In the JournalsPerspective

Type 1 vs. type 2 diabetes accelerates kidney disease degeneration

South Korean adults with chronic kidney disease are more likely to progress to end-stage renal disease if they have type 1 diabetes vs. type 2 diabetes, and the presence of metabolic syndrome further increases the odds, according to findings published in Diabetes/Metabolism Research and Reviews.

“Despite advances in care for [type 1 diabetes] patients with impaired kidney function — including tools for glycemic control, blood pressure management and the renin-angiotensin system blockers — the incidence of ESRD caused by [type 1 diabetes] has not decreased during the past 20 years in the United States,” Jae Hyeon Kim, MD, PhD, a clinical assistant professor in the department of endocrinology and metabolism at the Samsung Medical Center of Sungkyunkwan University School of Medicine in Seoul, South Korea, and colleagues wrote. “However, information on ESRD risk for [type 1 diabetes] patients in Korea is limited.”

Kim and colleagues examined the potential progression to ESRD in 2,429,485 adults with an estimated glomerular filtration rate of less than 60 mL/min/1.73 m2 who underwent biannual medical examinations between 2009 and 2016. Data were pulled from the Korean National Health Insurance Service, and ESRD diagnoses were confirmed in medical claims records during an average follow-up of 4.4 years. Among the total cohort, 1,945,433 participants did not have diabetes (mean age, 57.29 years; 57.96% women), 480,543 had type 2 diabetes (mean age, 66.28 years; 53.79% women) and 3,508 had type 1 diabetes (mean age, 64.82 years; 51.57% women).

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South Korean adults with chronic kidney disease are more likely to progress to end-stage renal disease if they have type 1 diabetes vs. type 2 diabetes.
Adobe Stock

The researchers reported that 43,693 individuals presented with ESRD during follow-up. A higher percentage of those with type 1 diabetes had the ESRD (11.35%) vs. those with type 2 diabetes (4.53%) and those without diabetes (1.11%; P < .0001 for all), according to the researchers, who added that those with type 1 diabetes also had a higher incidence rate (2,928.14 per 100,000 person-years) compared with those with type 2 diabetes (1,126.12 per 100,000 person-years) and those without the disease (245.67 per 100,000 person-years). In fact, those with type 1 diabetes were more than nine times as likely to progress to ESRD than those without diabetes (OR = 9.267; 95% CI, 8.378-10.251) while the odds were more than doubled vs. those with type 2 diabetes (OR = 2.58; 95% CI, 2.336-2.849) based on fully adjusted models, which included eGFR and cardiovascular complications such as stroke and atrial fibrillation among the considerations. This model also illustrated that ESRD was more than three times as likely to be present for an individual with type 2 diabetes compared with someone without any form of diabetes (OR = 3.642; 95% CI, 3.558-3.728).

When including metabolic syndrome into the analysis, participants with type 1 diabetes who had the syndrome were twice as likely to be diagnosed with ESRD compared with those who did not have metabolic syndrome (OR = 2.023; 95% CI, 1.501-2.727), the researchers wrote. – by Phil Neuffer

Disclosures: The authors report no relevant financial disclosures. 

South Korean adults with chronic kidney disease are more likely to progress to end-stage renal disease if they have type 1 diabetes vs. type 2 diabetes, and the presence of metabolic syndrome further increases the odds, according to findings published in Diabetes/Metabolism Research and Reviews.

“Despite advances in care for [type 1 diabetes] patients with impaired kidney function — including tools for glycemic control, blood pressure management and the renin-angiotensin system blockers — the incidence of ESRD caused by [type 1 diabetes] has not decreased during the past 20 years in the United States,” Jae Hyeon Kim, MD, PhD, a clinical assistant professor in the department of endocrinology and metabolism at the Samsung Medical Center of Sungkyunkwan University School of Medicine in Seoul, South Korea, and colleagues wrote. “However, information on ESRD risk for [type 1 diabetes] patients in Korea is limited.”

