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TOPLINE:

A Danish nationwide study of nearly 30,000 patients with diabetes and severe chronic kidney disease (CKD) showed that maintaining A1c levels between 6.7% and 7.1% minimised long-term complications, challenging current conservative glycaemic targets in this high-risk population.

METHODOLOGY:

• Researchers conducted this nationwide registry-based cohort study to investigate the association between A1c levels and complications in 27,113 patients with diabetes and severe CKD (median age, 77.4 years; 53.6% men; type 1 diabetes, 30.5%).
• Severe CKD was defined by two registered estimated glomerular filtration rate (eGFR) measurements < 30 mL/min/1.73 m² at least 90 days apart.
• Patients were matched to two reference groups: 80,131 individuals with diabetes and mild-to-moderate CKD (eGFR, 30-59 mL/min/1.73 m²) and 80,797 individuals with diabetes and no-to-mild CKD (eGFR ≥ 60 mL/min/1.73 m²).
• The 1-year risk for major adverse cardiovascular events, microvascular complications, and hospitalisations due to hypoglycaemia was estimated across A1c levels.
• The median follow-up duration was 5.4 years for patients with severe CKD.

TAKEAWAY:

• The risk for major adverse cardiovascular events significantly increased at A1c levels ≥ 7.2% and < 5.8% compared with an A1c level of 6.3%-6.6% (P < .01 and P < .001, respectively).
• The risk for microvascular complications significantly increased at A1c levels ≥ 7.2% (P < .001), and the risk for hospitalisation due to hypoglycaemia significantly increased at A1c levels ≥ 6.7% (P < .001).
• The relationship between A1c and outcomes remained consistent across sex, age, and diabetes type subgroups.
• Also, the relationship between A1c and long-term complications in patients with severe CKD mirrored that seen in those with no-to-mild or mild-to-moderate CKD.

IN PRACTICE:

"Overall, an HbA1c range of 6.7–7.1% (50–54 mmol/mol) seems to be the most favorable in regard to long-term complications and death in individuals with severe CKD. This is aligned with current guidelines, which recommend an HbA1c target of approximately 7% (53 mmol/mol) in individuals with diabetes and CKD. Our data do not support the current recommendations that propose conservative glycemic treatment of those with severe CKD," the authors wrote.

SOURCE:

This study was led by Dea H. Kofod, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark. It was published online on June 07, 2025, in Diabetes Care.

LIMITATIONS:

Due to the observational nature of this study, researchers could not conclude whether high or low A1c levels caused poor outcomes in patients with severe CKD. The study lacked data on non-hospitalised hypoglycaemic events or dosages of insulin and other glucose-lowering medications. Additionally, the analyses were based on baseline A1c values as measurements beyond baseline were not collected systematically, and the study could not account for changes during follow-up.

DISCLOSURES:

This study was supported by grants from the Augustinus Foundation, the Danish Society of Nephrology's research foundation, Skibsreder Per Henriksen, R. og Hustru's Fond, Johnny Weileby's Fond, and Helen og Ejnar Bjørnow's Fond. Kofod reported receiving speaker honoraria from Bayer outside the submitted work. Some authors reported receiving speaker honoraria, research grants, and speaking fees; serving as advisors, speakers, and lecturers; and having other ties with various pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.