (C), 69 patients with short diabetes duration (< 10 years), normoalbuminuria (< 30 mg/24 h) without receiving antihypertensive treatment (SN), 211 with longstanding diabetes (≥ 10 years) and normoalbuminuria (LN), 163 with microalbuminuria (30-299 mg/24 h) (Mi) and 186 with macroalbuminuria (> 300 mg/24 h) (Ma).24 h-CASP and 24 h-CPP was measured using a tonometric wrist-watch-like device (BPro, HealthStats, Singapore) and derived using N-point moving average.ResultsIn C, SN, LN, Mi and Ma mean ± SD 24 h-CASP was: 114 ± 17, 115 ± 13, 121 ± 13, 119 ± 16 and 121 ± 13 mmHg (p < 0.001); and 24 h-CPP: 38 ± 8, 38 ± 7, 44 ± 10, 46 ± 11 and 46 ± 11 mmHg, (p < 0.001).Following rigorous adjustment (24 h mean arterial pressure and conventional risk factors), 24 h-CASP and 24 h-CPP increased with diabetes, albuminuria degree, previous cardiovascular disease (CVD), retinopathy and autonomic dysfunction (p ≤ 0.031).Odds ratios per 1 standard deviation increase in 24 h-CASP, 24 h-CPP and 24 h systolic blood pressure (24 h-SBP) were for CVD: 3.19 (1.68-6.05), 1.43 (1.01-2.02) and 2.39 (1.32-4.33), retinopathy: 4.41 (2.03-9.57), 1.77 (1.17-2.68) and 3.72 (1.85-7.47) and autonomic dysfunction: 3.25 (1.65-6.41), 1.64 (1.12-2.39) and 2.89 (1.54-5.42).Conclusions24 h-CASP and 24 h-CPP was higher in patients vs. controls and increased with diabetic complications independently of covariates. Furthermore, 24 h-CASP was stronger associated to complications than 24 h-SBP.The prognostic significance of 24 h-CASP and 24 h-CPP needs to be determined in follow-up studies.Trial registrationClinicalTrials.gov ID NCT01171248.

High urinary sulphate excretion was significantly associated with slower decline in (51)Cr-EDTA-assessed GFR in diabetic nephropathy, independent of known progression promoters.