Die Präsentation wird geladen. Bitte warten

Die Präsentation wird geladen. Bitte warten

Univ Prof. Prim. Dr. Guntram Schernthaner Vorstand der 1. Medizinischen Abteilung Rudolfstiftung Wien Non-Stop Revolution in der Diabetologie : Dramatischer.

Ähnliche Präsentationen


Präsentation zum Thema: "Univ Prof. Prim. Dr. Guntram Schernthaner Vorstand der 1. Medizinischen Abteilung Rudolfstiftung Wien Non-Stop Revolution in der Diabetologie : Dramatischer."—  Präsentation transkript:

1 Univ Prof. Prim. Dr. Guntram Schernthaner Vorstand der 1. Medizinischen Abteilung Rudolfstiftung Wien Non-Stop Revolution in der Diabetologie : Dramatischer Rückgang der Diabeteskomplikationen in den letzten 20 Jahren

2 Typ 1 Diabetes: Mortalität der Patienten mit jugendlichem Diabetes betrug nach 30 Jahren Diabetesdauer 50% - Mortalität war um 600% höher als bei gleichaltrigem Patienten ohne Diabetes Typ 2 Diabetes: Patienten in der UKPDS-Studie, die bei Studienbeginn im Mittel nur 53 Jahre alt waren keine Komplikationen aufwiesen, waren nach 20 Jahren (Durchschnittsalter 73 Jahre) in 44% verstorben Diabetes war in der westlichen Welt die häufigste Erblindungsursache 50% aller Fussamputationen erfolgten bei Diabetespatienten 30-50% aller Hämodialyse-Patienten hatten Diabetes Herzinfarkt, Schlaganfall, PAVK und Herzinsuffizienz finden sich bei Patienten mit Diabetes 2-3 x häufiger als bei Patienten ohne Diabetes Schicksal der Diabetespatienten im letzten Drittel des 20. Jahrhunderts

3 1972

4 Risk Reduction for Mortality in Diabetic versus Nondiabetic Patients the Framingham Study in comparison of Later and Earlier Period Preis et al. Circulation 2009;119: % 0 -30% -23% - 60% - 58% Non-Diabetics Diabetics HR 0.70HR 0.77 HR 0.40HR 0.42 HR 0.95HR 1.40 All-cause mortalityCVD mortalityNon-CVD mortality p<0.001 p=0.05 Non-DiabeticsDiabetics earlier: later:

5 Decline in Age-standardized mortality rates from 1997 to 2006 Comparison of a diabetic cohort with the UK general population Men Women Diabetic Nondiabetic Gulliford MC & Charlton J. Am J Epidemiol 2009;169:455–461 The study included a cohort of 48,556 subjects with type 2 diabetes rst diagnosed between 1996 and 2006, drawn from 197 family practices in the United Kingdom General Practice Research Database (UKGPRD). There were 6,630 deaths observed Relative mortality for patients diagnosed in 2006 was 37% lower than for those diagnosed in 1996

6 Explaining the Decline in Early Mortality in Men and Women With Type 2 Diabetes Cohort study including 48,579 patients with type 2 diabetes first diagnosed between 1996 & 2006 in 197 general practices in the U.K. From 1996 to 2006, incidence of type 2 diabetes increased and the mean age at diagnosis declined in women All-cause mortality in the first 24 months after diabetes diagnosis declined signficantly in both in men and women per 1,000 person-years Men from 47.9 in 1996 to 25.2 in 2006 Women from 37.4 in 1996 to 27.6 in 2006 In a multiple regression model adjusting for age and comorbidity prescription of statins before or after diagnosis, renin-angiotensin system drugs before or after diagnosis, and metformin after diagnosis were associated with lower mortality A population-based cohort study Charlton J et al: Diab Care 2008; 31:1761-6

7 Age-standardised rates for mortality within two years of diabetes diagnosis by year of diagnosis ( ) in UK Women Men Charlton J et al: Diab Care 2008; 31: person years Cohort study including 48,579 patients with type 2 diabetes first diagnosed between 1996 & 2006 in 197 general practices in the U.K. Decline of mortality from in men: 47 % and in women: 26 %

8 Women % % % % % Men RAS drugsStatins RAS drugsMetforminStatins 36,3 34,4 13,9 13, ,8 31,5 2,2 1, % Metformin Treatment Changes in Patients with Type 2 Diabetes between Charlton J et al: Diab Care 2008; 31:1761-6

9 Age-specific prevalences for diabetes in Denmark (1995–2007) Men Women Carstensen B et al. Diabetologia 2008; 51:2187–2196

