1.8.2.0 Glyce­mic Tar­gets

In­ten­sive glycemic con­trol with the goal of achiev­ing near-‍nor­mo­glycemia has been shown in large prospec­tive ran­domized stud­ies to delay the onset and pro­gres­sion of al­bu­minuria and re­duced eGFR in pa­tients with type 1 di­a­betes (27,28) and type 2 di­a­betes (1,29–34). In­sulin alone was used to lower blood glu­cose in the Di­a­betes Con­trol and Com­pli­ca­tions Trial (DCCT)/Epi­demi­ol­o­gy of Di­a­betes In­ter­ven­tions and Com­pli­ca­tions (EDIC) study of type 1 di­a­betes, while a va­ri­ety of agents were used in clin­i­cal tri­als of type 2 di­a­betes, sup­port­ing the con­clu­sion that glycemic con­trol it­self helps pre­vent CKD and its pro­gres­sion. The ef­fects of glu­cose-low­er­ing ther­a­pies on CKD have helped define A1C tar­gets (see Table 6.2).

The pres­ence of CKD af­fects the risks and benefits of in­ten­sive glycemic con­trol and a num­ber of specific glu­cose-low­er­ing med­i­ca­tions. In the Ac­tion to Con­trol Car­dio­vas­cu­lar Risk in Di­a­betes (AC­CORD) trial of type 2 di­a­betes, ad­verse ef­fects of in­ten­sive glycemic con­trol (hy­po­glycemia and mor­tal­i­ty) were in­creased among pa­tients with kid­ney dis­ease at base­line (35,36). More­over, there is a lag time of at least 2 years in type 2 di­a­betes to over 10 years in type 1 di­a­betes for the ef­fects of in­ten­sive glu­cose con­trol to man­i­fest as im­proved eGFR out­comes (33,37,38). There­fore, in some pa­tients with preva­lent CKD and sub­stan­tial co­mor­bidity, tar­get A1C lev­els may be less in­ten­sive (1,39).