Effect of Kidney Disease in the ACCORD Trial

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In the landmark ACCORD trial (NEJM JW Gen Med Jul 1 2008 and N Engl J Med 2008; 358:2545), which involved >10,000 patients with longstanding type 2 diabetes, all-cause and cardiovascular-related mortality were significantly higher in patients randomized to intensive glycemic control (target glycosylated hemoglobin [HbA1c], <6%) than in those who received less-intensive control (target HbA1c, 7.0%–7.9%). In this post-hoc analysis, researchers examined whether renal function influenced this outcome.

At baseline, 64% of participants had no chronic kidney disease (CKD), and 14%, 14%, and 8% had stage 1, 2, and 3 CKD, respectively (patients with more severe CKD were excluded). In the CKD group, intensively treated patients had significantly higher mortality than nonintensively treated patients: Annual rates were 2.4% vs. 1.8% for all-cause mortality and 1.3% vs. 0.9% for cardiovascular-related mortality. In contrast, intensive treatment was not associated with higher mortality in the non-CKD group.

Comment

These findings suggest that clinicians should be especially restrained in pursuing tight glycemic control in patients with longstanding type 2 diabetes who have CKD. Unsurprisingly, severe hypoglycemia was more common in CKD patients who were randomized to tight glycemic control than in other patients, but whether hypoglycemia mediated the higher death rate was not established in this analysis.

Allan S. Brett, MD reviewing Papademetriou V et al. Kidney Int 2015 Mar. –

 

 

Citation(s):

  1. Papademetriou V et al. Chronic kidney disease and intensive glycemic control increase cardiovascular risk in patients with type 2 diabetes. Kidney Int 2015 Mar; 87:649. (http://dx.doi.org/10.1038/ki.2014.296)
    PubMed abstract (Free)