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End stage renal disease in type 1 diabetes: time trends and risk factors
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Paediatrics. (Swedish Childhood Diabetes Study)
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background and aims: Sweden has a high incidence of type 1 diabetes (T1D) and the incidence is increasing worldwide. The incidence is now twice as high as when the registration of childhood onset T1D in Sweden started in 1977. One of the major risk factors for developing late complications such as renal failure (ESRD) is duration of T1D. With a disease onset early in life this could lead to young patients with serious complications. It is therefore of interest to follow these patients to see how the risk for complications develops over time. In the first study, time trends in onset of ESRD due to diabetes (type 1 and 2) and other causes of kidney failure were studied as well as the age at onset of ESRD. To follow up on this, the aim of the second study was to look at cumulative incidence in ESRD and analyse possible time trends and gender differences in a younger diabetes population with known T1D duration. An earlier study had shown a low incidence of ESRD and now 8 more years of follow up could be added. Besides genetics, metabolic control is a factor with strong impact on the future risk of complications. The social environment of the child and adolescent with diabetes influence the understanding and management of the disease and hence the blood glucose control. Social vulnerability and/or low education imposes even more stress on the individual which could negatively influence disease management. The aim of the third study was therefore to study the impact of socio-economic status (SES) on the risk of developing ESRD in the young diabetes population. The aim of the fourth study was to analyse time trends in the treatment choices once the patients develop ESRD, the survival and cause of death in treatment and how it has developed over time.

Study population: In all studies, data from the Swedish Renal Register (SRR) were used. The data on the T1D patients with onset before the age of 15, used in studies II-IV, came from the Swedish Childhood Diabetes Register (SCDR).  In study II we also retrieved data from the Swedish National Diabetes Register (NDR) and the Diabetes Incidence Study in Sweden (DISS). All registers have national coverage. The diabetes registers were linked to the SRR to find the patients who had developed ESRD. In study III we used the linkage between the SCDR, the SRR and Longitudinal integration database for health insurance and labour market studies (LISA).

Results: Even though the incidence of ESRD in Sweden remained stable, the incidence of ESRD due to T1D decreased over the studied years, 1991-2010. We did not see a concurrent change for T2D. The age when the T1D patients developed ESRD had increased by 3 years and this was not seen in patients with other causes of ESRD. For patients in the SCDR the increase in age was almost 6 years. The cumulative incidence of ERSD in Sweden due to T1D is still low, 5.6% at a maximum follow up of 38 years (median 23). The incidence of ESRD is decreasing when comparing onset of T1D in the 1970´s and 80´s to onset in the 90´s, even when adjusting for T1D duration. Once they had developed ESRD, the survival in renal replacement therapy (RRT) had also improved over the years. The longest survival was seen after receiving a kidney transplant which about 50% of the patients do.

When analysing social risk factors for development of ESRD we found that the educational level of both parents, but especially the mothers, affected the child’s risk of developing ESRD. The strongest association of education however was seen in the T1D patients own education. There was also an increased risk of developing ESRD if any or both of the parents had received income support.

Conclusion: The incidence of ESRD due to T1D is decreasing in Sweden and the age at onset of ESRD has increased by at least 3 years. There was a significant decrease in development of ESRD over time. The patients have a longer survival once in RRT today and many of them are transplanted, further improving their survival. Growing up in families with a lower SES increases the risk of later developing ESRD, a finding worthy of recognition in the clinical setting.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2018. , p. 59
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1996
Keywords [en]
End stage renal disease, renal replacement therapy, type 1 diabetes, diabetes nephropathy, socioeconomy and epidemiology
National Category
Pediatrics
Research subject
Epidemiology; Pediatrics
Identifiers
URN: urn:nbn:se:umu:diva-153161ISBN: 978-91-7601-967-2 (print)OAI: oai:DiVA.org:umu-153161DiVA, id: diva2:1261563
Public defence
2018-11-30, Betula, målpunkt L, by 6M, plan 0, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2018-11-09 Created: 2018-11-07 Last updated: 2018-11-09Bibliographically approved
List of papers
1. Renal replacement therapy due to type 1 diabetes; time trends during 1995-2010: a Swedish population based register study
Open this publication in new window or tab >>Renal replacement therapy due to type 1 diabetes; time trends during 1995-2010: a Swedish population based register study
Show others...
2014 (English)In: Journal of diabetes and its complications, ISSN 1056-8727, E-ISSN 1873-460X, Vol. 28, no 2, p. 152-155Article in journal (Refereed) Published
Abstract [en]

Background: End stage renal disease (ESRD), is the most severe complication of diabetes mellitus. This population-based study analysed time trends for start of renal replacement therapy (RRT) due to type 1 diabetes compared to type 2 diabetes and other diagnoses. Material and Methods: We used data on patients who were registered 1995-2010 in the Swedish Renal Registry, a nationwide register covering 95 % of all patients with uraemia. The patients were analysed according to their original kidney disease. The incidence was analysed by calendar year, age at start of RRT and gender. Results: Of 17389 patients who were registered, 1833 had type 1 diabetes; 65% were men. The mean age at onset of RRT for patients with type 1 diabetes was 52.8 years which increased by more than 3 years over the studied period. The number of patients in need of RRT due to type 1 diabetes decreased, while RRT due to type 2 diabetes increased during the period studied. Conclusions: The overall incidence of RRT in Sweden is rather constant over the years but the need for RRT in type 1 diabetes patients decreased and patients with type 1 diabetes tend to become older at onset of RRT. 

