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Diabetic Microvascular Disease: The Role of Glycemic Control and the Impact on Public Health

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Title: Diabetic Microvascular Disease: The Role of Glycemic Control and the Impact on Public Health


1
Diabetic Microvascular DiseaseThe Role of
Glycemic Control and the Impact on Public Health
  • Robert E. Ratner, MD
  • MedStar Research Institute
  • Georgetown University Medical School
  • Washington, DC

2
EVERY 24 HOURS
  • New Cases 4,100
  • Amputations 230 (60 of non-traumatic
    amputations annually)
  • Blindness 55 (1 cause)
  • Kidney Failure 120 (1 cause)

Derived from NIDDK, National Diabetes Statistics
fact sheet. HHS, NIH, 2005.
3
Adjusted ESRD incident rates of ESRD due to
diabetes
illi
illi
lla
lla
Incident ESRD patients adjusted for age, gender,
race.
USRDS, accessed July 13, 2007
4
Prevalence of Visual Impairment per 100 Adults
with Diabetes, by Age, United States, 19972003
Source National Diabetes Surveillance System
CDC website (http//www.cdc.gov/diabetes/statistic
s/index.htm)
5
What Complications do People with Diabetes Get?
Ramsey SD. Pharmacoeconomics 3285, 1999
6
Cumulative Incidence of Proliferative
Retinopathy The Pittsburgh EDC Study

Diagnosed between 1965-1969 1970-1974
1975-1980
Pambianco G. Diabetes 551463, 2006
7
Cumulative Incidence of Overt Nephropathy The
Pittsburgh EDC Study

Diagnosed between 1965-1969 1970-1974
1975-1980
Pambianco G. Diabetes 551463, 2006
8
Cumulative Incidence of Autonomic Neuropathy The
Pittsburgh EDC Study

Diagnosed between 1965-1969 1970-1974
1975-1980
Pambianco G. Diabetes 551463, 2006
9
Cumulative Incidence of Peripheral Neuropathy
The Pittsburgh EDC Study

Diagnosed between 1965-1969 1970-1974
1975-1980
Pambianco G. Diabetes 551463, 2006
10
Cumulative Incidence of Hard End-Points The
Pittsburgh EDC Study
Total CAD
Renal Failure



Pambianco G. Diabetes 551463, 2006
11
Metabolic Pathways Leading to Microvascular
Complications
Brownlee M. Diabetes 541615, 2005
12
Metabolic Pathways Leading to Microvascular
Complications
Brownlee M. Diabetes 541615, 2005
13
Metabolic Pathways Leading to Microvascular
Complications
Brownlee M. Diabetes 541615, 2005
14
Prevalence of RetinopathyThe AusDiab Study
Tapp RJ. Diabetes Res Clin Pract 73315, 2006
15
Prevalence of MicroalbuminuriaThe AusDiab Study
Tapp RJ. Diabetes Res Clin Pract 73315, 2006
16
DCCT Relationship between Glycemic Control and
Retinopathy Progression
Lachin J. Diabetes 57995, 2008
17
DCCT Microvascular Complications and Glycemic
Control
Lachin J. Diabetes 57995, 2008
18
Microvascular Endpoints (cumulative)
renal failure or death, vitreous haemorrhage or
photocoagulation 346 of 3867 patients (9)
19
Aggregate Clinical Endpoints
20
Glucose Control Study Summary
The intensive glucose control policy maintained a
lower HbA1c by mean 0.9 over a median follow
up of 10 years from diagnosis of type 2 diabetes
with reduction in risk of 12 for any diabetes
related endpoint p0.029 25 for microvascular
endpoints p0.0099 21 for retinopathy at twelve
years p0.015 33 for albuminuria at twelve
years p0.000054
21
Microvascular Endpoints
22
Steno 2 Long-term Outcomes of Intensive
Management
Gaede P. NEJM 358580, 2008
23
Steno 2 Long-term Outcomes of Intensive
Management
Gaede P. NEJM 358580, 2008
24
Steno 2 Long-term Outcomes of Intensive
Management
Gaede P. NEJM 358580, 2008
25
Steno 2 Long-term Outcomes of Intensive
Management
Gaede P. NEJM 358580, 2008
26
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32
UKPDS A1c as Predictor of Micro- and
Macrovascular Disease
10
9
Microvascular
8
7
6
Est. Hazard Ratio
5
4
3
Myocardial infarction
2
1
-
5
6
7
8
9
10
11
Updated Mean A1c
Stratton IM et al. BMJ. 2000 321405-412.
33
Temporal Changes in Glycemic Control NHANES
Hoerger TJ. Diabetes Care 3181, 2008
34
Age-adjusted Mortality, age 35-74 yearsNHANES
Gregg EW. Ann Int Med 147149, 2007
35
Age-adjusted Mortality, age 35-74 yearsNHANES
Gregg EW. Ann Int Med 147149, 2007
36
VADT Correlation of Retinopathy with Coronary
Calcium Scores
Reaven P. Diabetes Care 31952, 2008
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