10 The Danish National Diabetes Register: Trends in incidence, prevalence and mortality The prevalence of diabetes increased 6% per year The lifetime risk of diabetes was 30% The mortality rate in the diabetic population decreased 4% per year, compared with only 2% per year in the non-diabetic population The mortality rate decreased 40% during the first 3 years after inclusion in the register Conclusions: The mortality rate in diabetic patients decreased faster than that of the nondiabetic population Carstensen B et al. Diabetologia 2008; 51:2187–2196

11 Diabetic Retinopathy Diabetic Retinopathy, particularly in its vision-threatening stages, has a substantial, negative impact on the patient Fenwick EK et al. Postgrad Med J. 2012; 88: Fenwick EK et al. Invest Ophthalmol Vis Sci. 2012; 53:

12 Ca. 12 Millionen Amerikaner haben einen Diabetes mellitus 5,3 Millionen haben eine diabetische Retinopathie haben eine proliferative diabetische Retinopathie neue Fälle / Jahr mit proliferativer diabetischer Retinopathie neue Fälle / Jahr mit diabetischer Makulopathie Epidemiologie

13 Clinical Stages of Diabetic Retinopathy Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1991;98: BDRPPDR PDR (Background)(Preproliferative) No Diabetic Retinopathy Proliferative Diabetic Retinopathy NPDR Nonproliferative Diabetic Retinopathy STAGESSTAGES Biochemical changes, endothelial leukocyte adhesion, basement membrane thickening, pericyte loss, changes in retinal blood flow Mild to Moderate Moderate to Severe Neovascularization None Macular Edema SEVERITYSEVERITY

14 Age-standardized prevalence of diabetic retinopathy by Diabetes duration, in diabetic subjects aged 20 to 79 years Vision-threatening Diabetic Retinopathy Any Diabetic Retinopathy Proliferative Diabetic Retinopathy Diabetic Macular Edema 20 years <10 years 10 to <20 years Age-standardized prevalence per 100 Yau et al. Diabetes Care 2012: 35: A pooled analysis of 35 studies ( ) providing data from patients with diabetes (Meta-analysis for eye disease study group)

15 Age-standardized prevalence of Diabetic Retinopathy in Type 1 versus Type 2 Diabetes aged 20 to 79 years Vision-threatening Diabetic Retinopathy Any Diabetic Retinopathy Proliferative Diabetic Retinopathy Diabetic Macular Edema Type 2 Type 1 Age-standardized prevalence per 100 Yau et al. Diabetes Care 2012: 35: A pooled analysis of 35 studies ( ) providing data from patients with diabetes (Meta-analysis for eye disease study group)

16 Decline of Age-standardized Prevalence of Diabetic Retinopathy (Age Range: years) in Studies Pre-2000 vs. Post ,6 9,3 15,6 3,5 5,5 7, Age-standardized prevalence per ,6 24, Vision-threatening Diabetic Retinopathy Any Diabetic Retinopathy Proliferative Diabetic Retinopathy Diabetic Macular Edema Yau et al. Diabetes Care 2012: 35: Post-2000 studies Pre-2000 studies 20 Age-standardized prevalence per % - 41 % - 49 % - 50 % A pooled analysis of 35 studies ( ) providing data from patients with diabetes (Meta-analysis for eye disease study group)

17 HbA1c Age-standardized prevalence of diabetic retinopathy by HbA1c, in diabetic subjects aged 20 to 79 years Vision-threatening Diabetic Retinopathy Any Diabetic Retinopathy Proliferative Diabetic Retinopathy Diabetic Macular Edema Yau et al. Diabetes Care 2012: 35: Age-standardized prevalence per % 7.0 % % % A pooled analysis of 35 studies ( ) providing data from patients with diabetes (Meta-analysis for eye disease study group)

18 Incidence and Progression of Diabetic Retinopathy During 17 Years of a Population-Based Screening Program in England Patients with Type 2 Diabetes, who had annual retinal photography, from Patients with non-proliferative Diabetic Retinopathy at baseline Patients without Diabetic Retinopathy at baseline Proliferative Diabetic Retinopathy Preproliferative Retinopathy Sight-threatening maculopathy after 10 yearsafter 5 yearsafter 10 yearsafter 5 years 11 % 53 % 9,6 % 6,1 % 23 % 5,2 % 1,5 % 16,4 % 1,2 % 0,68 % 4 % 0,59 % Jones CD et al. Diabetes Care 2012; 35:592-6

19 Proportion of End Stage Renal Disease in Patients with Diabetes Yoon K et al. Lancet 2006;368:1681–1688 Malaysia Republic of Korea USA Japan New Zealand Taiwan Philippines Austria Australia Proportion (%) Pakistan

