Intensified antihypertensive therapy is associated with improved survival in type 1 diabetic patients with nephropathy

Pt, Sawicki; Mühlhauser, Ingrid; Didjurgeit, Ulrike; Baumgartner, Amy; Bender, R.; Berger, Michael

doi:10.1097/00004872-199508000-00015

Cited by 47 publications

(30 citation statements)

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“…Following the selection criteria of the reviews, 16 publications [28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43] referring to our three reference programmes should have been identified. In practice, a total of 11 were identified [5,28,30,32,34,38,39,[43][44][45][46], and seven [28,32,34,35,38,39,46] were included in at least one of the reviews.…”

Section: Resultsmentioning

confidence: 99%

Meta-analysis does not allow appraisal of complex interventions in diabetes and hypertension self-management: a methodological review

Lenz¹,

Steckelberg²,

Richter

et al. 2007

Diabetologia

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Common methodologies used in systematic reviews do not allow adequate appraisal of complex interventions. The aim of the present study was to describe and critically appraise current methods of systematic reviews on complex interventions, using diabetes and hypertension patient education as examples. PubMed, the Cumulative Index to Nursing and Allied Health (CINAHL), the Cochrane Library and Health Technology Assessment databases were searched. Systematic reviews focusing on diabetes or hypertension patient education were included. Authors were contacted. Two investigators independently evaluated the reviews. The available evidence of three patient education programmes of diabetes and hypertension self-management implemented in Germany was used as a reference. We included 14 reviews; 12 reviews mentioned that the included education programmes were multidimensional. Reviews on comparable topics identified different publications of the same programme. Identical programmes were classified differently within and between reviews.Education programmes were dissected to analyse effects of single components. Different components of identical programmes were used. Interdependencies between components were not explored. Six reviews performed metaanalysis across programmes with heterogeneous educational or organisational approaches. The complexity of efficacy measures was disregarded: e.g. HbA 1c was used as an isolated outcome variable without considering treatment goals, effects on hypoglycaemia, body weight or quality of life. Our results indicate that methods of current systematic reviews are not fully equipped to appraise patient education and self-management programmes. Since these are complex and heterogeneous interventions, consideration of aggregated evidence is necessary.

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Section: Resultsmentioning

confidence: 99%

Meta-analysis does not allow appraisal of complex interventions in diabetes and hypertension self-management: a methodological review

Lenz¹,

Steckelberg²,

Richter

et al. 2007

Diabetologia

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“…We have recently shown that intensification of antihypertensive treatment in IDDM patients with diabetic nephropathy is associated not only with a reduction of the progression of nephropathy and retinopathy by also with a major improvement in life expectancy [23]. In this study mortality was 56 per 1000 py in the control group as compared to 9 per 1000 py in the intervention group.…”

Section: Patients With Iddmmentioning

confidence: 53%

“…A combination of hypertension, coronary artery disease and autonomic neuropathy with increased sympathetic activity to the myocardium is very often present in these patients and is the hallmark of a very poor prognosis [4,27]. To date a reduction of mortality in diabetic nephropathy has been documented in a controlled prospective study only for conventional antihypertensive treatment based on cardioselective beta blockers and diuretics [23]. In patients with nephropathy a relatively diminished effect on mortality during antihypertensive treatment with ACE inhibitors is possible and has been described in randomised studies [14,26].…”

Section: Patients With Iddmmentioning

confidence: 99%

Antihypertensive treatment and mortality in diabetic patients What is the evidence?

