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Mechanisms of Diabetic Complications: The Glucose Hypothesis |

Relation of Glycemic Control to Diabetic Microvascular Complications in Diabetes Mellitus

Ronald Klein, MPH, MD; Barbara E. K. Klein, MPH, MD; and Scot E. Moss, MA
[+] Article and Author Information

From the University of Wisconsin Medical School, Madison, Wisconsin. Note: This article is one of a series of articles comprising an Annals of Internal Medicine supplement entitled “Risks and Benefits of Intensive Management in Non-Insulin-dependent Diabetes Mellitus: The Fifth Regenstrief Conference.” To view a complete list of the articles included in this supplement, please view its Table of Contents. Acknowledgments: The authors thank their collaborators, Karen Cruickshanks, PhD; Matthew D. Davis, MD; and Polly Newcomb, PhD, who provided scientific advice; the 452 Wisconsin physicians and their staffs who participated in and supported this study; and Terry Spennetta and Earl Shrago, MD, who provided laboratory support (P30 AM AG 26659, Public Health Service, National Institutes of Health, Bethesda, Maryland). Grant Support: By National Institutes of Health grant EYO-3083 (R Klein, BEK Klein) and, in part, by Research to Prevent Blindness (Dr. Klein, Senior Scientific Investigator Award). Requests for Reprints: Ronald Klein, MD, MPH, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, 610 North Walnut Street, 460 WARF, Madison, WI 53705-2397. Current Author Addresses: Drs. Klein. Klein, and Moss: Department of Ophthalmology and Visual Sciences. University of Wisconsin-Madison, 610 North Walnut Street, 460 WARF, Madison, WI 53705-2397.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1996;124(1_Part_2):90-96. doi:10.7326/0003-4819-124-1_Part_2-199601011-00003
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Objective: To describe the relation between glycated hemoglobin and the incidence or progression, or both, of diabetic microvascular complications in persons with insulin-dependent (IDDM) and non–insulin-dependent diabetes mellitus (NIDDM).

Design: Population-based cohort study.

Setting: An 11-county area in southern Wisconsin.

Patients: All persons with IDDM diagnosed before age 30 and taking insulin (n = 996) and a probability sample (based on duration of disease) of persons diagnosed with diabetes at age 30 or older who were either taking insulin (n = 674) or not taking insulin (n = 696) and who participated in a baseline examination from 1980 to 1982. Survivors of the cohort were re-examined again in 1984 to 1986 and 1990 to 1992.

Measurements: The incidence and progression of diabetic retinopathy was determined by masked grading of stereoscopic color fundus photographs using the modified Early Treatment Diabetic Retinopathy Study severity scale. Gross proteinuria was determined using a dipstick. Ten-year incidence of renal dialysis or transplantation or loss of tactile sensation or of temperature sensitivity was based on self-reported history.

Results: The glycated hemoglobin level at baseline was strongly related to the incidence or progression, or both, of diabetic retinopathy, the incidence of gross proteinuria, and the incidence of loss of tactile sensation or temperature sensitivity in persons with either IDDM or NIDDM.

Conclusions: These prospective epidemiologic data suggest that glycemic control is similarly related to the incidence and progression of diabetic microvascular complications in both IDDM and NIDDM. However, further evidence from clinical trials in persons with NIDDM is necessary to assess the risks and benefits of such treatment in preventing these complications.

Figures

Grahic Jump Location
Figure 1.
The relation of incidence (top), progression (center), and progression to proliferative retinopathy (bottom) in persons with younger-onset diabetes, persons with older-onset diabetes taking insulin, and persons with older-onset diabetes not taking insulin over a 10-year period to glycated hemoglobin levels by quartile for the whole population at baseline.P

Values of glycated hemoglobin for each quartile from left to right are 5.4% to 8.5%, 8.6% to 10.0%, 10.1% to 11.5%, and 11.6% to 20.8%. values are based on the Mantel-Haenszel test of trend. PDR equals proliferative diabetic retinopathy (Reproduced from reference 32 with permission of the authors and the American Medical Association.).

Grahic Jump Location
Grahic Jump Location
Figure 2.
The 10-year incidence of macular edema by quartile of glycated hemoglobin level at baseline in three groups: the younger-onset group taking insulin, the older-onset group taking insulin, and the older-onset group not taking insulin in the Wisconsin Epidemiologic Study of Diabetic Retinopathy.

Values of glycated hemoglobin for each quartile from left to right are 5.4% to 8.5%, 8.6% to 10.0%, 10.1% to 11.5%, and 11.6% to 20.8%.

Grahic Jump Location
Grahic Jump Location
Figure 3.
The 10-year incidence of gross proteinuria (top) and renal failure (bottom) by quartile of glycated hemoglobin at baseline in three groups: the younger-onset group taking insulin, the older-onset group taking insulin, and the older-onset group not taking insulin in the Wisconsin Epidemiologic Study of Diabetic Retinopathy.

Values of glycated hemoglobin for each quartile from left to right are 5.4% to 8.5%, 8.6% to 10.0%, 10.1% to 11.5%, and 11.6% to 20.8%.

Grahic Jump Location
Grahic Jump Location
Figure 4.
The 10-year incidence of self-reported history of loss of tactile sensation (top) and loss of temperature sensitivity (bottom) by quartile of glycated hemoglobin at baseline in three groups: the younger-onset group taking insulin, the older-onset group taking insulin, and the older-onset group not taking insulin in the Wisconsin Epidemiologic Study of Diabetic Retinopathy.

Values of glycated hemoglobin for each quartile from left to right are 5.4% to 8.5%, 8.6% to 10.0%, 10.1% to 11.5%, and 11.6% to 20.8%.

Grahic Jump Location

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