Cause-specific mortality in a cohort of Brazilian patients with type 1 diabetes

Prevalence of cardiovascular autonomic neuropathy in an admixed population of patients with type 1 diabetes. Lessons from a pioneer multicentre study in Brazil

AIMS

To evaluate the prevalence of cardiovascular autonomic neuropathy (CAN) and its associated factors in Brazilian patients with type 1 diabetes (T1D).

METHODS

This cross-sectional, multicentre study was conducted in 14 public clinics in ten Brazilian cities. From 1760 patients, 1712 were included (97.3 %): 953 females (55.7 %), 930 (54.3 %) Caucasians, aged 29.9 ±11.9 years and with diabetes duration of 15.4 ± 9.2 years. CAN was evaluated using cardiovascular autonomic reflex tests.

RESULTS

The prevalence of CAN was 23.4 %. Multivariable hierarchical logistic regression showed CAN associated with age, smoking, lower socioeconomic status, higher yearly medical appointments, insulin therapeutic regimens, higher levels of HbA1c, total cholesterol, uric acid, diastolic blood pressure and heart rate, presence of retinopathy, diabetic kidney disease and a tendency to be associated with severe hypoglycemia. Lower health-related quality of life was also found in univariate analysis in these patients.

CONCLUSIONS

Patients with T1D presented an important prevalence of CAN that was associated with other diabetes-related chronic complications, and also with demographic, clinical and laboratorial traditional risk factors. Considering lack of formal policy, our data could be used for guiding public health approach to awareness and CAN's screening, diagnosis and clinical management in patients with T1D in Brazil.

Diabetes duration or age at onset and mortality in insulin-dependent diabetics: a systematic review and meta-analysis

BACKGROUND

This meta-analysis was conducted given the contradictory findings from studies on the influence of diabetes duration or age at onset on mortality in patients with insulin-dependent diabetes mellitus (IDDM).

METHODS

Electronic databases (PubMed, Embase, Cochrane, Web of Knowledge, Scopus, and CINHAL) were comprehensively searched to identify relevant studies until October 31, 2022. All of the selected articles contained statistics on hazard ratios, relative risks (RRs), or odds ratios, or data for estimating the association between diabetes duration or age at onset and total mortality in IDDM patients. Regardless the heterogeneity assessed by the I² statistic, pooled RRs and 95% confidence intervals (CI) for total mortality were acquired via random effect meta-analysis with inverse variance weighting.

RESULTS

This meta-analysis finally included 19 studies involving 122, 842 individuals. Both age at onset and diabetes duration were positively associated with an increased mortality rate in IDDM patients. Specifically, the pooled RRs for age at onset and diabetes duration were 1.89 (95%CI 1.43-2.50) and 1.89 (95%CI 1.16-3.09) respectively. Subgroup analyses revealed that only prepubertal onset was associated with a greater survival advantage than pubertal or postpubertal onset.

CONCLUSIONS

The findings of this meta-analysis and systematic review suggest that a later age at onset or longer diabetes duration is associated with increased risk of total mortality in IDDM patients. However, this conclusion shall be interpreted with caution due to the possibility of residual confounding and be confirmed in the future by well-designed studies.

Increased risk of death following recurrent ketoacidosis admissions: a Brazilian cohort study of young adults with type 1 diabetes

BACKGROUND

Recurrent DKA (rDKA) remains an acute type 1 diabetes complication even in post-insulin era. This study aimed to analyze the predictors and effects of rDKA on the mortality of patients with type 1 diabetes.

METHODS

Patients hospitalized (n = 231) wih diabetic ketoacidosis (between 2007 and 2018) were included. Laboratorial and clinical variables were collected. Mortality curves were compared in four groups: diabetic ketoacidosis as a new-onset type 1 diabetes (group A), single diabetic ketoacidosis episode after diagnosis of type 1 diabetes (group B), 2-5 diabetic ketoacidosis events (group C), and > 5 diabetic ketoacidosis events during follow-up period (group D).

