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Randomized Controlled Trial
. 2014 Oct;25(10):2342-50.
doi: 10.1681/ASN.2013091004. Epub 2014 Jun 12.

Renal outcomes in patients with type 1 diabetes and macroalbuminuria

Ian H de Boer  1 , Maryam Afkarian  2 , Tessa C Rue  3 , Patricia A Cleary  4 , John M Lachin  4 , Mark E Molitch  5 , Michael W Steffes  6 , Wanjie Sun  4 , Bernard Zinman  7 ; Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Research Group
Affiliations
Randomized Controlled Trial

Renal outcomes in patients with type 1 diabetes and macroalbuminuria

Ian H de Boer et al. J Am Soc Nephrol. 2014 Oct.

Abstract

Macroalbuminuria, defined as urine albumin excretion rate (AER)≥300 mg/d, has long been considered a stage of irreversible kidney damage that leads reliably to GFR loss. We examined the long-term renal outcomes of persons with type 1 diabetes who developed incident macroalbuminuria during the Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) study. One hundred fifty-nine participants developed incident macroalbuminuria and were subsequently followed for a median duration of 9 years (maximum of 25 years). At the time of macroalbuminuria diagnosis, mean (SD) age was 37 (9) years, mean (SD) duration of diabetes was 17 (5) years, median AER was 524 mg/d, and mean (SD) eGFR was 108 (20) ml/min per 1.73 m(2). Ten years after macroalbuminuria diagnosis, the cumulative incidence of a sustained reduction in AER to <300 mg/d was 52%, mostly but not entirely under treatment with renin-angiotensin system inhibitors. The cumulative incidence of impaired GFR (sustained eGFR<60 ml/min per 1.73 m(2)) 10 years after macroalbuminuria diagnosis was 32%, including 16% who developed ESRD. Lower hemoglobin A1c and BP and regression to AER<300 mg/d were associated with reduced risk of developing impaired GFR. In conclusion, people with type 1 diabetes who develop macroalbuminuria are at high risk of progressive kidney disease. However, through at least 10 years of follow-up, AER could often be controlled, and GFR frequently remained in the normal range.

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Figures

Figure 1.
Figure 1.
Cumulative incidence of macroalbuminuria by treatment assignment in the DCCT/EDIC study by duration of type 1 diabetes. The cumulative incidence of macroalbuminuria, defined as AER≥300 mg/d, is shown according to the group to which participants had been randomly assigned in the DCCT.
Figure 2.
Figure 2.
Distributions of prevalent AER and eGFR by time after onset of incident macroalbuminuria among 159 DCCT/EDIC participants. (A) Prevalence of normoalbuminuria, microalbuminuria, macroalbuminuria, and nephrotic syndrome. (B) Prevalence of impaired GFR. RAS, renin-angiotensin system.
Figure 3.
Figure 3.
Cumulative incidence of low eGFR among individuals with macroalbuminuria in the DCCT/EDIC study evaluated from the time of macroalbuminuria onset. All four GFR outcomes are depicted simultaneously.
Figure 4.
Figure 4.
Cumulative incidence of nephrotic-range albuminuria by treatment assignment in the DCCT/EDIC study by duration of type 1 diabetes. The cumulative incidence of nephrotic-range albuminuria, defined as AER≥3000 mg/d, is shown according to the group to which participants had been randomly assigned in the DCCT.
See this image and copyright information in PMC

Comment in

  • Are post-trial observational studies useful?
    Heerspink HJ, de Zeeuw D. Heerspink HJ, et al. J Am Soc Nephrol. 2014 Oct;25(10):2148-50. doi: 10.1681/ASN.2014040410. Epub 2014 Jun 12. J Am Soc Nephrol. 2014. PMID: 24925718 Free PMC article. No abstract available.

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