Study Questions Aggressive Glucose Control in All Patients with Diabetes and Renal Failure

Aggressive glucose control does not improve survival in patients with diabetes and renal failure, according to a study. The results suggest that physicians should individualize hemoglobin (Hb) A1c targets for these patients and not rely on recommendations based on studies in the general population…

Uncontrolled blood glucose levels can cause serious health problems for patients with diabetes and kidney failure; however, studies provide conflicting results on the benefits and risks of aggressive glucose control in these individuals.

By studying 24,875 dialysis patients for up to 3 years of follow-up, Mark Williams, MD, Joslin Diabetes Center, Boston, Massachusetts, and his colleagues found that only sustained extremes — either high or low — in blood glucose levels increased patients’ risk of dying prematurely. Type 2 diabetes patients with Hb A1c levels >11.0% were particularly at risk, with a 21% increased likelihood of dying during the study. In the small (5.5%) subgroup of patients with Type 1 diabetes, those with Hb A1c levels >9% had a 52% increased risk of dying during the study.

“In the absence of randomized, controlled trials, these results suggest that aggressive glucose control cannot be routinely recommended for all diabetic hemodialysis patients on the basis of reducing mortality risk,” the authors concluded. They encouraged physicians who treat patients with diabetes and kidney failure to individualize glucose targets based on the potential risks and benefits for each patient.

In reviewing the results of this study in an accompanying editorial, Joachim Ix, MD University of California, San Diego and Veterans Affairs San Diego Healthcare System, San Diego, California, noted that, “To date, there are no data available from randomized clinical trials targeting different hemoglobin A1c levels and powered for cardiovascular events or mortality in end-stage renal disease populations. In their absence, the marked statistical power and elegant analyses provided by these … investigators provide useful insights.” He agreed that individualized Hb A1c targets might be more appropriate than a one-size-fits-all target.

Clinical Journal of the American Society Nephrology (CJASN) August, 2010