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), 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 (HbA_1c) 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 A_1c 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.”

Source: Journal Watch General Medicine