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8/2/2019 Intensive Diabetes Therapy and GFR in Type 1
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Intensive Diabetes Therapy and
GFR in Type 1 Diabetes
Wan Aisyah Wan Muda
5th April 2012
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Background
Impaired GFR is the final common pathway of
diabetic kidney disease
Risks of cardiovascular disease events and
progression to ESKD are quicker with impaired
GFR
Type 1 Diabetes at higher risk of getting
kidney disease
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Background
Combination of two study - DCCT and EDIC
Intensive therapy that lowered glycated
haemoglobin (HbA1C) levels reduced risk of
micro/macroalbuminuria, therefore reducing
long term risk of impaired GFR among Type 1
DM
Effects on development of impaired GFRwithin follow up period of 22years
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Methods
In DDCT study, 1441 Type 1 DM were randomly assignedto 6.5 years of:
a) Intensive diabetes therapy of 3 or more insulin/dayor on pump with aim of HbA1C
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Results
Impaired GFR
sustained estimated GFR of < 60ml/min/1.73m
2
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Cumulative incidence 20 yrs after
Incidence occurs in 2% of intensive therapy and5.5% of conventional therapy
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Rates of decrease in GFR
DCCT study Overall reduction in mean estimated GFR of 1.7ml/min
EDIC study Slower rate of reduction in GFR of 2.5ml/min for both
Combined : average decrease 1.27ml/min (intensive) and 1.56ml/min (conventional)
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Conclusion
Long term risk of impaired GFR significantly
lowered in persons treated for an average of
6.5 yrs with DCCT intensive therapy. This is
evident after 10 yrs of randomisation.
Impairment of GFR may be prevented in Type
1 DM with the therapy and this is also in line
with current recommendations of earlyglycemic control ( target HbA1C of < 7%)
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Discussion
Absolute incidence of impaired GFR was low. Mayreflects incidence rate of impaired GFR in Type 1DM generally.
Association of other biomarkers e.g BP, BMI, use
of antihypertensive and use of RAAS are alsomeasured to explore covariates associated withtreatment effect
Intensive therapy also provides significantreduction (73%) in risk of combined outcome ofimpaired GFR and death. Risks of impaired GFRnot influenced by number of deaths in study
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Limitations
Non randomised use of medications other thaninsulin.
?Applicable to Type 2 DM
Persons with advanced complications of diabeteswho at risk of progressive decrease in GFR maynot get same benefit as did those in treatedgroup.
Use of RAAS inhibitors discouraged during DCCTand this may give different effects if added to theintensive therapy.
Recommended