Association Between Glycemia and Mortality in Diabetic Individuals on Renal Replacement Therapy in the U.K.

Author:

Adler Amanda1,Casula Anna2,Steenkamp Retha2,Fogarty Damian3,Wilkie Martin4,Tomlinson Laurie5,Nitsch Dorothea5,Roderick Paul6,Tomson Charles R.V.7

Affiliation:

1. Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, U.K.

2. UK Renal Registry, Southmead Hospital, Bristol, U.K.

3. Public Health, Health Services, and Primary Care, Queen’s University, Belfast, U.K.

4. Sheffield Kidney Institute, Sheffield, U.K.

5. Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, U.K.

6. Primary Care and Population Sciences, University of Southampton, Southampton, U.K.

7. Academic Renal Unit, School of Clinical Sciences, University of Bristol, Bristol, U.K.

Abstract

OBJECTIVE In the U.K., one-third of patients receiving treatment with dialysis have diabetes. Guidelines from organizations representing patients with renal disease or diabetes advocate tight glycemic control in patients with end-stage renal disease, despite glucose-lowering trials having excluded these patients. RESEARCH DESIGN AND METHODS Using national UK Renal Registry data, we tested whether glycemia as measured by hemoglobin (Hb) A1c (HbA1c) level is associated with death in adults with diabetes starting hemodialysis or peritoneal dialysis between 1997 and 2006, and observed for at least 6 months. Of 7,814 patients, we excluded those who had died within 6 months; had received transplants; were lost/recovered; or lacked measures of HbA1c, ethnicity, or Hb. Categorizing HbA1c measured in the first 6 months of starting dialysis as <6.5% (<48 mmol/mol), 6.5–7.4% (48–57 mmol/mol) (reference value), 7.5–8.4% (58–68 mmol/mol), and ≥8.5% (≥69 mmol/mol), we adjusted in proportional hazards models for age, sex, ethnicity, deprivation, year, dialysis type, and Hb, and tested for interactions. RESULTS Of 3,157 patients observed for a median time of 2.7 years, 1,688 died. For patients ≥60 years of age, we found no association between HbA1c and death; among younger patients, relative to those with HbA1c values 6.5–7.4%, the hazard ratio for HbA1c level 7.5–8.4% was 1.2 (95% CI 0.9–1.5), and for HbA1c level >8.5% was 1.5 (1.2–1.9). The projected difference in median survival time between younger patients with a reference HbA1c value versus >8.5% was 1 year. CONCLUSIONS In the absence of trials, and confounding notwithstanding, these observational data support improved glycemic control in younger patients prior to and during dialysis.

Publisher

American Diabetes Association

Subject

Advanced and Specialized Nursing,Endocrinology, Diabetes and Metabolism,Internal Medicine

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