American Diabetes Association
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Range of Risk Factor Levels, Control and Temporal Trends for Nephropathy and End-stage Kidney Disease in Patients with Type 1 and Type 2 Diabetes

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Version 2 2022-09-02, 17:15
Version 1 2022-08-19, 14:53
posted on 2022-09-02, 17:15 authored by Janita Halminen, Naveed Sattar, Araz Rawshani, Björn Eliasson, Katarina Eeg-Olofsson, Deepak L Bhatt, Aidin Rawshani



To investigate trends, optimal levels for cardiometabolic risk factors, and multifactorial risk control in diabetic nephropathy and end-stage kidney disease (ESKD) in patients with diabetes and matched controls. 

Research Design and Methods

This study included 701,622 patients with diabetes from the Swedish National Diabetes Register and 2,738,137 controls. Trends were analyzed with standardized inc­idence rates. Cox regression was used to assess excess risk, optimal risk factor levels, and risk according to the number of risk factors, in diabetes. 


ESKD incidence among patients with and without diabetes initially declined until 2007 and increased thereafter, whereas diabetic nephropathy decreased throughout follow-up. In patients with diabetes, baseline values for glycated hemoglobin, systolic blood pressure, triglycerides, and body mass index were associated with outcomes. Hazard ratio for ESKD in patients with type 2 diabetes who had all included risk factors at target was 1.60 (95% CI, 1.49–1.71) compared with controls, and in type 1 diabetes 6.10 (95% CI, 4.69–7.93). Risk for outcomes increased in a stepwise fashion for each risk factor not at target. Excess risk for ESKD in type 2 diabetes showed a hazard ratio of 2.32 (95% CI, 2.30–2.35) and in type 1 diabetes, 10.92 (95% CI, 10.15–11.75), compared with controls.


Incidence of diabetic nephropathy has declined substantially, whereas ESKD incidence has increased. Traditional and modifiable risk factors below target levels were associated with lower risks for outcomes, particularly notable for the causal risk factors of SBP and HbA1c, with potential implications for care. 


This work was supported by grants from the Swedish state under an agreement between the Swedish government and the county councils concerning economic support of research and education of doctors [ALFGBG-966187]; the Swedish Heart and Lung Foundation [2019-0532]; the Swedish Research Council [2019-02019].


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