OBJECTIVE A common belief is that only a minority of patients with type 1 diabetes (T1D) develop advanced kidney disease and that incidence is higher among men and lower in those diagnosed at a younger age. However, because few patients with T1D survived to older ages until recently, long-term risks have been unclear.

RESEARCH DESIGN AND METHODS We examined the 50-year cumulative kidney complication risk in a childhood-onset T1D cohort diagnosed during 1950–80 (n = 932; mean baseline age 29 years, duration 19 years). Participants were 144 who died before baseline, 130 followed with periodic surveys, and 658 followed with biennial surveys and a maximum of nine examinations for 25 years. Micro- and macroalbuminuria were defined as an albumin excretion rate of 20–199 and ≥200 μg/min, respectively, and end-stage renal disease (ESRD) as dialysis or kidney transplantation. Cumulative incidence was estimated at 10-year intervals between 20 and 50 years duration and compared by calendar year of diabetes onset.

RESULTS By 50 years of T1D duration, ESRD affected 60% of the cohort; macroalbuminuria, 72%; and microalbuminuria, 88%. Little evidence existed for declines in cumulative incidence in recent cohorts, except for ESRD (microalbuminuria 3% increase, macroalbuminuria no change; ESRD 45% decrease by 40 years of T1D duration). Onset before age 6 years was associated with the lowest risk; incidence generally did not differ by sex.

CONCLUSIONS Some degree of kidney disease in T1D is virtually universal at long durations and not declining, which has major implications for health care and research strategies. ESRD has declined, but continues to affect >25% of the population by 40 years duration.