U. Didjurgeit

Smoking Is Associated With Progression of Diabetic Nephropathy

OBJECTIVE To investigate the association between cigarette smoking and the progression of diabetic nephropathy. RESEARCH DESIGN AND METHODS A prospective, follow-up study over one year was conducted in a sequential sample of 34 smokers, 35 nonsmokers, and 24 ex-smokers with type I diabetes, hypertension, and diabetic nephropathy. Progression of renal disease was defined according to the stage of nephropathy as an increase in proteinuria or serum creatinine or a decrease in the glomerular filtration rate. RESULTS Progression of nephropathy was less common in nonsmokers (11%) than in smokers (53%) and patients who had quit smoking (33%), P > 0.001. In a stepwise logistic regression analysis, cigarette pack years, 24-h sodium excretion, and GHb were independent predictive factors for the progression of diabetic nephropathy. Because blood pressure (BP) was well controlled in these patients and most values were within a normotensive range, neither standing, sitting, nor supine BP values were associated with progression of nephropathy. CONCLUSIONS Cigarette smoking represents an important factor associated with progression of nephropathy in treated hypertensive type I diabetic patients.

Intensified antihypertensive therapy is associated with improved survival in type 1 diabetic patients with nephropathy

Objective: To determine the prognosis of treated hypertensive type 1 (insulin-dependent) diabetic patients with overt nephropathy. Design: A controlled, prospective, parallel, 5-year follow-up trial. Setting: The tertiary care centre of the Heinrich Heine University Hospital in Dusseldorf, Germany. Patients and interventions: A sequential sample of 91 hypertensive patients with overt diabetic nephropathy participated in a diabetes treatment programme. Thereafter 45 patients received intensified antihypertensive therapy including blood pressure self-monitoring and self-adjustment of antihypertensive drug treatment with the goal of permanent normalization of blood pressure values below 140/90 mmHg. The remaining 46 patients were administered routine antihypertensive therapy and formed the control group. At baseline both groups were comparable in age, sex, metabolic control and renal function. The groups differed at baseline in their duration of diabetes and blood pressure values, which were higher in the intensified antihypertensive therapy group. Outcome measures: Total mortality and the need for renal replacement therapy. Main results: Blood pressure control was significantly improved in patients who were subjected to intensified antihypertensive therapy, whereas it deteriorated in the group of patients who received routine antihypertensive therapy. At follow-up, primary end points of the study occurred in five (11 %) patients of the intensified therapy group and in 19 (41%) patients of the routine therapy group. According to life table analysis, intensified antihypertensive therapy was associated with less frequent primary end points (P= 0.0058) and longer survival (P=0.01). The differences between the groups remained significant after adjustment for covariates in the proportional hazards model. Conclusion: Participation in a treatment programme aimed at intensification of antihypertensive therapy is associated with a reduction of mortality in hypertensive type 1 diabetic patients with overt nephropathy.

A time-limited, problem-orientated psychotherapeutic intervention in Type 1 diabetic patients with complications: a randomized controlled trial

Aims To examine the effects of a time‐limited, problem‐orientated psychotherapeutic intervention on self‐defined psychological problems and metabolic control in Type 1 diabetic patients with microvascular complications.

Effects of intensified antihypertensive treatment in diabetic nephropathy: mortality and morbidity results of a prospective controlled 10-year study.

OBJECTIVE The aim of this study was to describe the effect of intensified antihypertensive therapy based on a structured teaching and treatment programme on the prognosis of hypertensive type 1 (insulin-dependent) diabetic patients with kidney disease. DESIGN The study was a controlled, prospective, parallel, 10-year follow-up trial. PATIENTS AND INTERVENTIONS A sequential sample of 91 hypertensive type 1 diabetic patients with overt diabetic nephropathy was prospectively followed for 10 years. Forty-five patients (intensified antihypertensive therapy; IT group) participated in an intensified antihypertensive therapy programme and 46 patients received routine antihypertensive treatment as provided by family physicians, consultants and local hospitals (routine antihypertensive therapy; RT group). OUTCOME MEASURES The main endpoint was death; secondary endpoints were renal replacement therapy, blindness and amputation. RESULTS Blood pressure was reduced in the IT group and increased in the RT group. During the follow-up period, 29 patients died, seven in the IT group and 22 in the RT group. The survival curves were significantly different (P = 0.0008). The main causes of death were cardiac. In a multiple Cox proportional hazards model, allocation to the IT group reduced the mortality risk [relative risk (RR) = 0.213; 95% confidence interval 0.089-0.509, P = 0.00051, while age (P = 0.0039) and mean blood pressure (P= 0.0113) increased this risk. In multiple Cox or multiple logistic regression models, the risks of dialysis (RR = 0.269, 95% confidence interval 0.110-0.656, P = 0.0039), blindness (odds ratio = 0.158, 95% confidence interval 0.037-0.684, P= 0.0136), and amputation (RR = 0.181, 95% confidence interval 0.047-0.703, P= 0.0135) were significantly lower in the IT group compared with the RT group (log rank P = 0.0008). CONCLUSION We conclude that intensified antihypertensive treatment, based on a hypertension teaching and treatment programme, reduces long-term morbidity and mortality in patients with diabetic nephropathy.

