Glycemic Control in Patients with Diabetic Kidney Disease; Time to Recognize Perils of Iatrogenic Hypoglycemia?Moving away from Intensive Glycemic Control.

The chronic complications of Diabetes Mellitus (DM), which may be present in as many as 50% of the patients at the time of diagnosis, are a major burden for both individuals with the disease and health systems and it has been estimated that as much as 60-70% of healthcare expenditure related to diabetes (about 670 billion dollars a year) is currently attributable to chronic complications of the disease. These high prevalence rates are widely acknowledged to further rise as poor lifestyle choices and their consequences continue to rise. Adding to that is an aging population and urbanization that together will make situation even more challenging. Type 2 diabetes affects about 90-95% of newly diagnosed patients of diabetes and accounts for majority of cases of Chronic Kidney Disease (CKD). In other words, CKD affects about 20-40% of individuals with diabetes making it one of the most common complication related to the disease. The risk of renal failure is 25 times higher in diabetic patients than in the non-diabetic population. Thus patients with diabetes and renal failure represent a special risk group as they have higher morbidity and mortality and are at a higher risk of hypoglycaemia than diabetic individuals with normal renal function. In addition, for all the physicians who are taking care of patients of diabetes and kidney disease, formulation of comprehensive plan of management directed at modification of risk factors of cardiovascular disease (CVD) is of utmost importance as majority of patients with CKD die as a result of cardiovascular complications rather than progression to ESRD, (accounting for about 70% of deaths over the age of 65). The contrasting results available from clinical trials in recent years have generated perplexity amid concerns that glucose-lowering therapies, under certain circumstances, might even be detrimental; in light of the fact that intensive glycemic control increased the risk for death by 22% in the ACCORD trial. Moreover it should be pooled data of some extensive reviews which has been carried in last one and half year have demonstrated that intensive glycemic control significantly increases the risk of cardiovascular and all-cause mortality in patients of CKD. So it is increasingly problematic for clinicians to continue aggressive glycemic control for the treatment of renal outcome in patients of advanced renal insufficiency with multiple co-morbidities. Thus, a lower survival benefit due to multiple comorbidities combined with general lower life expectancy necessitates a balanced approach. Suggesting the need for revised and extended target of HBA1C in this patient population.