Abstract and Introduction
Context: The relative importance of the control of different metabolic risk factors for the prevention of chronic kidney disease among patients with diabetes in real life conditions is insufficiently understood.
Objective: We evaluated the effect of the achievement of glycated hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDLc) or non–high-density lipoprotein cholesterol (non-HDLc) goals (ABC goals) on the development of incident chronic kidney disease (iCKD) among patients with diabetes.
Methods: In a nationwide registry of all individuals diagnosed with diabetes assisted by the health system in Colombia, we analyzed the association between baseline or sustained goal achievement and development of iCKD over a 4-year follow-up. iCKD was defined as a new occurrence of an estimated glomerular filtration rate less than 60 mL/min/1.73 m2, hemodialysis, peritoneal dialysis, or kidney transplant.
Results: The study included 998 790 adults with diabetes (56% female, mean age 59). There were 125 626 cases of iCKD. After adjustment for multiple confounders, a baseline SBP less than 130 mm Hg (odds ratio [OR] 0.79 [0.78–0.80]) and a baseline HbA1c less than 7.0% (OR 0.86 [0.85–0.87]) were negatively associated with iCKD. Sustained achievement showed stronger negative associations with iCKD than just baseline achievement. Considering each goal separately, sustained non-HDLc less than 130 mg/dL had the strongest negative association with iCKD (OR 0.67 [0.65–0.69]). Patients who maintained the triple ABC goal over the entire follow-up had 32% (29–34) lower odds of developing CKD, 38% (34–42) if they additionally kept a normal body mass index (BMI). Sustained ABC control including a normal BMI was more strongly associated with a lower incidence of CKD in patients of Black race (OR 0.72 vs 0.89; P for interaction = .002).
Conclusion: At the country level, sustained achievement of ABC goals and most especially non-HDLc were associated with substantial reductions in iCKD.
Chronic kidney disease (CKD) is a major health issue worldwide. Progressing CKD leads not only to end-stage renal disease (ESRD) but also to multiple adverse clinical outcomes, including cardiovascular disease, death, and disability. In sharp contrast to other noncommunicable diseases, CKD prevalence seems to be increasing over time. Recent studies from the Global Burden of Disease Collaboration estimate the global prevalence of CKD at 9.1%, an increase of almost 30% over the last 30 years. Low- or middle-income countries bear 80% of the disease burden from CKD.
Diabetes is currently the second leading cause of CKD and the top cause of ESRD. In 2019, type 2 diabetes was estimated to have caused 2.5 million incident CKD (iCKD) cases and more than 400 000 deaths. The risk of developing diabetic nephropathy does not follow closely the degree of hyperglycemia, especially among patients with type 1 diabetes, indicating that other disturbances must act synergistically with hyperglycemia to promote the development of glomerular and tubular changes that characterize CKD. These alterations include excess plasma free fatty acids, oxidative stress, vascular shear stress induced by transmitted systemic hypertension, impaired autoregulation, hyperperfusion or hypoperfusion, and activation of the renin-angiotensin-aldosterone system.
This multifactorial pathogenesis suggests that successful and continued control of the main risk factors may substantially affect the appearance of new CKD in people with diabetes. The positive and long-lasting effect of early glycemic control on the development of CKD has been proven for patients with type 1 diabetes in the Diabetes Control and Complications Trial—Epidemiology of Diabetes Interventions and Complications (DCCT-EDIC) study, and for patients with type 2 diabetes in the United Kingdom Prospective Diabetes Study (UKPDS). However, the associations between tight blood pressure or blood lipids control and the risk of iCKD have not been equally robust. This may be due to a host of factors, but it is important to note that treatment goals, pharmacological agents, and guideline adoption have all changed notably since the publication of these milestone trials.
With this background, we aimed to evaluate the association between the achievement of glycated hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDLc) or non–high-density lipoprotein cholesterol (non-HDLc) goals, the so-called ABC goals of diabetes, and the development of iCKD in a nationwide sample of nearly all patients with diabetes in the Colombian Health System. We also explored the differential effect of achieving these goals only at baseline vs sustaining them over time, and whether these associations differed in subgroups defined by race or body mass index (BMI).
J Endo Soc. 2023;7(3) © 2023 Endocrine Society