Chronic kidney disease and intensive glycemic control increase cardiovascular risk in patients with type 2 diabetes

Abstract

Results of the main Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial indicate that intensive glucose lowering increases cardiovascular and all-cause mortality. As the contribution of mild-to-moderate chronic kidney disease (CKD) to these risks is not known, we assessed the impact on cardiovascular outcomes in this population. Renal function data were available on 10,136 patients of the original ACCORD cohort. Of those, 6,506 were free of CKD at baseline and 3,636 met the criteria for CKD. Participants were randomly assigned to a treatment strategy of either intensive or standard glycemic goal. The primary outcome, all-cause and cardiovascular mortality, and prespecified secondary outcomes were evaluated. Risk for the primary outcome was 87% higher in patients with than in those without CKD (hazard ratio of 1.866; 95% CI: 1.651-2.110). All prespecified secondary outcomes were 1.5 to 3 times more frequent in patients with than in those without CKD. In patients with CKD, compared with standard therapy, intensive glucose lowering was significantly associated with both 31% higher all-cause mortality (1.306: 1.065-1.600) and 41% higher cardiovascular mortality (1.412: 1.052-1.892). No significant effects were found in patients without CKD. Thus, in high-risk patients with type II diabetes, mild and moderate CKD is associated with increased cardiovascular risk. Intensive glycemic control significantly increases the risk of cardiovascular and all-cause mortality in this population.

Diabetic Kidney Disease

“…Targeting low HbA1C (6%-6.9%) compared with standard therapy in this population did not reduce risk of cardiovascular (CV) or microvascular complications but increased the risk of severe hypoglycemia (54)(55)(56). Furthermore, an analysis of patients with DM2 and early-stage CKD showed 30% and 40% higher risks for allcause mortality and CV mortality, respectively, with intensive glycemic control compared with standard therapy (57). The finding that intensive glycemic control incurs great risk of hypoglycemia and does not benefit the risk of CVD or all-cause mortality has been sustained over the long term (8-10 years).…”

Prevalence of Chronic Kidney Disease (CKD) in Type 2 Diabetes Mellitus Patients: START-India Study

“…The currently available data in the public domain, is either from some specific regions in the country or it doesn't capture the prevalence of CKD specifically in T2DM population [9,14]. Therefore, it was eminent to perform a pan-India epidemiological study to get a clear cut idea on the prevalence of CKD in T2DM patients.…”

Metformin in advanced chronic kidney disease: are current guidelines overly restrictive?

“…41,42 Indeed, in a post hoc analysis of the ACCORD data, intensive glycaemic control was found to significantly increase cardiovascular and all-cause mortality in CKD patients, but not in non-CKD patients. 43 Therefore, metformin may have a particular advantage over other therapies in this high-risk population.…”