Summary
Observational studies have shown the strong association between level of glycemic
control and the key outcome measure, risk of glomerular filtration rate (GFR) loss
rather than subsequent course of albumin excretion, in type 1 diabetes patients at
all stages of nephropathy. However, it has not been clear if clinical interventions
designed to normalize glycemic control are equally effective at all stages, such as
primary prevention in normoalbuminuric patients, secondary prevention in microalbuminuria
and macroalbuminuria, or tertiary prevention aimed at slowing or reversing further
loss of GFR once impaired. Substantial randomized controlled trial data from the Diabetes
Control and Complications Trial and Epidemiology of Diabetes Interventions and Complications
exists to support postponement, but not outright prevention, of GFR loss in normoalbuminuric
patients. Although secondary and tertiary prevention systematic studies are limited
to methodologically insufficient insulin pump and transplantation trials, the reversal
of advanced glomerular lesions observed in whole-pancreas transplant recipients who
experienced long-term glycemic normalization offers convincing support for further
research into glycemic interventions specifically for GFR preservation. In light of
existing literature, we encourage the design of secondary and tertiary prevention
trials that incorporate biomarker methods for identifying patients at highest risk
of GFR loss because interventions to normalize hyperglycemia are resource-intensive
and may be applied unnecessarily to clinical populations at low long-term GFR loss
risk.
Keywords
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Article info
Footnotes
Financial support: Supported by research funding from the Juvenile Diabetes Research Foundation, the Canadian Diabetes Association, and the Banting and Best Diabetes Centre, and by research funding from Medtronic Minimed, Inc, and Boehringer-Ingelheim (B.A.P.).
Conflict of interest statement: none.
Identification
Copyright
© 2012 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
