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Intensive Glycemic Control and End-Stage Renal Disease in Type 2 Diabetes

One case of ESRD was prevented for every 430 intensively treated patients. In recent randomized trials, intensive glycemic control did not prevent macrovascular events in patients with longstanding type 2 diabetes. In one of those trials (ADVANCE, with 11,000 patients overall; JW Gen Med Jun 6 2008 (Link to: http://general-medicine.jwatch.org/cgi/content/full/2008/606/1) ), intensive control prevented macroalbuminuria, a surrogate endpoint for microvascular disease, from developing in some patients. Now, the researchers present information on the most important renal endpoint progression to end-stage renal disease (ESRD). After 5 years, mean glycosylated hemoglobin (HbA1c) levels were 7.3% and 6.5% in the standard- and intensive-treatment groups, respectively. ESRD occurred in 20 standard-treatment patients and in 7 intensive-treatment patients. The difference is statistically significant, but about 430 patients underwent intensive glycemic control to prevent 1 case of ESRD. Researchers found no significant differences between groups in incidences of "renal death" or doubling of serum creatinine level. Comment: The authors believe that their results show "intensive glucose lowering using ADVANCE-like regimens may be beneficial for many people with diabetes." However, the word "many" here is in the eye of the beholder: Editorialists express concern about the large number needed to treat and note that intensive control can confer both benefits and harms. They conclude that "an A1c target <6.5% for type 2 diabetes should be used cautiously, if at all perhaps only in well-informed patients who are younger, at lower risk for hypoglycemia, and free of symptomatic cardiovascular disease." Allan S. Brett, MD (Link to: http://general-

medicine.jwatch.org/misc/board_about.dtl#aBrett)
Published in Journal Watch General Medicine (Link to: http://general-medicine.jwatch.org) March 26, 2013

Citation(s):
Perkovic V et al. Intensive glucose control improves kidney outcomes in patients with type 2 diabetes. Kidney Int 2013 Mar; 83:517. (http://dx.doi.org/10.1038/ki.2012.401 (Link to: http://dx.doi.org/10.1038/ki.2012.401) ) Medline abstract (Link to: /cgi/external_ref?access_num=23302714&link_type=MED) (Free) Shurraw S and Tonelli M. Intensive glycemic control in type 2 diabetics at high cardiovascular risk: Do the benefits justify the risks? Kidney Int 2013 Mar; 83:346. (http://dx.doi.org/10.1038/ki.2012.431 (Link to: http://dx.doi.org/10.1038/ki.2012.431) ) Medline abstract (Link to: /cgi/external_ref?access_num=23446251&link_type=MED) (Free)

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