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In This Issue of Diabetes Care

A 38-year prospective nationwide study in Sweden of younger patients with type 1 diabetes suggests that there has been decreasing cumulative incidence and risk of end-stage renal disease (ESRD) in the country. According to Toppe et al. (p. 27), the pattern is likely an effect of improved diabetes care. They also suggest that young age at onset of diabetes is likely to prolong the time until severe complications develop. The study included 18,760 unique patients with type 1 diabetes with a duration of at least 14 years and age at onset between zero and 34 years. They combined data from a series of national registries to estimate the rates of ESRD over the study period. The authors found that cumulative incidence was low at 5.6% after up to 38 years of diabetes duration. They also found a decrease in the incidence of ESRD in patients who were diagnosed more recently, which was independent of diabetes duration. On that basis, they suggest that changes in diabetes care approaches may have contributed to the falling incidence rates. For example, a national recommendation was introduced in the 1980s to intensify insulin treatments and home blood glucose monitoring. They also highlight various aspects of the health care system that might have made a difference. These include 1) all hospital visits and medicines are free of charge up to age 18 years and 2) regardless of age, insulin, syringes, and glucose monitoring devices are free of charge in the country. They suggest that discrepancies in the design of health care systems around the world might explain the higher rates of ESRD. Commenting more widely, author Cecilia Toppe told Diabetes Care: “It is encouraging for clinicians to see that in recent years fewer patients develop ESRD due to diabetes. These fi ndings provide good arguments for intensifi ed treatment of known risk factors such as lipids, hypertension, and smoking habits.”