20 Median Percent of Population Year Year Crude Age-adjusted Incidence (per Population) William ME. Diabetic CKD/ESRD 2010: A Progress Report? Seminars in Dialysis 2010;l 23:129–133 Changing incidence rates of diabetic ESRD related to the underlying incidence of DM Growing Prevalence of Diabetes in the General US Population During 1996–2007 the rate of increase in the number of persons with diagnosed diabetes was greater than the rate of increase in the number of ESRD-D cases. Thus, among persons with diagnosed diabetes, the age-adjusted ESRD-D rate decreased during the period by 35%, from 304 to 199 per persons with diagnosed diabetes Significant Decline of the ESRD rate by 35% in persons with diagnosed during the period

21 All New Patients receiving Renal Replacement Therapy in Austria ( ) % 25% 30% 35% % 31 % 29 % 26 % Absolute Number of Patients with Type 2 Diabetes Absolute Number % Patients with Type 2 Diabetes Österreichisches Hämodialyseregister 2010 (2010 vs. 2004) -26 % Kramar, R. Oberbauer R. Austrian Dialysis and Transplantation Registry (OEDTR), Annual Report 2010, Austrian Society of Nephrology

22 Zahl der Hämodialyse Patienten mit Typ 2 Diabetes in Relation zur Zahl der Patienten mit diagnostiziertem Typ 2 Diabetes in Österreich (Vergleich 2004 versus 2010) Zahl der Patienten mit diagnostiziertem Typ 2 Diabetes Zahl der Hämodialyse (HD) Patienten mit Typ 2 Diabetes Zahl der HD Patienten mit Typ 2 Diabetes pro diagnostizierte Patienten mit Typ 2 Diabetes Abnahme von 2004 auf 2010 in Österreich - 33% Abnahme von 1996 auf 2007 in USA - 35%

23 Möllsten A. et al. Diabetes 2010; 59: 1803–1808 During a median time of follow-up of 20 years, only 127 out of (1.08%) patients had developed ESRD due to diabetic nephropathy The cumulative incidence at 30 years of type 1 diabetes duration was very low, 4.1% in males vs. 2.5% in females. Cumulative incidences of developing ESRD in young patients with type 1 diabetes with age at onset at 0–9 and 10–19 years (A Nationwide Population-Based Cohort Study in Sweden)

24 Diabetic Foot Syndrome First described on December 31st 1887 Definition: Diabetes Complications with an increased risk for trauma, Infection and Gangrene.

25 Schematischer Verlauf von der Polyneuropathie über das Trauma und das Ulkus bis hin zur Gangrän T NNN TT UNNU HS Neuropathie Prädisposition T Minimal-Trauma äußere Einwirkung U Ulkus Verletzung HS Heilungsstörung weitere Schädigung (Druckbelastung, Infektion) G Gangrän weitere Schädigung (Thrombose)

26

27 Diabetic Foot Syndrome: High risk for Amputation and early Mortality

28 Mortality in Patients after Amputation: A Comparison between Patients with and without Diabetes Median time to death was 27.2 months with diabetes (n=119) versus 46.7 months without diabetes (n=271) Years from Incident Amputation or Study end Date Survival Distribution Function 75% of diabetic patients are dead 6 years after amputation Survival rates 10 years after amputation Nondiabetic patients 22.9% Diabetic patients 8.4% p= p=0.01 Schofield CJ et al. Diabetes Care 2006;29:2252

29 Significant Decrease in Initial Lower Extremity Amputation (ILEA) Rates among Veterans Health Administration (VHA) Health Care System Users from 2000 to % - 33 % - 36 % - 19 % - 49 % Age- and sex-standardized ILEA rates per Above-kneeILEA rates Major amputation Below-knee Minor amputation Five Year follow-up of VHA clinic users with diabetes and without prior amputations in 2000 (n= ) and in 2004 (n= )

30 Age-adjsuted rates (per 1,000) Year Number (in thousands) From , p<0.05 Age-adjusted Nontraumatic Lower-Extremity Amputation (NLEA rates) among U.S. residents aged 40 years by diabetes status (1996–2008) Li Y et al. (Diab Care 2012; 35:273–277) Although patients with diagnosed diabetes increased dramatically from 5.4 million in 1988 to 17.1 million in 2008, the number of diabetes-related NLEA decreased from 83,153 in 1996 to in 2008

31 Age-adjsuted rates (per 1,000) Year From , p<0.05 Age-adjusted Nontraumatic Lower-Extremity Amputation (NLEA rates) among U.S. residents aged 40 years by diabetes status (1996–2008) No Diabetes Diabetes Despite the much greater decrease in NLEA rates in the diabetic population, the age-adjusted NLEA rate in the diabetic population was still about eight times the rate in the nondiabetic population in 2008 (3.9 vs. 0.5 per 1,000 persons) From 1996 to 2008 the NLEA rates in diabetic patients decreased by 67% (p<0.001) Li Y et al. (Diab Care 2012; 35:273–277) 3,9 11,3

