強化血糖控制對糖尿病患的長期腎臟健康有益


  【24drs.com】新研究指出,在近10年的追蹤期間,與接受標準照護的第二型糖尿病患者相比,接受了5年強化血糖控制治療的患者,比較不會發生末期腎病(end-stage renal disease,ESRD)。
  
  澳洲雪梨大學喬治全球衛生研究院Muh Geot Wong等人,將研究結果線上發表於3月23日的糖尿病照護期刊。
  
  研究人員追蹤了8,494名患者在腎臟方面的結果,這些患者先在「Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Released Controlled Evaluation (ADVANCE)」研究被隨機分組接受強化降血糖治療或標準照護,之後在「ADVANCE-ON」試驗完成追蹤。
  
  Wong醫師表示,這篇研究強調,一段期間的強化血糖控制,可以持續預防第二型糖尿病患者發生ESRD。
  
  重要的是,最初保有腎功能且無收縮高血壓者受益最多。
  
  Wong醫師強調,因此,我們的研究強調,盡早達到強化血糖控制對於預防後來發生嚴重的糖尿病腎病變的重要性。
  
  此外,不同於Action to Control Cardiovascular Risk in Diabetes (ACCORD)試驗:強化降血糖與慢性腎病(chronic kidney disease,CKD)患者的死亡風險增加有關。在ADVANCE-ON試驗中,不論開始時的腎功能情況,一段期間的緊密血糖控制並不會影響整體的各種原因死亡率、心血管死亡率、重大心血管事件、MI或中風。
  
  Wong醫師等人指出,儘管實施了生活型態調整與降血壓等標準照護的最佳實務,糖尿病腎病患者依舊有相當高比率惡化成ESRD 。
  
  在已開發國家和許多開發中國家,糖尿病目前已超越腎小球性腎炎成為ESRD的最常見原因,因此,再度關注強化血糖控制對於發生ESRD的影響。
  
  ADVANCE試驗的第二型糖尿病患者,接受了強化的或標準的降血糖介入,介入期間中位數為5.0年,試驗後接著參與ADVANCE-ON追蹤試驗者,全部都是接受標準照護,繼續追蹤6年(中位數為5.4年)。
  
  2014年9月,研究者針對ADVANCE-ON發表了整體結果;目前的分析則是更加深入地瞭解,不同初始腎功能的糖尿病患進行強化血糖控制對於ESRD(定義為需要透析或腎臟移植)、心血管事件、死亡等風險有何影響。
  
  在ADVANCE試驗中,接受強化降血糖的患者比接受標準照護者更不會發生ESRD(7例相較於20例;風險比[HR]為0.35;P = .02),且這個效益持續到試驗後追蹤期-ADVANCE-ON (29 例相較於53例;HR, 0.54;P < .01)。
  
  用不同的方式表示,在9.9年間,使用強化降血糖治療預防1例ESRD,需要被治療的病人數目(NNT)為194名患者。
  
  開始時為第1或第2期CKD的患者,預防1例ESRD的NNT值較少、為109,收縮壓< 140 mm Hg者也是,NNT值為120。第3期以上的CKD或收縮壓> 140 mm Hg者, NNT值比較多(分別是NNT = 393與368名患者)。
  
  Wong醫師等人指出,研究結果強調,在糖尿病腎病發展前開始強化血糖控制的重要性,因為腎功能已經降低的患者所觀察到的腎臟效益比較小。
  
  他們結論指出,我們的資料建立更多證據指出,強化血糖控制對於限制腎病惡化有重要影響,且可減少第二型糖尿病患因為糖尿病腎病變而需要透析或移植的人數。
  
  資料來源: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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