Behaviour therapy versus doctor's anti-smoking advice in diabetic patients

Abstract. Objectives. To evaluate the efficacy of a structured behaviour therapy programme on smoking cessation in diabetic patients.

Uncontrolled Hypertension in Type 1 Diabetes: Assessment of Patients' Desires about Treatment and Improvement of Blood Pressure Control by a Structured Treatment and Teaching Programme

Control of arterial blood pressure at near‐normal levels is of importance for the prognosis of patients with Type 1 (insulin‐dependent) diabetes mellitus. In non‐diabetic populations patient compliance to antihypertensive therapy is frequently poor, especially in young people. Thirty‐seven consecutive eligible patients with longstanding Type 1 diabetes and persistently uncontrolled hypertension were questioned about their preferences regarding hypertension treatment. Throughout they expressed a strong desire for more information about hypertension and for active participation in monitoring of blood pressure and therapeutic decision‐making. In addition, they showed considerable reluctance to accept a pharmacological intervention. Therefore, in order to improve blood pressure control, the patients participated in a structured outpatient hypertension treatment and teaching programme for groups of about 6 patients consisting of four teaching sessions at weekly intervals. The programme comprised home‐monitoring of blood pressure and involvement of the patients in treatment decision‐making. In 34 patients who had a complete follow‐up examination after an average of 16 months, mean sitting arterial pressure had decreased from 111 to 101 mmHg (p < 0.001) and 53 % of the patients were below 140/90 mmHg. The number and dosage of prescribed antihypertensive agents remained unchanged by the intervention. Sodium intake was not reduced during the study, but pulse rate decreased significantly in patients treated with β‐adrenergic blockers and serum uric acid rose in patients on diuretic therapy, suggesting increased adherence of the patients to prescribed antihypertensive drug therapy. In 34 comparable Type 1 diabetic patients who were not subjected to a hypertension treatment and teaching programme mean arterial blood pressure remained unchanged during a 12‐month period.

Mortality and Morbidity in Treated Hypertensive Type 2 Diabetic Patients with Micro- or Macroproteinuria

In order to describe the natural history of high risk diabetic patients treated for hypertension we have followed a sequential sample of 100 hypertensive Type 2 diabetic patients with elevated urinary protein excretion (≥60 mg 24 h−1) for a period of 1–7 years. Antihypertensive treatment was instituted in all patients and, in addition, the patients were offered the possibility of participation in an intensified antihypertensive therapy programme. After a mean follow‐up of 4 years overall mortality was 13 %. Nineteen percent of all patients experienced a cardiovascular event and 7 % a cerebrovascular event. In conclusion, in this study the overall mortality was lower that previously reported in proteinuric Type 2 diabetic patients. Antihypertensive treatment may account for this outcome.

Self-management of oral anticoagulation: long-term results.

