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Kidney disease in childhood-onset diabetes.

The increasing prevalence of obesity in children and adolescents in many parts of the world is strongly implicated in the increasing incidence of type 1 and type 2 diabetes during childhood.1,2 Whether youth affords some protection from the vascular complications of diabetes is uncertain, but the importance of this question is clear given the major public health and economic impact associated with earlier development of diabetic complications, including kidney disease. Some studies suggested that the prepubertal years of diabetes contribute less to the risk of diabetic kidney disease than the postpubertal years; however, this concept is controversial.3–8 Nevertheless, up to 40% of persons with type 1 diabetes develop overt diabetic nephropathy within 20 to 25 years of the onset of diabetes. 
 
Most studies that examine the risk of microalbuminuria and diabetic nephropathy in patients with type 1 diabetes are based on prevalence cohorts, often with short-term follow-up, and included patients with varying durations of diabetes.9–12 Accordingly, selection and survivor biases may be introduced that impact on the assessment of the role of age at onset of diabetes on the development and progression of diabetic kidney disease. The Steno group13 recently described the frequency of microalbuminuria and macroalbuminuria in an inception cohort of patients who were followed up from the onset of type 1 diabetes. Age at the diagnosis of diabetes averaged 27.5 years in this cohort, and the investigators reported that after about 18 years of diabetes, the cumulative incidences of microalbuminuria and macroalbuminuria were 33.6% and 14.6%, respectively. They also observed that permanent regression from microalbuminuria to normoalbuminuria was rare, with most of those who experienced regression relapsing to microalbuminuria. Their findings suggest that the development of microalbuminuria in older-onset type 1 diabetes is often associated with progressive nephropathy.