Okada Tomonari, Nakao Toshiyuki, Matsumoto Hiroshi, Shino Tamami, Nagaoka Yume, Tomaru Ryo, Wada Toshikazu
Department of Nephrology, Tokyo Medical University.
Intern Med. 2007;46(12):807-14. doi: 10.2169/internalmedicine.46.6355. Epub 2007 Jun 15.
The influence of glycemic control on cardiovascular (CV) complications or survival is not clear in diabetic patients with end-stage renal disease (ESRD). Although glycohemoglobin (HbA1c) is widely used as a marker of hyperglycemia in these patients, it may be unreliable because of shortened erythrocyte lifespan. Glycated albumin (GA) is an alternative marker. We investigated the relation between these markers and development of CV complications or survival in diabetic ESRD patients.
We obtained three variables as markers of glycemic control: 1) mean HbA1c levels during 1-year after initiation of dialysis (HbA1c1), 2) mean HbA1c levels during 3 months from August to October 2002 (HbA1c2), 3) GA on October 2002 (GA2) from 78 type 2 diabetic patients on chronic hemodialysis. We examined the influence of these variables on survival or development of CV diseases using the multivariate Cox proportional-hazards models until September 2006.
The 3-year survival rate was 73%. A total of 27 patients died, 15 from CV diseases. A total of 23 CV diseases developed in 20 patients. Neither HbA1c1 nor HbA1c2 was associated with all-cause mortality, CV mortality or development of CV diseases. GA2 was also not associated with mortality. However, the higher GA2 group (GA > or = 23.0%) had a significantly higher rate of development of CV diseases than the lower GA2 group (GA < 23.0%) (log-rank test p=0.03). The higher GA2 group was significantly associated with development of CV diseases relative to the lower GA2 group (hazard ratio 3.25, p=0.04).
Neither HbA1c levels nor GA levels, at initiation of dialysis or on chronic dialysis, predicted mortality in diabetic ESRD patients. However, poor glycemic control as reflected by higher GA levels may be associated with the development of CV diseases. More studies are needed to clarify the beneficial effect of glycemic control in these patients.
在终末期肾病（ESRD）糖尿病患者中，血糖控制对心血管（CV）并发症或生存率的影响尚不清楚。尽管糖化血红蛋白（HbA1c）在这些患者中被广泛用作高血糖的标志物，但由于红细胞寿命缩短，它可能不可靠。糖化白蛋白（GA）是一种替代标志物。我们研究了这些标志物与糖尿病ESRD患者CV并发症发生或生存率之间的关系。
我们获取了三个作为血糖控制标志物的变量：1）透析开始后1年内的平均HbA1c水平（HbA1c1），2）2002年8月至10月3个月期间的平均HbA1c水平（HbA1c2），3）2002年10月78例接受慢性血液透析的2型糖尿病患者的GA（GA2）。我们使用多变量Cox比例风险模型研究这些变量对生存率或CV疾病发生的影响，直至2006年9月。
3年生存率为73%。共有27例患者死亡，15例死于CV疾病。20例患者共发生23例CV疾病。HbA1c1和HbA1c2均与全因死亡率、CV死亡率或CV疾病发生无关。GA2也与死亡率无关。然而，GA2较高组（GA≥23.0%）CV疾病发生率显著高于GA2较低组（GA<23.0%）（对数秩检验p=0.03）。与GA2较低组相比，GA2较高组与CV疾病发生显著相关（风险比3.25，p=0.04）。
透析开始时或慢性透析时的HbA1c水平和GA水平均不能预测糖尿病ESRD患者的死亡率。然而，较高GA水平所反映的血糖控制不佳可能与CV疾病的发生有关。需要更多研究来阐明血糖控制对这些患者的有益作用。
