Cardiovascular risk factors and incident albuminuria in screen-detected type 2 diabetes.

BACKGROUND: It is unclear whether cardiovascular risk factor modification influences the development of renal disease in people with type 2 diabetes identified through screening. We determined predictors of albuminuria 5 years after a diagnosis of screen-detected diabetes within the ADDITION-Europe study, a pragmatic cardiovascular outcome trial of multifactorial cardiovascular risk management. METHODS: In 1826 participants with newly diagnosed, screen-detected diabetes without albuminuria, we explored associations between risk of new albuminuria (≥2.5 mg mmol-1 for males and ≥3.5 mg mmol-1 for females) and (1) baseline cardio-metabolic risk factors and (2) changes from baseline to 1 year in systolic blood pressure (ΔSBP) and glycated haemoglobin (ΔHbA1c ) using logistic regression. RESULTS: Albuminuria developed in 268 (15%) participants; baseline body mass index and active smoking were independently associated with new onset albuminuria in 5 years after detection of diabetes. In a model adjusted for age, gender, baseline HbA1c and blood pressure, a 1% decrease in HbA1c and 5-mm Hg decrease in SBP during the first year were independently associated with lower risks of albuminuria (odds ratio), 95% confidence interval: 0.76, 0.62 to 0.91 and 0.94, 0.88 to 1.01, respectively. Further adjustment did not materially change these estimates. There was no interaction between ΔSBP and ΔHbA1c in relation to albuminuria risk, suggesting likely additive effects on renal microvascular disease. CONCLUSIONS: Baseline measurements and changes in HbA1c and SBP a year after diagnosis of diabetes through screening independently associate with new onset albuminuria 4 years later. Established multifactorial treatment for diabetes applies to cases identified through screening.

Performance of the UKPDS outcomes model for prediction of myocardial infarction and stroke in the ADDITION-Europe trial cohort.

OBJECTIVES: We assessed the performance of the UK Prospective Diabetes Study (UKPDS) outcomes model in predicting the risk of myocardial infarction (MI) and stroke in the Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen Detected Diabetes in Primary Care (ADDITION-Europe) a trial cohort of patients with screen-detected type 2 diabetes from the United Kingdom, Denmark, and The Netherlands. METHODS: We estimated the 5-year accumulated risk of MI and stroke for 2899 screen-detected people with type 2 diabetes by using the UKPDS outcomes model (version 1.3). We compared the predicted and actual risks by country and by intervention group (routine care; intensive multifactorial treatment). We assessed discrimination and goodness of fit by using area under receiver operating characteristic curves and the Hosmer-Lemeshow chi-square test. Multiple imputations were used to overcome missing data. RESULTS: The UKPDS outcomes model overestimated the risk of MI and stroke. Mean predicted/actual ratios of 5-year accumulated risk were 2.31 for MI in the routine care group and 3.97 in the intensive multifactorial treatment group and 1.59 and 1.48 for stroke, respectively. The differences in absolute risk between the intervention groups were underestimated for MI (observed vs. predicted: 0.0127 vs. 0.0009) and slightly overestimated for stroke (-0.0013 vs. -0.0004). The area under the receiver operating characteristic curve was 0.72 (95% confidence interval 0.66-0.79) for MI and 0.70 (95% confidence interval 0.64-0.77) for stroke. The Hosmer-Lemeshow test statistic was nonsignificant in all groups. The model performed better in absolute risk prediction in Denmark and the United Kingdom than in The Netherlands. CONCLUSIONS: The UKPDS outcomes model has moderate discriminatory ability in the ADDITION-Europe trial cohort but overestimated absolute risk. The model may need updating for cardiovascular disease risk prediction in contemporary diabetes populations where patients may be diagnosed earlier in the disease trajectory and in whom cardiovascular risk is therefore lower.