强化血糖控制对糖尿病患的长期肾脏健康有益


  【24drs.com】新研究指出,在近10年的追踪期间,与接受标准照护的第二型糖尿病患者相比,接受了5年强化血糖控制治疗的患者,比较不会发生末期肾病(end-stage renal disease,ESRD)。
  
  澳洲悉尼大学乔治全球卫生研究院Muh Geot Wong等人,将研究结果在线发表于3月23日的糖尿病照护期刊。
  
  研究人员追踪了8,494名患者在肾脏方面的结果,这些患者先在「Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Released Controlled Evaluation (ADVANCE)」研究被随机分组接受强化降血糖治疗或标准照护,之后在「ADVANCE-ON」试验完成追踪。
  
  Wong医师表示,这篇研究强调,一段期间的强化血糖控制,可以持续预防第二型糖尿病患者发生ESRD。
  
  重要的是,最初保有肾功能且无收缩高血压者受益最多。
  
  Wong医师强调,因此,我们的研究强调,尽早达到强化血糖控制对于预防后来发生严重的糖尿病肾病变的重要性。
  
  此外,不同于Action to Control Cardiovascular Risk in Diabetes (ACCORD)试验:强化降血糖与慢性肾病(chronic kidney disease,CKD)患者的死亡风险增加有关。在ADVANCE-ON试验中,不论开始时的肾功能情况,一段期间的紧密血糖控制并不会影响整体的各种原因死亡率、心血管死亡率、重大心血管事件、MI或中风。
  
  Wong医师等人指出,尽管实施了生活型态调整与降血压等标准照护的最佳实务,糖尿病肾病患者依旧有相当高比率恶化成ESRD 。
  
  在已开发国家和许多开发中国家,糖尿病目前已超越肾小球性肾炎成为ESRD的最常见原因,因此,再度关注强化血糖控制对于发生ESRD的影响。
  
  ADVANCE试验的第二型糖尿病患者,接受了强化的或标准的降血糖介入,介入期间中位数为5.0年,试验后接著参与ADVANCE-ON追踪试验者,全部都是接受标准照护,继续追踪6年(中位数为5.4年)。
  
  2014年9月,研究者针对ADVANCE-ON发表了整体结果;目前的分析则是更加深入地了解,不同初始肾功能的糖尿病患进行强化血糖控制对于ESRD(定义为需要透析或肾脏移植)、心血管事件、死亡等风险有何影响。
  
  在ADVANCE试验中,接受强化降血糖的患者比接受标准照护者更不会发生ESRD(7例相较于20例;风险比[HR]为0.35;P = .02),且这个效益持续到试验后追踪期-ADVANCE-ON (29 例相较于53例;HR, 0.54;P < .01)。
  
  用不同的方式表示,在9.9年间,使用强化降血糖治疗预防1例ESRD,需要被治疗的病人数目(NNT)为194名患者。
  
  开始时为第1或第2期CKD的患者,预防1例ESRD的NNT值较少、为109,收缩压< 140 mm Hg者也是,NNT值为120。第3期以上的CKD或收缩压> 140 mm Hg者, NNT值比较多(分别是NNT = 393与368名患者)。
  
  Wong医师等人指出,研究结果强调,在糖尿病肾病发展前开始强化血糖控制的重要性,因为肾功能已经降低的患者所观察到的肾脏效益比较小。
  
  他们结论指出,我们的资料建立更多证据指出,强化血糖控制对于限制肾病恶化有重要影响,且可减少第二型糖尿病患因为糖尿病肾病变而需要透析或移植的人数。
  
  资料来源:http://www.24drs.com/
  
  Native link:Intensive Glucose Control, Long-term Kidney Benefit in Diabetes

Intensive Glucose Control, Long-term Kidney Benefit in Diabetes

By Marlene Busko
Medscape Medical News

Compared with patients with type 2 diabetes who received standard care, those who received 5 years of intensive glucose-lowering treatment were less likely to develop end-stage renal disease (ESRD) during a total of almost 10 years of follow-up, new research indicates.

The study, by Dr Muh Geot Wong, from the George Institute for Global Health, University of Sydney, Australia, and colleagues, was published online March 23 in Diabetes Care.

The researchers homed in on renal outcomes in 8494 patients who had first been randomized to receive intensive glucose lowering vs standard care in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Released Controlled Evaluation (ADVANCE) study and then completed the follow-up ADVANCE-ON trial.

"This study highlighted that a period of intensive glucose control continues to protect against the development of ESRD in patients with type 2 diabetes," Dr Wong told Medscape Medical News.

Importantly, those with initial preserved kidney function and without systolic hypertension benefited the most.

Thus, "our results highlight the importance of achieving intensive glucose control as early as possible to prevent the development of future serious diabetic kidney disease," Dr Wong emphasized.

Moreover, unlike in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial — where intensive glucose lowering was tied to an increased mortality risk in patients with chronic kidney disease (CKD) — in ADVANCE-ON, a period of tight glucose control did not affect overall all-cause mortality, cardiovascular mortality, major cardiovascular events, MI, or stroke — regardless of baseline kidney function.

Diabetes Now Number One Cause of ESRD

Despite the implementation of "best-practice" standards of care for lifestyle modification and blood-pressure lowering, there remains a high level of progression to ESRD for those with diabetic kidney disease, Dr Wong and colleagues note.

And diabetes has now surpassed glomerulonephritis as the most common cause of ESRD in the developed world and many developing countries.

Hence, there is a renewed interest in the role of intensive glucose control in development of ESRD, they note.

The type 2 diabetes patients in ADVANCE received intensive or standard glucose-lowering interventions for a median of 5.0 years, and those who went on to participate in the ADVANCE-ON posttrial all received standard care and were followed for a further 6 years (median, 5.4 years).

In September 2014, the researchers published overall results from ADVANCE-ON; the current analysis takes a deeper dive into how intensive glucose control in diabetic patients with different initial renal function affected the risk of ESRD (defined as needing dialysis or a kidney transplant), cardiovascular events, and death.

Patients who received intensive glucose lowering in ADVANCE were less likely to develop ESRD than patients who received standard care (seven events vs 20 events; hazard ratio [HR], 0.35; P = .02), and this benefit persisted in the posttrial follow-up, ADVANCE-ON (29 events vs 53 events; HR, 0.54; P < .01).

NNT to Prevent One ESRD Event Is 109 for Those With Early Disease

Expressed differently, the number needed to treat (NNT) with intensive glucose-lowering therapy to prevent one ESRD event during 9.9 years was 194 patients.

The NNT to prevent one ESRD event was lower for patients with baseline stage 1 or 2 CKD, at 109, or systolic blood pressure < 140 mm Hg, at 120, and it was greater for patients with baseline stage 3 or higher CKD or systolic blood pressure > 140 mm Hg (NNT = 393 and 368 patients, respectively).

"Our results highlight the importance of commencing intensive glucose control before diabetic kidney disease develops, as lesser renal benefit was observed in participants with an established reduction in kidney function," Dr Wong and colleagues state.

"Our data build on a growing body of evidence indicating an important role for intensive glucose control in limiting the progression of kidney disease and in curbing the growing number of patients around the world with type 2 diabetes requiring dialysis or transplantation as a result of diabetic kidney disease," they conclude.

The ADVANCE trial and ADVANCE-ON follow-up study were funded by unrestricted grants from Servier and the Australia National Health and Medical Research Council. Dr Wong reports fees for scientific lectures from AstraZeneca. Disclosures for the coauthors are listed in the article.

Diabetes Care. Published online March 23, 2016.

    
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