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      Incident cardiovascular-kidney disease, diabetic ketoacidosis, hypoglycaemia and mortality in adult-onset type 1 diabetes: a population-based retrospective cohort study in Hong Kong

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          Summary

          Background

          Type 1 diabetes can occur at any age. The majority of literature on type 1 diabetes were reported in children whereas adult-onset type 1 diabetes is less well characterised. This study aims to compare the risk of diabetes-related complications and mortality in Chinese with adult-onset type 1 diabetes versus those with youth-onset type 1 diabetes and adult-onset type 2 diabetes.

          Methods

          Between 2000 and 2018, 2738 people with type 1 and 499,288 with type 2 diabetes underwent metabolic and complication assessment in Hong Kong Hospital Authority. They were followed for incident diabetic ketoacidosis (DKA), severe hypoglycaemia, end-stage kidney disease (ESKD), cardiovascular disease (CVD) and all-cause mortality until 2019.

          Findings

          In multivariable Cox regression adjusted for sex, diabetes duration and calendar year, people with type 1 diabetes diagnosed aged ≥40 years had a lower hazard of DKA (hazard ratio HR [95% CI] 0.47 [0.32–0.70]) but higher hazards of severe hypoglycaemia (HR 1.37 [1.13–1.67]), ESKD (HR 4.62 [2.90–7.37]), CVD (HR 11.44 [6.92–18.91]) and mortality (HR 16.22 [11.43–23.02]) versus those diagnosed aged <20 years. Compared with peers with type 2 diabetes presenting at comparable age, people with type 1 diabetes diagnosed aged ≥40 years had higher age-, sex- and diabetes duration-adjusted hazards of DKA (HR 19.87 [13.95–28.31]), severe hypoglycaemia (HR 3.26 [2.81–3.80]), ESKD (HR 1.58 [1.20–2.09]) and mortality (HR 2.26 [1.96–2.60]), and a similar hazard of CVD (HR 1.11 [0.87–1.43]). These associations remained constant after adjustment for metabolic indices.

          Interpretation

          People with type 1 diabetes diagnosed in late adulthood had elevated risks of a broad range of complications and mortality compared with people with youth-onset type 1 diabetes and people with type 2 diabetes presenting at same age bands.

          Funding

          This study did not receive any specific funding.

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          Most cited references42

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          A new equation to estimate glomerular filtration rate.

          Equations to estimate glomerular filtration rate (GFR) are routinely used to assess kidney function. Current equations have limited precision and systematically underestimate measured GFR at higher values. To develop a new estimating equation for GFR: the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Cross-sectional analysis with separate pooled data sets for equation development and validation and a representative sample of the U.S. population for prevalence estimates. Research studies and clinical populations ("studies") with measured GFR and NHANES (National Health and Nutrition Examination Survey), 1999 to 2006. 8254 participants in 10 studies (equation development data set) and 3896 participants in 16 studies (validation data set). Prevalence estimates were based on 16,032 participants in NHANES. GFR, measured as the clearance of exogenous filtration markers (iothalamate in the development data set; iothalamate and other markers in the validation data set), and linear regression to estimate the logarithm of measured GFR from standardized creatinine levels, sex, race, and age. In the validation data set, the CKD-EPI equation performed better than the Modification of Diet in Renal Disease Study equation, especially at higher GFR (P < 0.001 for all subsequent comparisons), with less bias (median difference between measured and estimated GFR, 2.5 vs. 5.5 mL/min per 1.73 m(2)), improved precision (interquartile range [IQR] of the differences, 16.6 vs. 18.3 mL/min per 1.73 m(2)), and greater accuracy (percentage of estimated GFR within 30% of measured GFR, 84.1% vs. 80.6%). In NHANES, the median estimated GFR was 94.5 mL/min per 1.73 m(2) (IQR, 79.7 to 108.1) vs. 85.0 (IQR, 72.9 to 98.5) mL/min per 1.73 m(2), and the prevalence of chronic kidney disease was 11.5% (95% CI, 10.6% to 12.4%) versus 13.1% (CI, 12.1% to 14.0%). The sample contained a limited number of elderly people and racial and ethnic minorities with measured GFR. The CKD-EPI creatinine equation is more accurate than the Modification of Diet in Renal Disease Study equation and could replace it for routine clinical use. National Institute of Diabetes and Digestive and Kidney Diseases.
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            A WHO expert consultation addressed the debate about interpretation of recommended body-mass index (BMI) cut-off points for determining overweight and obesity in Asian populations, and considered whether population-specific cut-off points for BMI are necessary. They reviewed scientific evidence that suggests that Asian populations have different associations between BMI, percentage of body fat, and health risks than do European populations. The consultation concluded that the proportion of Asian people with a high risk of type 2 diabetes and cardiovascular disease is substantial at BMIs lower than the existing WHO cut-off point for overweight (> or =25 kg/m2). However, available data do not necessarily indicate a clear BMI cut-off point for all Asians for overweight or obesity. The cut-off point for observed risk varies from 22 kg/m2 to 25 kg/m2 in different Asian populations; for high risk it varies from 26 kg/m2 to 31 kg/m2. No attempt was made, therefore, to redefine cut-off points for each population separately. The consultation also agreed that the WHO BMI cut-off points should be retained as international classifications. The consultation identified further potential public health action points (23.0, 27.5, 32.5, and 37.5 kg/m2) along the continuum of BMI, and proposed methods by which countries could make decisions about the definitions of increased risk for their population.
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                Author and article information

                Contributors
                Journal
                Lancet Reg Health West Pac
                Lancet Reg Health West Pac
                The Lancet Regional Health: Western Pacific
                Elsevier
                2666-6065
                16 March 2023
                May 2023
                16 March 2023
                : 34
                : 100730
                Affiliations
                [a ]Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, PR China
                [b ]Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, PR China
                [c ]Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, PR China
                Author notes
                []Corresponding author. Department of Medicine and Therapeutics, The Chinese University of Hong Kong, 9/F Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Special Administrative Region, PR China. andrealuk@ 123456cuhk.edu.hk
                Article
                S2666-6065(23)00048-2 100730
                10.1016/j.lanwpc.2023.100730
                10240381
                37283964
                35919d14-f465-477d-9b3b-3c37acd2547f
                © 2023 The Author(s)

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 5 October 2022
                : 7 February 2023
                : 15 February 2023
                Categories
                Articles

                adult-onset diabetes,cardiovascular disease,diabetic ketoacidosis,end-stage kidney diseases,hypoglycaemia,mortality,type 1 diabetes

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