C FOOTE1,2,3, M JUN1, L SUKKAR1,3, A KANG1, K ROGERS1, J BAKER1, A SCARIA1, R PECOITS-FILHO4, A CASS5, D SULLIVAN6, M GALLAGHER1,2, C POLLOCK7, GERMAINE WONG8, J KNIGHT1, D PEIRIS1, M JARDINE1,2, ON BEHALF OF THE EXTEND 45 STUDY STEERING COMMITTEE
1The George Institute for Global Health, UNSW, Sydney, Australia, 2Concord Repatriation General Hospital, Sydney, Australia, 3University of Sydney, Sydney, Australia, 4Pontifícia Universidade Católica do Paraná, , Curitiba, Brazil, 5Menzies School of Health Research, Darwin, Australia, 6NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia, 7Kolling Institute for Medical Research, , Sydney, Australia, 8Centre for Kidney Research, University of Sydney, Sydney, Australia
Aim: To assess glycaemic control according to glucose-lowering treatment intensity and kidney function (estimated glomerular filtration rate[eGFR]) among NSW adult diabetics.
Background: Diabetics managed with more intensive therapy may be less likely to achieve glycaemic targets possibly reflecting disease severity or reluctance to increase treatment. How kidney function affects these relationships is unknown.
Methods: Based on data from the EXTEND45 study (45 and Up Study linked to hospital and community pathology datasets by the Centre for Health Record and Linkage[CHeReL] and the Medicare Benefits Schedule[MBS] and Pharmaceutical Benefits Scheme[PBS] datasets provided by the Department of Human Services) (2006-2014), a population-based cohort of 2,937 prevalent diabetics with an eGFR measurement was identified. Diabetes treatment was classified as mono-, dual-/triple- and insulin-based therapy. Mean HbA1c and not-at-target HbA1c (HbA1c ≥7%) over 2 years was compared according to glucose-lowering therapy and eGFR categories using logistic regression.
Results: Of 2937 prevalent diabetics, 67.2%, 20.1%, 9.2% and 3.5% had eGFR >60, 45-59, 30-44 and <30mL/min/1.73m2, attaining mean HbA1c of 7.22%, 7.14%, 7.12%, 7.13%, respectively. Overall, approximately half were managed with monotherapy, one-quarter with dual/triple-therapy and one-quarter with insulin-based therapy. Mean HbA1c increased as treatment intensified (6.81%, 7.23% and 7.83% for mono, dual/triple and insulin therapy, respectively). There was increased odds of not-at-target HbA1c with more intense treatment in adjusted models (OR 2.63[95% CI:2.17-3.18]; 5.07[4.13-6.23] for dual/triple- and insulin-based therapy, respectively, compared with monotherapy). Lower eGFR was not associated with not-at-target HbA1c in adjusted models (OR 1.06[0.86-1.31], 0.98[0.73-1.32], 0.89[0.55-1.42] for eGFR 45-59, 30-44, <30mL/min/1.73m2, respectively, compared with eGFR>60).
Conclusions: In a community cohort of prevalent diabetics, more intense treatment was associated with not attaining HbA1c targets at all levels of eGFR.
Dr Celine Foote is a nephrologist at Concord Repatriation General Hospital and is an Honorary Senior Research Fellow at the George Institute for Global Health. She has an interest in geriatric and palliative nephrology.