32 Leading Causes of Death in Type 2 Diabetes Cancer, 29 % CVD, 31 % Renal, 2 % External, 7 % Other, 31 % Renal, 3 % Infection, 7 % External, 2 % Other, 18 % CVD, 43 % Cancer, 27 % Pathways Epidemiologic Study Lin et al. Ann Fam Med 2009 Alberta Diabetes Surveillance System

33 Increased Risk 3.5 Reduced Risk Summary OR: Bladder (Larsson, Diabetologia, 2006); N=16 Pancreas (Huxley, Br J Cancer, 2005); N=36 Non Hodgkin`s lymphoma (Mitri et al, 2008); N=5 Colorectal (Larsson, J Natl Can Inst 2005); N=15 Prostate (Kasper, Cancer Epi); N=19 Liver (El-Serag et al, 2006); N=20 Breast (Larsson, Int J Can, 2007); N=20 Endometrial (Friberg, Diabetologia 2007); N=16 Meta-analyses, Diabetes & Cancer Risk

34 Mortalität bei Diabetespatienten mit Krebserkrankungen signifikant höher als bei Nichtdiabetikern Diagnose oft verspätet gestellt – weniger Sreeeninguntersuchunten ? Erhöhte Perioperative Mortaliät Erhöhtes Risiko für Re-Occurence Aufgrund der Co-Morbiditäten erhöhte Toxizität der Chemotherapie Vermindertes Ansprechen auf Chemotherapie Gestörte Immunologische Infektabwehr bei Hyperglykämie Diabetes entgleist relativ oft bei Chemotherapie

35 Increases in clinically severe Obesity in the United States ( ) Sturm R. Arch Intern Med. 2003; 163: % Increase (1986=100%) BMI 35 (Obesity Grade II) BMI 30 (Obesity Grade I) BMI 40 BMI 45 BMI 50 Year

36 Patients with Morbid Obesity(n=1015) 41.2 Abnormal in % mg/dl 150 mg/dl 85 mm/Hg 130 mm/Hg 50 mg 40 mg Triglyceride Components of the Metabolic Syndrome: IDF- Criteria Blood Glucose preprandial Diastolic Waist circumference Systolic HDL Female Male Hypertension male > 94cm, female > 80cm Impaired Glucose Tolerance 24.6% (HbA1c: 5.8±0.5) Type 2 Diabetes 19.4% (HbA1c: 7.8±1.7) Normal Glucose Tolerance 56.0% (HbA1c: 5.5±0.5) Rudolfstiftung Hospital Vienna

37 Significant lowering of HbA1c after Bariatric Surgery in 60 Type 2 Diabetic Patients with Morbid Obesity 6,1 5,5 7,4 5,7 9,1 5, HbA1c (%) <0.001 Postoperative, BMI 29.3± HbA1c (%) >8.00<6.8 Preoperative, BMI 39.8±17.5 p-Value0.004<0.001 Schernthaner G et al. Diabetes Care, 2011; 34; Supplement 2: S

38 Follow-up, years Mean Weight Change % Mean Weight Change Percentages from Baseline for Controls and the 3 Surgery Groups over 20 Years in the Swedish Obese Subjects Study Controls Banding Vertical banded gastroplasty Gastric bypass No. Of Patients Sjöström L (JAMA 2012; 307:56) Banding Vertical banded gastroplasty Gastric bypass Controls

39 Diabetes (n=345) Non-Diabetes (n=1658) 0.84 ( )HR 0.63 ( ) Treatment Effect Diabetes vs. Non-Diabetes: p< Diabetes or Non-Diabetes: Risk Factor Treatment Interaction Analyses in the SOS-Study Sjöström L (JAMA 2012; 307:56) Incidence per 1000 person- years

40 Non-Stop Revolution in der Diabetologie: Status 2012 Kardiovaskuläre Mortalität bei Typ 2 Diabetes wurde um 60% gesenkt Proliferative Retinopathie nahm um 67% ab Diabetisches Maculaödem wurde um 41% rdeuziert Die kumulative Inzidenz einer terminalen Niereninsuffizienz bei Patienten mit Typ 1 Diabetes liegt nach 30 jähriger Diabetesdauer nur mehr bei ca 3% Signifikanter Rückgang (ca 35%) der Patienten mit Typ 2 Diabetes an der Hämodialyse (USA, Österreich) Rückgang der Fussamputationen um 35-50% Diabetesremission bei Patienten mit morbider Adipositas nach metabolischer chirurgischer Íntervention in ca 70% Neue Herausforderung: Früherkennung bestimmter Krebserkrankungen, die bei Patienten mit Typ 2 Diabetes signifikant häufiger auftreten


Herunterladen ppt "Univ Prof. Prim. Dr. Guntram Schernthaner Vorstand der 1. Medizinischen Abteilung Rudolfstiftung Wien Non-Stop Revolution in der Diabetologie : Dramatischer."

Ähnliche Präsentationen


Google-Anzeigen