Real-world data support intensive risk factor control in diabetes patients with CKD
medwireNews: Data from primary care indicate that more successful control of vascular risk factors in patients with type 2 diabetes and chronic kidney disease (CKD) is associated with reduced risk for cardiovascular disease (CVD) and mortality.
The findings complement those of the Steno-2 trial, which, although an influential randomized trial, was relatively small, say Shota Hamada (Institute for Health Economics and Policy, Tokyo, Japan) and Martin Gulliford (King’s College London, UK).
However, they note that because their study was observational, being based on data from the UK Clinical Practice Research Datalink, it is possible that doctors treated generally healthier patients more intensively, so they were more often classified as having good risk factor control.
“For example, stringent management of [glycated hemoglobin] might not be targeted for vulnerable participants due to concerns for greater risk of hypoglycaemia, a form of confounding by contraindication,” they write in BMJ Open.
Among 11,431 diabetes patients who also had CKD, the risk for mortality was reduced by 23% among those with two controlled risk factors, compared with one or none, and the size of the risk reduction increased to 30% and 40% among those with three and four controlled risk factors, respectively.
Four controlled risk factors was defined as glycated hemoglobin below 53 mmol/mol (<7.0%), blood pressure below 140/90 mmHg, total cholesterol below 5 mmol/L, and not currently smoking. The same relationship between number of controlled risk factors and outcomes was observed for CVD mortality, coronary heart disease, and stroke, and was also present in 36,429 patients with type 2 diabetes but no CKD.
These associations were independent of variables including age, sex, CKD stage, body mass index, diabetes duration, CVD history, and medication use.
Patients with CKD were older than those without, at an average of 71 versus 62 years, and had a longer duration of diabetes. They also had a higher risk for CVD outcomes for any given level of risk factor control. For example, those with four controlled risk factors had a 16% higher mortality risk than patients without CKD but with four controlled risk factors.
Overall, 63% of patients with CKD died from CVD causes, compared with 54% of those without, and 5% versus less than 1% died of renal causes.
This combination of high absolute risk and a large relative reduction associated with multiple risk factor control suggests that intensive treatment of CVD risk factors “may be one of the main approaches to potentially reducing the burden of diabetes and CKD,” write the researchers.
But they caution that more research is needed to ascertain the appropriateness of the strategy in patients with differing general health.
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