Intensive glycemic control and renal outcome

Abstract

Diabetes is the leading cause of chronic kidney disease (CKD) in many countries around the world, accounting for up to 50% of people who develop end-stage renal disease. The risk of morbidity and mortality is particularly high in people with both conditions, highlighting the importance of preventing the development and progression of earlier stage CKD in people with diabetes. Inadequate glycemic control has been associated with poor outcomes in diabetes, with early observational studies suggesting that tighter glycemic control may improve microvascular and macrovascular outcomes in patients with diabetes. Since then, large trials assessing the effect of intensive glycemic control in the general diabetic population have provided strong evidence that intensive therapy reduces the incidence and progression of microvascular outcomes including microalbuminuria, a key early marker of diabetic nephropathy (DN). These results have been consistent across both type 1 and type 2 diabetic populations demonstrating that intensive glycemic therapy provides clear benefits, delays the onset or progression of DN, particularly in its early stages. Whilst the benefits of intensive glycemic therapy for people with diabetes and early stage CKD have been well established, controversy remains as to whether intensive therapy slows the progression of established DN, particularly among individuals who have a reduced glomerular filtration rate. In addition, severe hypoglycemia has been associated with intensive glycemic therapy, raising safety concerns that may be of particular relevance for patients with decreased kidney function (CKD stages 3-5). Until further data are available, an individualized approach to glucose management is recommended in people with reduced glomerular filtration rate.