Age at Type 2 Diabetes Diagnosis and Cause-Specific Mortality: Observational Study of Primary Care Patients in England.

ObjectiveTo examine the associations between age at type 2 diabetes diagnosis and the relative and absolute risk of all-cause and cause-specific mortality in England.Research design and methodsIn this cohort study using primary care data from the Clinical Practice Research Datalink, we identified 108,061 individuals with newly diagnosed type 2 diabetes (16-50 years of age), matched to 829,946 individuals without type 2 diabetes. We estimated all-cause and cause-specific mortality (cancer, cardiorenal, other [noncancer or cardiorenal]) by age at diagnosis, using competing-risk survival analyses adjusted for key confounders.ResultsComparing individuals with versus without type 2 diabetes, the relative risk of death decreased with an older age at diagnosis: the hazard ratio for all-cause mortality was 4.32 (95% CI 3.35-5.58) in individuals diagnosed at ages 16-27 years compared with 1.53 (95% CI 1.46-1.60) at ages 48-50 years. Smaller relative risks by increasing age at diagnosis were also observed for cancer, cardiorenal, and noncancer or cardiorenal death. Irrespective of age at diagnosis, the 10-year absolute risk of all-cause and cause-specific mortality were higher in individuals with type 2 diabetes; yet, the absolute differences were small.ConclusionsAlthough the relative risk of death in individuals with versus without type 2 was higher at younger ages, the 10-year absolute risk of all investigated causes of death was small and similar in the two groups. Further multidecade studies could help estimate the long-term risk of complications and death in individuals with early-onset type 2 diabetes

Evaluation of a fourth-generation subcutaneous real-time continuous glucose monitor (CGM) in individuals with diabetes on peritoneal dialysis

   Objective: To evaluate the performance of a real-time continuous glucose monitor (CGM) in individuals with diabetes on peritoneal dialysis (PD).  Research Design and methods: Thirty type 2 diabetes participants on continuous ambulatory peritoneal dialysis (CAPD) wore a Guardian Sensor™ 3 on the upper arm paired with Guardian Connect™ for 14 days. We compared CGM readings against Yellow Springs Instrument (YSI) venous glucose during an 8-hour in-clinic session with glucose challenge.  Results: The mean absolute relative difference (MARD) was 10.4% (95% confidence interval: 9.6, 11.7) from 941 CGM-YSI matched pairs; 81.3% of readings were within 15/15% of YSI values in the full glycemic range. Consensus error grid analysis showed 99.9% of sensor values in zones A and B. There were no correlations between pH, uremia, hydration status and MARD.  Conclusion: We showed satisfactory performance of a real-time CGM sensor in  PD patients with diabetes, supporting future use to facilitate treatment decisions.</p

Aspects of Multicomponent Integrated Care Promote Sustained Improvement in Surrogate Clinical Outcomes: A Systematic Review and Meta-analysis

OBJECTIVE The implementation of the Chronic Care Model (CCM) improves health care quality. We examined the sustained effectiveness of multicomponent integrated care in type 2 diabetes. RESEARCH DESIGN AND METHODS We searched PubMed and OvidMEDLINE (January 2000-August 2016) and identified randomized controlled trials comprising two or more quality improvement strategies from two or more domains (health system, health care providers, or patients) lasting ≥12 months with one or more clinical outcomes. Two reviewers extracted data and appraised the reporting quality. RESULTS In a meta-analysis of 181 trials (N = 135,112), random-effects modeling revealed pooledmean differences in HbA1c of20.28%(95%CI20.35 to20.21) (23.1mmol/mol [23.9 to 22.3]), in systolic blood pressure (SBP) of 22.3 mmHg (23.1 to 21.4), in diastolic blood pressure (DBP) of 21.1 mmHg (21.5 to 20.6), and in LDL cholesterol (LDL-C) of 20.14 mmol/L (20.21 to 20.07), with greater effects in patients with LDL-C ≥3.4 mmol/L (20.31 vs. 20.10 mmol/L for 12 months (SBP 23.4 vs. 21.4 mmHg, Pdifference = 0.034; DBP 21.7 vs. 20.7 mmHg, Pdifference = 0.047; LDL-C 20.21 vs. 20.07 mmol/L for 12-month studies, Pdifference = 0.049). Patients with median age <60 years had greater HbA1c reduction (20.35% vs. 20.18% for ≥60 years [23.8 vs. 22.0 mmol/mol]; Pdifference = 0.029). Team change, patient education/self-management, and improved patient-provider communication had the largest effect sizes (0.28-0.36% [3.0-3.9 mmol/mol]). CONCLUSIONS Despite the small effect size of multicomponent integrated care (in part attenuated by good background care), team-based care with better information flow may improve patient-provider communication and self-management in patients who are young, with suboptimal control, and in low-resource settings

Diabetes Management in Chronic Kidney Disease: Synopsis of the KDIGO 2022 Clinical Practice Guideline Update.

Description: The KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease is an update of the 2020 guideline from Kidney Disease: Improving Global Outcomes (KDIGO). Methods: The KDIGO Work Group updated the guideline, which included reviewing and grading new evidence that was identified and summarized. As in the previous guideline, the Work Group used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to appraise evidence and rate the strength of recommendations and expert judgment to develop consensus practice points. New evidence led to updating of recommendations in the chapters Comprehensive Care in Patients With Diabetes and CKD (Chapter 1) and Glucose-Lowering Therapies in Patients With T2D and CKD (Chapter 4). New evidence did not change recommendations in the chapters Glycemic Monitoring and Targets in Patients With Diabetes and CKD (Chapter 2), Lifestyle Interventions in Patients With Diabetes and CKD (Chapter 3), and Approaches to Management of Patients With Diabetes and CKD (Chapter 5). Recommendations: The updated guideline includes 13 recommendations and 52 practice points for clinicians caring for patients with diabetes and chronic kidney disease (CKD). A focus on preserving kidney function and maintaining well-being is recommended using a layered approach to care, starting with a foundation of lifestyle interventions, self-management, and first-line pharmacotherapy (such as sodium–glucose cotransporter-2 inhibitors) demonstrated to improve clinical outcomes. To this are added additional drugs with heart and kidney protection, such as glucagon-like peptide-1 receptor agonists and nonsteroidal mineralocorticoid receptor antagonists, and interventions to control risk factors for CKD progression and cardiovascular events, such as blood pressure, glycemia, and lipids. In light of the emergence of new high-quality evidence, the KDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease (1) update follows only 2 years after the original 2020 guideline (2). The overall scope and systematic literature search for the update were unchanged from the original guideline and addressed both type 1 diabetes (T1D) and type 2 diabetes (T2D), all stages of chronic kidney disease (CKD), and patients who had a kidney transplant or those treated with hemodialysis or peritoneal dialysis (2). High-quality evidence on patient care, specifically from randomized controlled trials, was evaluated. This led to revision of recommendations on what constitutes comprehensive care, use of sodium–glucose cotransporter-2 (SGLT2) inhibitors, and use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs), as well as the introduction of a new section on use of mineralocorticoid receptor antagonists (MRAs).</p