RELATIVE RISK HbA 1c Relative Risk of Progression of Diabetic Complications by Mean HbA1c Based on DCCT Data
Intensive Therapy for Diabetes: Reduction in Incidence of Complications *Not statistically significant due to small number of events. † Showed statistical significance in subsequent epidemiologic analysis. DCCT Research Group. N Engl J Med . 1993;329:977-986; Ohkubo Y, et al. Diabetes Res Clin Pract . 1995;28:103-117; UKPDS 33: Lancet. 1998;352: 837-853; Stratton IM, et al. Brit Med J . 2000;321:405-412. T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus. 16%* 52* 41%* Cardiovascular disease – 58% 60% Neuropathy 24% – 33% 70% 54% Nephropathy 17% – 21% 69% 63% Retinopathy 8% 7% 9% 7% 9% 7% A1C T2DM UKPDS T2DM Kumamoto T1DM DCCT
Recommendations For Treatment Of Retinopathy
Annual screening should be done when the child is ≥ 10 years old and has diabetes for 3-5 years
Is this early enough for a child with poorly controlled diabetes for longer than 3-5 years?
Recommendations For Microalbuminuria Testing
Annual screening for urinary albumin should begin when
Child is ≥ 10 yrs old
DM of 5 years duration
If urine albumin: creat ratio on spot urine is abnormal (30-299 mg/gm creatinine)
Confirm with 2 additional urine specimens
Obtain up: down urine specimen to rule out orthostatic proteinuria
Recommendations For Microalbuminuria Treatment
ACE Inhibitors may reverse microalbuminuria or delay rate of progression to macro-albuminuria
Treat BP aggressively
Should these children all be referred to a nephrologist for evaluation and treatment?
Should children with poorly controlled DM be evaluated sooner?
Should children with HTN be evaluated sooner?
Repeat with child sitting and relaxed on 2 more occasions
HTN defined as BP≥ 95% for age, sex and height measured on at least 3 separate days
High normal BP is ≥ 90% but < 95%
Rule out non-diabetes causes
BP: When to Treat
High normal BP
Diet (limit salt) and exercise for 3-6 months
If still high normal, treat with ACE inhibitor
Consider adding ARBs if 90% on maximal doses
Treat with ACEI to achieve BP< 90%
At what age to treat?
At what level to treat?
Children with diabetes have increased muscle thickness & stiffness
Carotid artery intima media thickness is significantly increased in youth with diabetes compared to controls matched for age and gender
-correlated with LDL-C levels
Brachial artery reactivity is decreased in children with diabetes compared to matched controls
Radial artery tonometry -> stiffer vessels in children with diabetes compared to BMI, age, sex matched controls
Cardiovascular Disease Risk Factors in Adolescents with Type 1 Diabetes Mellitus M.V. Karantza, S. Bababeygy, H.N. Hodis, W.J. Mack, C.-R. Liu, C.-H. Liu, and F.R. Kaufman Division of Endocrinology, Diabetes, and Metabolism, Childrens Hospital Los Angeles Supported by ADA Clinical Research Award 1-01-CR-06
Background Atherosclerosis is a Major Cause of Morbidity and Mortality in Patients with T1DM