Cumulative Kidney Complication Risk by 50 Years of Type 1 Diabetes: The Effects of Sex, Age, and Calendar Year at Onset

Abstract

Objective: A common belief is that only a minority of patients with type 1 diabetes (T1D) develop advanced kidney disease and that incidence is higher among men and lower in those diagnosed at a younger age. However, because few patients with T1D survived to older ages until recently, long-term risks have been unclear.

Research design and methods: We examined the 50-year cumulative kidney complication risk in a childhood-onset T1D cohort diagnosed during 1950-80 (n = 932; mean baseline age 29 years, duration 19 years). Participants comprised 144 who died prior to baseline, 130 followed with periodic surveys, and 658 followed with biennial surveys and a maximum of nine examinations for 25 years. Micro- and macroalbuminuria were defined as an albumin excretion rate of 20-199 and ≥200 μg/min, respectively, and end-stage renal disease (ESRD) was defined as dialysis or kidney transplantation. Cumulative incidence was estimated at 10-year intervals between 20 and 50 years^, duration and compared by calendar year of diabetes onset.

Results: By 50 years^, T1D duration, ESRD affected 60% of the cohort; macroalbuminuria, 72%; and microalbuminuria, 88%. Little evidence existed for declines in cumulative incidence in recent cohorts, except for ESRD (microalbuminuria 3% increase, macroalbuminuria no change; ESRD 45% decrease by 40 years of T1D duration). Onset before age 6 years was associated with the lowest risk; incidence generally did not differ by sex.

Conclusions: Some degree of kidney disease in T1D is virtually universal at long durations and not declining, which has major implications for formulating health care and research strategies. ESRD has declined, but continues to affect >25% of the population by 40 years^, duration.

Figure 1

Cumulative incidence of kidney complications by duration of T1D, age at onset (AON), diagnosis cohort, and sex. A: Cumulative incidence of microalbuminuria (A), macroalbuminuria (B), ESRD (C), and ESRD/mortality (D) by AON and duration of T1D. Cumulative incidence of microalbuminuria (E), macroalbuminuria (F), ESRD (G), and ESRD/mortality (H) by sex and diagnosis cohort at 30 and 40 years of T1D duration. yrs, years.

Figure 1

Cumulative incidence of kidney complications by duration of T1D, age at onset (AON), diagnosis cohort, and sex. A: Cumulative incidence of microalbuminuria (A), macroalbuminuria (B), ESRD (C), and ESRD/mortality (D) by AON and duration of T1D. Cumulative incidence of microalbuminuria (E), macroalbuminuria (F), ESRD (G), and ESRD/mortality (H) by sex and diagnosis cohort at 30 and 40 years of T1D duration. yrs, years.