Effect of Kidney Disease in the ACCORD Trial

April 28, 2015

Effect of Kidney Disease in the ACCORD Trial

  1. Allan S. Brett, MD

Higher mortality with intensive glucose lowering occurred primarily in patients with chronic kidney disease.

  1. Allan S. Brett, MD

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.

Editor Disclosures at Time of Publication

  • Disclosures for Allan S. Brett, MD at time of publication Nothing to disclose

Citation(s):

Reader Comments (3)

CARLOS-EDUARDO GIRALDO Physician Physician, Hospital San Vicente de Paul Caldas -Colombia

Glycemic control is nowadays changing and inf fact, is a challenge for all physicians because it implies a close patient relationship in order to understand adherence; it is curious the way of table 1 where exposed during the analysis: many differences between the control group and the exposed shows the natural history of Chronic Kidney Disease; and indirectly: the adherence of the patients.
Consider adherence to the management is the key at the moment of establish goals during the glycaemic control more than HBA1C alone, nevertheless, know the risks of tight glycemic control in CKD patients stage I,II,III is important at the moment of the counseling.
It is important to remember that physicians are named to treat patients instead of illnesses understand adherence, socioeconomic situation and physiopatological changes are the cornerstone during the management of Chronic patients.

SUDARSAN CHAKRABORTY Physician, Internal Medicine, Calcutta,India

CKD with micro/overt albuminuria is a cardiovascular risk. Tight glycemic control with CKD will cause more hypoglycemia(even severe) which is an added cardiovascular barden.

James Dale DO Physician, Internal Medicine, Luray Va

Too much is made of blood glucose control in patients in general and when carried into the chronically ill population bad things can happen. These people often eat poorly and they make mistakes with medication more often. Keep it simple for them. Control sugar enough to avoid polyuria, thirst and weight loss. Don't worship at the A1C shrine in people with chronic disease.

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