RESULTS

During the follow-up period (approximately 1823 days), the mortality rate was 16.02% (37/231). The median age at death was 38.7 years. In the survival curve analysis, at 1926 days (5 years), the probabilities of death were indicated by ratios of 7.78%, 4.58%, 24.40%, and 26.63% in groups A, B, C, and D, respectively. One diabetic ketoacidosis episode compared with ≥ 2 events had a relative risk of 4.49 (p = 0.004) of death and > 5 events had 5.81 (p = 0.04). Neuropathy (RR 10.04; p < 0.001), retinopathy (relative risk 7.94; p < 0.01), nephropathy (RR 7.10; p < 0.001), mood disorders (RR 3.57; p = 0.002), antidepressant use (RR 3.09; p = 0.004), and statin use (RR 2.81; p = 0.0024) increased the risk of death.

CONCLUSIONS

Patients with type 1 diabetes with > 2 diabetic ketoacidosis episodes have four times greater risk of death in 5 years. Microangiopathies, mood disorders, and use of antidepressants and statins were important risk factors for short-term mortality.

Epidemiology and risk factors of hypoglycemia in subjects with type 1 diabetes in Brazil: a cross-sectional, multicenter study

Objective

The aim of this study was to investigate the factors associated with hypoglycemia and severe hypoglycemia (SH) in individuals with type 1 diabetes mellitus (T1D) in Brazil.

Materials and Methods

This multicenter, cross-sectional study was conducted between August 2011 and August 2014 across 10 Brazilian cities. The data were obtained from 1,760 individuals with T1D. Sociodemographic and clinical characteristics related to hypoglycemic events in the previous 4 weeks were evaluated.

Results

Of 1,760 individuals evaluated, 1,319 (74.9%) reported at least one episode of hypoglycemia in the previous 4 weeks. The main factors associated with hypoglycemia were lower hemoglobin A1c (HbA1c) level, better adherence to self-monitoring of blood glucose (SMBG), and higher education level. Episodes of SH were reported by 251 (19%) individuals who, compared with subjects with nonsevere hypoglycemia, received lower doses of prandial insulin and higher doses of basal insulin, in addition to reporting less frequent use of long-acting basal insulin analogs. The percentage of SH episodes was evenly distributed across all ranges of HbA1c levels, and there were no correlations between the mean number of nonsevere or severe hypoglycemic events and HbA1c values. Higher alcohol consumption and more frequent hospitalizations were independently associated with SH.

Conclusion

Although individuals presenting with hypoglycemia had lower HbA1c values than those not presenting hypoglycemia, there were no correlations between the number of nonsevere hypoglycemia or SH and HbA1c values. Also, the frequency of SH was evenly distributed across all ranges of HbA1c values. Better adherence to SMBG and higher education level were associated with hypoglycemia, while alcohol consumption, higher doses of basal insulin, and more frequent hospitalizations in the previous year were associated with SH.

Overall and Cause-Specific Mortality in Patients With Type 1 Diabetes Mellitus: A Population-Based Cohort Study in Taiwan From 1998 Through 2014

Background

To investigate all-cause and cause-specific mortality in Taiwanese patients with type 1 diabetes.

Methods

A cohort of 17,203 patients with type 1 diabetes were identified from Taiwan’s National Health Insurance claims in the period of 1998–2014. Person-years were accumulated for each individual from date of type 1 diabetes registration to date of death or the last day of 2014. Age, sex, and calendar year standardized mortality ratios (SMRs) were calculated with reference to the general population.

Results

In up to 17 years of follow-up, 4,916 patients died from 182,523 person-years. Diabetes (30.15%), cancer (20.48%), circulatory diseases (13.14%), and renal diseases (11.45%) were the leading underlying causes of death. Mortality rate (26.93 per 1,000 person-years) from type 1 diabetes in Taiwan was high, the cause of death with the highest mortality rate was diabetes (8.12 per 1,000 person-years), followed by cancer (5.52 per 1,000 person-years), and circulatory diseases (3.54 per 1,000 person-years). The all-cause SMR was significantly elevated at 4.16 (95% confidence interval, 4.04–4.28), with a greater all-cause SMR noted in females than in males (4.62 vs 3.79). The cause-specific SMR was highly elevated for diabetes (SMR, 16.45), followed by renal disease (SMR, 14.48), chronic hepatitis and liver cirrhosis (SMR, 4.91) and infection (SMR, 4.59). All-cause SMRs were also significantly increased for all ages, with the greatest figure noted for 15–24 years (SMR, 8.46).