Dear Sir, The increasing number of indications for oral anticoagulation has raised concerns how this therapy should be undertaken. In addition, control of oral anticoagulation therapy has been reported to be often inadequate. Prospective randomized controlled investigations suggest that patients’ self-management of oral anticoagulation may lead to improved control. Prospective long-term studies of this intervention are not available. Therefore, we have assessed during a period of 5 years the effects of patients’ self-management of oral anticoagulation on long-term compliance with this kind of therapy, accuracy of control, measures of treatment-related quality of life and bleeding and thromboembolic complications. A structured teaching and treatment programme for self-management of oral anticoagulation was offered to 178 patients. Follow-up was until death or for a period of 5 years resulting in 809 patient years (py). In the initial randomized controlled part of this study [1] we have shown that self-management of oral anticoagulation can be reliably performed by patients and improves quality of anticoagulation control and treatment-related quality of life. In the second part of this study, we have demonstrated patients’ compliance to this form of therapy in the long-term and we have shown that it is associated with an improvement of the quality of anticoagulation control, which is maintained during the follow-up of 5 years. Before participation in the self-management programme the squared international normalized ratio (INR) deviation in the intervention group was 1.32 and only 29% of INR measurements were within the target range. At the end of the randomized controlled part of this study, the squared INR deviation from the mean of the target range in the intervention group was 0.65 with 53% of INR values being within the target range. After 5 years the squared INR deviation was even lower at 0.44 and the percentage of INR values within target range increased to 62%. Hence, not only the improvement in the quality of anticoagulation control after participation in the self-management programme is long lasting, but it may even improve further with the duration of patients’ selfmanagement. Our prospective study confirms and extends previous controlled study results [2–4] indicating that this form of anticoagulation treatment improves both quality of care and quality of life and supports patients’ demand for a broader access to this form of treatment. As in this study the control-group patients have also participated in the self-management programme after 6 months, it is not possible to evaluate the risk of complications in a randomized controlled way. However, when compared with the previously published risk evaluations in this prospective study self-management of oral anticoagulation was associated with a relatively low risk of major bleeding (0.62 per 100 py), while the risk of thromboembolic complications (1.1 per 100 py) was comparable with results in an anticoagulation clinic. From the 150 patients available for the final 5-year examination, 134 (89%) performed self-monitoring and 116 (77%) self-adaptation of cumarin dosage. At baseline 32% of patients were within the INR target range; during the final year of the follow-up period 62% of INR self-measurements were within the target range. On self-monitoring, the mean time within the target range was 225 days per year (d/ y) and 80 d/y below and 60 d/y above the target range. During the follow-up period, five major bleeding complications (0.62 per 100 py) and nine thromboembolic events (1.1 per 100 py) occurred. When compared with baseline, parameters of quality of life improved (Table 1). We conclude from these results that after participation in a structured teaching and treatment programme, compliance with self-management of oral anticoagulation persists in the long-term, results in an Journal of Internal Medicine 2003; 254: 515–516

Effects of intensification of antihypertensive care in diabetic nephropathy

The overall quality of antihypertensive care in diabetic patients in Germany is poor. Only a minority of unselected hypertensive patients reach permanent normotensive blood pressure control. Previously, we have shown in a prospective randomized 3-year follow-up study in essential hypertension that implementation of a hypertension teaching and treatment program into routine care results in a significant improvement of blood pressure control. Subsequently, we have performed a prospective, controlled 5-year follow-up trial in hypertensive type I diabetic patients with nephropathy. One-half of a sequential sample of about 100 hypertensive patients with overt nephropathy participated in the program based on blood pressure self-monitoring with the goal of normalization of blood pressure values below 140/90 mm Hg (intensified care, IC). The remaining patients followed routine antihypertensive therapy and formed the control group (routine care, RC). During 5 years of follow-up in IC group patients, blood pressure control was significantly improved. The occurrence of primary study end points (need for dialysis and death) was significantly lower in the IC group patients. In conclusion, in patients with diabetic nephropathy, participation in a hypertension teaching treatment program results in a long-term improvement of blood pressure control and a decrease in mortality and morbidity.

Near-normotension and near-normoglycemia in blind Type I diabetic patients with overt diabetic nephropathy

In patients with diabetic nephropathy, near-normalization of blood pressure (BP) and blood sugar may have a beneficial impact on changes in kidney function, but visually impaired patients may face difficulties when striving for optimal control of hypertension and hyperglycemia. In a prospective feasibility study, we followed a group of nine blind Type I (insulin-dependent) diabetic patients (mean age 30 +/- 4 years) with overt diabetic nephropathy and uncontrolled hypertension. All patients received intensified insulin therapy after a structured diabetes treatment and teaching program, and adapted their antihypertensive drug treatment to self-monitored BP values. At recruitment, HbA1c values were 5.8 +/- 0.6%, and remained stable at 6.3 +/- 1.7% after a mean observation period of 27 months. BP pressure decreased from 150 +/- 14/99 +/- 14 mmHg to 130 +/- 17/86 +/- 10 mmHg after 1 year, and to 140 +/- 14/92 +/- 9 mmHg at the last examination, (p less than 0.05). Serum creatinine and creatinine clearance remained stable over the observation period at 165 +/- 56 mumol/L and 0.8 +/- 0.4 ml/s/1.72m2 at recruitment, and 152 +/- 47 mumol/L and 1.0 +/- 0.5 ml/s/1.72m2 at the final examination. Proteinuria decreased from 3.2 to 1.4 g/24 h (p less than 0.05). No patient needed renal replacement therapy.(ABSTRACT TRUNCATED AT 250 WORDS)