Keywords
Diabetes mellitus, Incidence, Nephropathy, Renal replacement therapy
National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:umu:diva-88411 (URN)10.1016/j.jdiacomp.2013.10.007 (DOI)000333542900010 ()
Available from: 2014-05-07 Created: 2014-05-05 Last updated: 2018-11-07Bibliographically approved
2. Decreasing Cumulative Incidence of End-Stage Renal Disease in Young Patients With Type 1 Diabetes in Sweden: a 38-Year Prospective Nationwide Study
Open this publication in new window or tab >>Decreasing Cumulative Incidence of End-Stage Renal Disease in Young Patients With Type 1 Diabetes in Sweden: a 38-Year Prospective Nationwide Study
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2019 (English)In: Diabetes Care, ISSN 0149-5992, E-ISSN 1935-5548, Vol. 42, no 1, p. 27-31Article in journal (Refereed) Published
Abstract [en]

Objective: Diabetic nephropathy is a serious complication of type 1 diabetes. Recent studies indicate that end-stage renal disease (ESRD) incidence has decreased or that the onset of ESRD has been postponed; therefore, we wanted to analyze the incidence and time trends of ESRD in Sweden.

Research design and methods: In this study, patients with duration of type 1 diabetes >14 years and age at onset of diabetes 0–34 years were included. Three national diabetes registers were used: the Swedish Childhood Diabetes Register, the Diabetes Incidence Study in Sweden, and the National Diabetes Register. The Swedish Renal Registry, a national register on renal replacement therapy, was used to identify patients who developed ESRD.

Results: We found that the cumulative incidence of ESRD in Sweden was low after up to 38 years of diabetes duration (5.6%). The incidence of ESRD was lower in patients with type 1 diabetes onset in 1991–2001 compared to onset in 1977–1984 and 1985–1990, independently of diabetes duration.

Conclusion: The risk of developing ESRD in Sweden in this population is still low and also seems to decrease with time.

Place, publisher, year, edition, pages
American Diabetes Association, 2019
National Category
Pediatrics Urology and Nephrology
Identifiers
urn:nbn:se:umu:diva-153168 (URN)10.2337/dc18-1276 (DOI)000453904900014 ()30352897 (PubMedID)
Funder
Swedish Research Council, 0753Västerbotten County Council
Available from: 2018-11-08 Created: 2018-11-08 Last updated: 2019-01-10Bibliographically approved
3. Socio-economic factors influencing the development of end-stage renal disease in people with Type 1 diabetes: a longitudinal population study
Open this publication in new window or tab >>Socio-economic factors influencing the development of end-stage renal disease in people with Type 1 diabetes: a longitudinal population study
2017 (English)In: Diabetic Medicine, ISSN 0742-3071, E-ISSN 1464-5491, Vol. 34, no 5, p. 676-682Article in journal (Refereed) Published
Abstract [en]

Aims: The development of end-stage renal disease (ESRD) in Type 1 diabetes is multifactorial. Familial socio-economic factors may influence adherence to and understanding of diabetes treatment, and also general health behaviour. We investigate how parental and personal education level and exposure to low economic status, indicated by the need for income support, influence the development of ERSD caused by Type 1 diabetes.

Methods: Participants were retrieved from the nationwide Swedish Childhood Diabetes Registry, which was linked to the Swedish Renal Registry, to find people with ESRD caused by Type 1 diabetes, and to Statistic Sweden to retrieve longitudinal socio-economic data on participants and their parents. Data were analysed using Cox regression modelling.

Results: Of 9287 people with diabetes of duration longer than 14 years, 154 had developed ESRD due to diabetes. Median diabetes duration (range) for all participants was 24.2 years (14.0-36.7 years). Low maternal education ( 12 years) more than doubled the risk of developing ESRD, hazard ration (HR) = 2.9 [95% confidence interval (95% CI): 1.7-4.8]. For people with a low personal level of education HR was 5.7 (3.4-9.5). In an adjusted model, the person's own education level had the highest impact on the risk of ESRD. If at least one of the parents had ever received income support the HR was 2.6 (1.9-3.6).

Conclusions: Socio-economic factors, both for the parents and the person with diabetes, have a strong influence on the development of ESRD in Type 1 diabetes. It is important for caregivers to give enough support to more vulnerable people and their families.

National Category
Pediatrics
Identifiers
urn:nbn:se:umu:diva-134699 (URN)10.1111/dme.13289 (DOI)000399672200012 ()27862276 (PubMedID)
Available from: 2017-06-30 Created: 2017-06-30 Last updated: 2018-11-08Bibliographically approved
4. Improved survival in Renal Replacement Therapy for type 1 diabetes patients in Sweden: a national register study
Open this publication in new window or tab >>Improved survival in Renal Replacement Therapy for type 1 diabetes patients in Sweden: a national register study
(English)Manuscript (preprint) (Other academic)
National Category
Pediatrics
Identifiers
urn:nbn:se:umu:diva-153172 (URN)
Available from: 2018-11-08 Created: 2018-11-08 Last updated: 2018-11-08

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