Impact of HbA1c Reduction on Major Kidney Outcomes in Type 2 Diabetes With Poor Glycemic Control and Advanced CKD
G Navarro-Blackaller1,2, A S Benitez-Renteria3, K Hernández-Morales1,2
1Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico.
Insights
For patients with type 2 diabetes and advanced chronic kidney disease, lowering glycated hemoglobin (HbA1c) did not reduce major adverse kidney events. Changes in HbA1c levels during follow-up were not associated with kidney outcomes in this high-risk group.
Area of Science:
- Nephrology
- Endocrinology
- Clinical Research
Background:
- Type 2 diabetes (DM) and advanced chronic kidney disease (CKD) present a significant clinical challenge.
- The kidney benefits of intensive glycemic control, measured by glycated hemoglobin (HbA1c), are not well-established in patients with DM and advanced CKD (grade 3b-5).
- Poor glycemic control in this population is associated with adverse kidney outcomes.
Purpose of the Study:
- To evaluate the association between glycated hemoglobin (HbA1c) levels and major adverse kidney events (MAKE) in patients with type 2 diabetes and advanced chronic kidney disease.
- To determine if reductions in HbA1c correlate with improved kidney outcomes, including kidney replacement therapy (KRT), estimated glomerular filtration rate (eGFR) decline, or death.
- To analyze the risk of MAKE in relation to different HbA1c categories at the end of follow-up.
Main Methods:
- Retrospective cohort study including 111 patients with type 2 diabetes, CKD grade 3b-5, and baseline HbA1c > 9%.
- Patients were categorized into groups based on end-of-follow-up HbA1c levels (e.g., < 7.0%, 7.0-7.9%, 8.0-8.9%, ≥ 9.0%).
- MAKE was defined as initiation of KRT, ≥ 25% or ≥ 40% eGFR decline, or death. Multivariate analysis was used to adjust for confounding variables.
Main Results:
- MAKE occurred in 67% of the included patients over a median follow-up of 60 months.
- Multivariate analysis revealed no significant association between HbA1c levels at the end of follow-up and the risk of MAKE or its individual components.
- No association was found between the magnitude of HbA1c percentage changes and the initiation of KRT or other MAKE components.
Conclusions:
- In patients with type 2 diabetes and advanced chronic kidney disease, achieving target HbA1c levels does not appear to mitigate the risk of major adverse kidney events.
- Changes in HbA1c during long-term follow-up are not demonstrably linked to kidney outcomes in this specific patient cohort.
- Further research may be needed to identify effective interventions for kidney protection in diabetic patients with advanced CKD.
Abstract:
Aims: In subjects with type 2 diabetes (DM), poor glycemic control, and advanced chronic kidney disease (CKD), the kidney benefit of the reduction of glycated hemoglobin (HbA1c) is not well established. Methods: In a retrospective cohort, we included patients with DM, CKD grade 3b-5, and HbA1c > 9% to evaluate the risk of developing major adverse kidney events (MAKE) defined as the start of kidney replacement therapy (KRT), ≥ 25% or ≥ 40% decline in the glomerular filtration rate (eGFR) from baseline, and death; patients were divided according to the HbA1c levels at the end of the follow-up into the following groups: > 75 mmol/mol (≥ 9.0%), 74-64 mmol/mol (8.9%-8.0%), 64-53 mmol/mol (7.9%-7.0%), and < 52 mmol/mol (< 7.0%). We described their characteristics and analyzed their risks, adjusting for confounding variables. Results: From 2015 to 2023, 111 patients were included. In 46 patients (41.4%), the HbA1c at the end of follow-up (60 months) was still > 75 mmol/mol (≥ 9%), and each patient had a mean of 4.9 HbA1c measurements. The mean age was 59 years, and 46% were male; the baseline eGFR was 25 mL/min/1.73 m2. MAKE occurred in 67% of cases. In a multivariate analysis, the risk of MAKE was not associated with the HbA1c groups, nor was it associated with any of the MAKE components individually, nor in certain subgroups. When evaluating the magnitude of percentage changes in HbA1 with the initiation of KRT, we did not find any association. Conclusions: With advanced CKD and poor glycemic control, changes in HbA1c during long follow-up are not associated with MAKE or its individual components.
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