Intensive Diabetes Management for High-Risk Patients: How Best to Deliver?

Type 2 diabetic patients with microalbuminuria or more advanced chronic kidney disease are at extremely high risk of cardiovascular disease (CVD) and end-stage renal disease (ESRD), with the risk of both increasing as kidney disease progresses. CVD and renal disease share many risk factors. The Steno-2 study demonstrated that intensive structured care, targeting these risk factors aggressively, slowed progression of nephropathy and retinopathy and reduced cardiovascular death in type 2 diabetic patients with microalbuminuria by 40–60% (1–3).

In this issue of Diabetes Care, Chan et al. (4), for the Structured Versus Usual Care on Renal Endpoint in Type 2 Diabetes (SURE) Study Group, provide further evidence of the benefits of intensive target-driven care and raise questions as to how best to deliver such care. They compared structured care, including a predefined protocol and tight treatment targets delivered by a diabetologist-led specialist team, with usual care, delivered by specialists or nonspecialists. The study was conducted in nine hospitals; 205 type 2 diabetic patients, aged 35–75 years with plasma creatinine 150–350 μmol/l, were randomized, and 167 completed the 2-year study. The main reasons for withdrawal included death (n = 19) and referral to nephrology for dialysis (n = 14). The number of patients reaching the primary end point (death or ESRD, defined as a need for dialysis or having plasma creatinine ≥500 μmol/l) was similar in the two groups, as was the number of clinical events, hospital admissions, and emergency room visits. However, after 2 years, the structured care group had lower diastolic blood pressure and A1C and was more likely to attain ≥3 treatment goals than was the usual care group (61% [ n = 63] vs. 28% [ n = 28], …