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Diabetic Microvascular Disease: The Role of Glycemic Control and the Impact on Public Health Robert E. Ratner, MD MedStar Research Institute Georgetown University Medical School Washington, DC
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Diabetes: The Numbers The National Diabetes Education Program www.ndep.nih.gov A joint program of NIH and CDC December 2006 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.
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Adjusted ESRD incident rates of ESRD due to diabetes lla illi lla illi Incident ESRD patients; adjusted for age, gender, & race. USRDS, accessed July 13, 2007
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Prevalence of Visual Impairment per 100 Adults with Diabetes, by Age, United States, 1997–2003 Source: National Diabetes Surveillance System – CDC website (http://www.cdc.gov/diabetes/statistics/index.htm)
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What Complications do People with Diabetes Get? Ramsey SD. Pharmacoeconomics 3:285, 1999
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Cumulative Incidence of Proliferative Retinopathy: The Pittsburgh EDC Study Pambianco G. Diabetes 55:1463, 2006 Diagnosed between 1965-1969 1970-1974 1975-1980 %
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Cumulative Incidence of Overt Nephropathy: The Pittsburgh EDC Study Pambianco G. Diabetes 55:1463, 2006 Diagnosed between 1965-1969 1970-1974 1975-1980 %
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Cumulative Incidence of Autonomic Neuropathy: The Pittsburgh EDC Study Pambianco G. Diabetes 55:1463, 2006 Diagnosed between 1965-1969 1970-1974 1975-1980 %
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Cumulative Incidence of Peripheral Neuropathy: The Pittsburgh EDC Study % Diagnosed between 1965-1969 1970-1974 1975-1980 Pambianco G. Diabetes 55:1463, 2006
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Cumulative Incidence of Hard End-Points: The Pittsburgh EDC Study Renal Failure Total CAD Pambianco G. Diabetes 55:1463, 2006 % % %
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Metabolic Pathways Leading to Microvascular Complications Brownlee M. Diabetes 54:1615, 2005
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Metabolic Pathways Leading to Microvascular Complications Brownlee M. Diabetes 54:1615, 2005
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Metabolic Pathways Leading to Microvascular Complications Brownlee M. Diabetes 54:1615, 2005
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Prevalence of Retinopathy: The AusDiab Study Tapp RJ. Diabetes Res Clin Pract 73:315, 2006
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Prevalence of Microalbuminuria: The AusDiab Study Tapp RJ. Diabetes Res Clin Pract 73:315, 2006
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DCCT: Relationship between Glycemic Control and Retinopathy Progression Lachin J. Diabetes 57:995, 2008
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DCCT: Microvascular Complications and Glycemic Control Lachin J. Diabetes 57:995, 2008
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Microvascular Endpoints (cumulative) renal failure or death, vitreous haemorrhage or photocoagulation 346 of 3867 patients (9%)
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Aggregate Clinical Endpoints
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Glucose Control Study Summary The intensive glucose control policy maintained a lower HbA 1c 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 p=0.029 25%for microvascular endpoints p=0.0099 21%for retinopathy at twelve years p=0.015 33%for albuminuria at twelve years p=0.000054
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Microvascular Endpoints 0.5 1 10 15 0567891011 37% decrease per 1% decrement in HbA1c p<0.0001 Updated mean HbA 1c Hazard ratio UKPDS 35. BMJ 2000; 321: 405-12
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Steno 2: Long-term Outcomes of Intensive Management Gaede P. NEJM 358:580, 2008
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Steno 2: Long-term Outcomes of Intensive Management Gaede P. NEJM 358:580, 2008
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Steno 2: Long-term Outcomes of Intensive Management Gaede P. NEJM 358:580, 2008
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Steno 2: Long-term Outcomes of Intensive Management Gaede P. NEJM 358:580, 2008
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UKPDS: A1c as Predictor of Micro- and Macrovascular Disease Microvascular Myocardial infarction - 1 2 3 4 5 6 7 8 9 10 56789 11 Updated Mean A1c Est. Hazard Ratio Stratton IM et al. BMJ. 2000; 321:405-412.
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Temporal Changes in Glycemic Control: NHANES Hoerger TJ. Diabetes Care 31:81, 2008
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Age-adjusted Mortality, age 35-74 years NHANES Gregg EW. Ann Int Med 147:149, 2007
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Age-adjusted Mortality, age 35-74 years NHANES Gregg EW. Ann Int Med 147:149, 2007
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VADT: Correlation of Retinopathy with Coronary Calcium Scores Reaven P. Diabetes Care 31:952, 2008
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