1997

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In follow-up studies patients with hypertension and non-insulin-dependent diabetes mellitus (NIDDM) have a four to sevenfold increase in total mortality when compared to non-diabetic normotensive subjects. Recently, the risk of mortality associated with hypertension in diabetes was assessed in 3648 newly diagnosed NIDDM patients [1], hypertension was present in 35 % of women and 46 % of men. When compared to normotensive diabetic patients the mortality risk associated with hypertension was doubled over a median follow-up period of 4.6 years. Cardiac events including sudden death accounted for 58 % and stroke for 13 % of all causes of death.Patients with insulin-dependent diabetes mellitus (IDDM) exhibit a dramatically reduced life expectancy when they develop diabetic nephropathy which is nearly always associated with hypertension [2]. Without antihypertensive treatment the 10-year mortality approaches 80 % in these patients and the main causes of death are myocardial infarction, cardiac failure, sudden death and stroke [3,4].Hence, there is no doubt that hypertension adds considerably to the already increased morbidity and mortality risk in NIDDM patients and is the major determinant of the prognosis in nephropathic IDDM patients. Evidence from intervention studies Patients with NIDDMTo date no prospective randomised intervention trials aiming at the relevant end points of cardiovascular morbidity and mortality have been published for hypertensive NIDDM patients. At least in Germany, the majority of these patients at diagnosis of diabetes are already above 65 years of age; until recently, there has been controversy over whether elderly patients would benefit from antihypertensive treatment. At the beginning of this decade intervention trials in older patients with essential hypertension were published including about 10 % NIDDM patients [5][6][7]. These trials have impressively shown that antihypertensive treatment with thiazide diuretics and beta blocking agents reduces morbidity and mortality both in patients with systolic and/or diastolic hypertension and gave no indication that these beneficial effects would be different in diabetic patients.The evidence from intervention trials in essential hypertension indicates that the overall benefit of antihypertensive treatment in the intervention group rises with an increase of the mortality risk in the control group. In a recent overview-evaluation of intervention trials in essential hypertension the mortality risk in the intervention group was correlated with the mortality risk in the control group and an equation for this linear correlation was proposed [8]. According to this equation it should be possible to estimate the benefit of antihypertensive treatment when the baseline risk of an untreated hypertensive population is known: y = 0.47x -2.9 (y = reduction of mortality due to antihypertensive treatment; x = mortality risk without antihypertensive treatment). Applying this equation to the increased mortality risk in newly diagnosed hypertensive NIDDM patients ...

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“…Most significant results were achieved in a prospective controlled study including patients with Type I diabetes and nephropathy-associated hypertension [61,62]. The intervention consisted of a combination of participation in the programme and specialized care in comparison to standard care.…”

Section: Prospective Controlled Trialsmentioning

confidence: 99%

Patient education - evaluation of a complex intervention

Mühlhauser

Berger

2002

Diabetologia

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Diabetes education or self-management programmes are complex interventions. Their evaluation is difficult because of problems in identifying and separately assessing the effect of the various components of the intervention. A phased approach defining sequential stages of a continuum of increasing evidence has been proposed as a framework for the design and evaluation of such complex interventions. As an example we present the available evidence for diabetes treatment and teaching programmes implemented in Germany. Evidence is compiled for structured group treatment and teaching programmes for Type I diabetes, noninsulin dependent Type II diabetes, and hypertension according to the following sequential stages of increasing evidence: (i) preclinical or theoretical phase; (ii) modelling the components of the intervention; (iii) exploratory trials; (iv) randomized controlled trials; (v) phase of implementation including replication and transfer to different settings. Evidence for most of these phases has been generated for the three programmes, although individual studies do not fulfill all important quality criteria by today's standards. The time span for gathering the evidence from the theoretical phase to surveillance after implementation was about 20 years. It can only be speculated which parts of the programmes are the most active ones. The presentation of a continuum of increasing evidence for diabetes education or self-management programmes could provide useful information for the appraisal of such complex interventions. Since this evidence cannot be readily extracted from databases we suggest that other research groups present their data in a similar way. [Diabetologia (2002[Diabetologia ( ) 45:1723[Diabetologia ( -1733

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Intensified antihypertensive therapy is associated with improved survival in type 1 diabetic patients with nephropathy

Cited by 47 publications

References 0 publications

Meta-analysis does not allow appraisal of complex interventions in diabetes and hypertension self-management: a methodological review

Meta-analysis does not allow appraisal of complex interventions in diabetes and hypertension self-management: a methodological review

Antihypertensive treatment and mortality in diabetic patients What is the evidence?

Patient education - evaluation of a complex intervention

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