Kim and colleagues examined the potential progression to ESRD in 2,429,485 adults with an estimated glomerular filtration rate of less than 60 mL/min/1.73 m2 who underwent biannual medical examinations between 2009 and 2016. Data were pulled from the Korean National Health Insurance Service, and ESRD diagnoses were confirmed in medical claims records during an average follow-up of 4.4 years. Among the total cohort, 1,945,433 participants did not have diabetes (mean age, 57.29 years; 57.96% women), 480,543 had type 2 diabetes (mean age, 66.28 years; 53.79% women) and 3,508 had type 1 diabetes (mean age, 64.82 years; 51.57% women).

#
South Korean adults with chronic kidney disease are more likely to progress to end-stage renal disease if they have type 1 diabetes vs. type 2 diabetes.
Adobe Stock

The researchers reported that 43,693 individuals presented with ESRD during follow-up. A higher percentage of those with type 1 diabetes had the ESRD (11.35%) vs. those with type 2 diabetes (4.53%) and those without diabetes (1.11%; P < .0001 for all), according to the researchers, who added that those with type 1 diabetes also had a higher incidence rate (2,928.14 per 100,000 person-years) compared with those with type 2 diabetes (1,126.12 per 100,000 person-years) and those without the disease (245.67 per 100,000 person-years). In fact, those with type 1 diabetes were more than nine times as likely to progress to ESRD than those without diabetes (OR = 9.267; 95% CI, 8.378-10.251) while the odds were more than doubled vs. those with type 2 diabetes (OR = 2.58; 95% CI, 2.336-2.849) based on fully adjusted models, which included eGFR and cardiovascular complications such as stroke and atrial fibrillation among the considerations. This model also illustrated that ESRD was more than three times as likely to be present for an individual with type 2 diabetes compared with someone without any form of diabetes (OR = 3.642; 95% CI, 3.558-3.728).

When including metabolic syndrome into the analysis, participants with type 1 diabetes who had the syndrome were twice as likely to be diagnosed with ESRD compared with those who did not have metabolic syndrome (OR = 2.023; 95% CI, 1.501-2.727), the researchers wrote. – by Phil Neuffer

Disclosures: The authors report no relevant financial disclosures. 

    Perspective
    George Bakris

    George Bakris

    Using data from the Korean National Health Insurance Service datasets from 2009 to 2016, investigators found a 2.58 times higher incidence of end-stage renal disease from chronic kidney disease among those with type 1 diabetes and a 9.2 times higher incidence compared with the type 2 diabetes and non-diabetes groups, respectively. In CKD patients with type 1 diabetes, the presence of metabolic syndrome increased the incidence of ESRD risk by an additional 2.02 times. The authors noted that patients with type 1 diabetes have a higher risk for ESRD incidence from CKD than do patients with type 2 diabetes in a Korean population and that metabolic syndrome may be a useful predictor for ESRD in CKD patients with type 1 diabetes.

    This study has some interesting findings that are very different from some relatively recent epidemiologic studies from the rest of the world, including Japan (Otani T, et al. BMJ Open Diabetes Res Care. 2016;doi:10.1136/bmjdrc-2015-000177). An editorial review of all large epidemiologic studies of CKD progression over the past 50 years showed a 40% reduction in the chance of CKD progression in type 1 diabetes if born after 1980 (Bakris G, et al. Diabetes Care. 2018;doi:10.2337/dci17-0047). It is well known that poor glycemic control is a key factor among those with type 1 diabetes associated with CKD progression, especially if a family history of CKD is present. A review of the Korean data clearly shows the worst glucose control among those with type 1 diabetes. There are no family history data. What is relatively novel in the type 1 diabetes group is the presence of metabolic syndrome contributing to increased risk, a variable clearly shown in type 2 diabetes for CKD progression. Given our current knowledge of type 1 diabetes, I think this study clearly indicates that if glycemic control is not maintained throughout life, risk of CKD is high.

    • George Bakris, MD
    • Professor of Medicine
      Director, AHA Comprehensive Hypertension Center
      The University of Chicago Medicine

    Disclosures: Bakris reports he serves on the planning committee for CMHC West and receives institutional research grants for involvement in trials of multiple newer diabetes drugs.