Kidney Analysis Results Mixed Bag with Intensive Metabolic Care

SAN DIEGO – Intensive glycemic control has slightly reduced macroalbuminuria over time in people with type 2 diabetes who are at high risk of cardiovascular disease, according to a secondary analysis of the ACCORD trial.

In the trial of more than 10,000 patients, randomized patients to tightly control their blood glucose – an HbA1c level below 6% – exhibited a slight decrease in the risk of occurrence of kidney cancer composite compared to those with a lower glucose goal of 7 -7.9% (HR 0.92, 95% CI 0.86-0.98), said Amy Mottl, MD, MPH, of the Kidney Center from the University of North Carolina to Chapel Hill, and his colleagues.

This risk reduction, however, was mainly due to a significant decrease in incident macroalbuminuria (HR 0.68, 95% CI 0.59-0.77), while target glucose ranges.

The results were presented here during the 2018 kidney week of the American Society of Nephrology (ASN) and published simultaneously in the Clinical Journal of the American Society of Nephrology.

Regarding the ACCORDION extension study, which was then randomized by half of ACCORD participants in a blood pressure or lipid test, different renal outcomes were reported.

For the blood pressure test, intensive treatment – target systolic BP <120 mmHg – was associated with a 16% greater risk of becoming composite kidney compared to a target systolic BP of less than 140 mmHg (HR 1.16, 95% CI 1.05-1.28). Similarly, in the lipid trial, the use of fenofibrate was also linked to a higher risk of renal composite outcome of 16% compared to placebo (HR 1.16, 95% CI 1.06-1). 27).

The researchers indicated that in the lipid and blood pressure trials, each of which included approximately 5,000 participants, this increased renal risk was due solely to a doubling of serum creatinine, as follows:

• Intensive blood pressure: HR 1.64 (95% CI: 1.30-2.06)
• Use of fenofibrate: HR 2.00 (95% CI: 1.61-2.49)

The other results, including incident macroalbuminuria, dialysis and mortality, were not different between the treatment groups.

Not Surprise, Pretty Surprise

"We were not surprised by the benefits of intensive glycemic control on reducing the risk of high levels of protein in the urine, but we were quite surprised by the adverse effects of the targets of intensive blood pressure and fenofibrates on a deterioration of kidney function, "said Mottl MedPage today.

"While the original ACCORD study and its subsequent ACCORDION study showed no benefit from intensive glucose, blood pressure goals and the use of fenofibrate with MACE [major adverse cardiovascular events]We thought that there might be a chance for the kidney results to be beneficial, "she continued. The results also showed how "kidney outcomes usually take longer, so long-term follow-up is extremely important."

This secondary analysis of results for the kidneys included all participants in the initial ACCORD trial who monitored the results for the kidneys after randomization in the trial. Incidental macroalbuminuria was defined as a urinary albumin-creatinine ratio> 300 μg / mg, whereas the need for dialysis was self-reported.

"In relation to the effects on [end-stage kidney disease] of the ACCORDION study alone or other recent trials involving similar BP targets (SPRINT) or fenofibrate (FIELD study), an inconsistency is again found between the effects on the DSSP and those on the doubling of serum creatinine, "noted Vlado Perkovic, MBBS, Ph.D., of the George Institute for Global Health, Australia, and co-authors, writing in an accompanying editorial.

However, editorialists warned against the assumption that the doubling of serum creatinine observed with intensive control of BP and the use of fibrate would automatically equate to kidney damage. Instead, they suggested that these results should be interpreted as "inconclusive" given the broad 95% confidence intervals for more reliable end-stage renal failure. [ESKD] results "and" limitations of the small number of creatinine measurements available. "Perkovic and his co-authors, however, noted that they felt that a potential benefit could be beneficial for DKT with intensive blood glucose control.

Mottl urged health care providers to approach patient care with the spirit that "one size does not fit all," adding that "in this era of precision medicine, we need to make sure adapt the right treatment strategies to the right patient. "

"In caring for elderly patients with type 2 diabetes and presenting a high risk of cardiovascular events, one must be particularly vigilant so as not to be too aggressive when setting blood pressure goals and I also recommend caution in the use of fibrate treatment. ", she said. . "Setting goals for glycemic control really depends on each patient and his overall risk of hypoglycemia, cardiovascular events and progressive renal failure."

1969-12-31T19: 00: 00-0500

Last update 26/10/2018