Conclusions

Type 1 diabetes in both genders and all ages was associated with significantly elevated SMRs for all-cause and mostly for diabetes per se and renal disease.

Diabetic Ketoacidosis in Patients with End-stage Kidney Disease: A Review

Diabetes mellitus is a highly prevalent disease. Chronic kidney disease is one of its chronic complications, and diabetic ketoacidosis is one of the most dreaded acute complications. The increasing prevalence of diabetes mellitus and renal failure has resulted in physicians increasingly encountering diabetic ketoacidosis in this complicated subgroup of patients. This review discusses the pathophysiologic understanding of diabetic ketoacidosis in patients with renal failure, its varying clinical presentation, and management and prevention. We have also highlighted the role of patient weight and proximity to dialysis as tools to assess and manage fluid status in this challenging group of patients.

Prevalence of chronic kidney disease in an admixed population of patients with type 1 diabetes. A multicenter study in Brazil

AIMS

To evaluate diagnosis, prevalence and associated factors of CKD in Brazilian patients with type 1 diabetes.

METHODS

This cross-sectional, multicenter study was conducted in 14 public clinics in 10 Brazilian cities. From 1760 patients, 1736 were included (98.6%): 977 females (56.3%), 932 (54%) Caucasians, aged 29.9 ± 11.9 years, age at diagnosis 14.7 ± 8.9 years, diabetes duration 15.5 ± 9.3 years and 12.2 ± 3.8 years of school attendance. CKD was determined by using estimated glomerular filtration rate and by the presence of albuminuria in two out of three morning urine samples.

RESULTS

The prevalence of CKD was 33.7%. Overall, 28.1% of the patients could not be classified due to insufficient number of urine samples for albuminuria determination. Multivariable analysis showed that female gender, diabetes duration, high levels of HbA1c and uric acid, use of renin-angiotensin system inhibitors, retinopathy, high systolic blood pressure, and economic status (medium, low and very low) were associated with CKD.

CONCLUSIONS

Although a high prevalence of CKD, associated comorbidities and retinopathy was observed in our study, a large number of patients are still undiagnosed, making CKD a challenge in routine clinical practice in admixed populations with T1D in a developing country like Brazil.

Relationship between health care insurance status, social determinants and prevalence of diabetes-related microvascular complications in patients with type 1 diabetes: a nationwide survey in Brazil

AIMS

To evaluate the relationship between social determinants, health care insurance status and occurrence of diabetes-related chronic complications (DRCC) in Brazilian patients with type 1 diabetes.

METHODS

A multicenter cross-sectional study conducted between August 2011 and August 2014 in 14 public clinics in 10 Brazilian cities. Data were obtained from 1760 patients, aged 29.9 ± 11.9 years, with diabetes duration of 15.5 ± 9.3 years; 55.9% female, 54.5% Caucasians, 69.7% were attended exclusively by the public Brazilian National Health Care System (BNHCS) and 30.3% had also private health care insurance. Patients' information was obtained through a questionnaire and a chart review form.

RESULTS

The social determinants associated with having both private and public health care insurance were being employed, belonging to medium or high socioeconomic status, having more years of school attendance and having younger age. Regarding DRCC, patients that had private and public health care had lower rates of diabetic retinopathy and of any other DRCC. Chronic kidney disease was not associated with health care coverage status after adjusting for classical clinical risk factors.

CONCLUSIONS

Brazilian patients with type 1 diabetes had better clinical control and lower rates of DRCC, mainly retinopathy, when also having private health care insurance. These patients presented less frequently predictors of chronic complications such as high levels of HbA1c and blood pressure. BNHCS should change the approach for screening DRCC such as diabetic retinopathy, using methods such as telemedicine that would lead to earlier diagnosis, better outcomes and will be cost-effective sometime after its implementation.