Department of Medicine, Division of Nephrology, University Hospital, Oberdürrbacherstrasse 6, D-97080 Würzburg, Germany.
Circulation. 2009 Dec 15;120(24):2421-8. doi: 10.1161/CIRCULATIONAHA.109.857268.
Patients on maintenance dialysis treatment experience an excess mortality, predominantly of sudden cardiac death. Poor glycemic control is associated with cardiovascular comorbidities in the general population. This study investigated the impact of glycemic control on cardiac and vascular outcomes in diabetic hemodialysis patients.
Glycohemoglobin A1c (HbA(1c)) was measured in 1255 hemodialysis patients with type 2 diabetes mellitus who participated in the German Diabetes and Dialysis Study (4D Study) and were followed up for a median of 4 years. Using Cox regression analyses, we determined hazard ratios to reach prespecified, adjudicated end points according to HbA(1c) levels at baseline: sudden cardiac death (n=160), myocardial infarction (n=200), stroke (n=103), cardiovascular events (n=469), death caused by heart failure (n=41), and all-cause mortality (n=617). Patients had a mean age of 66+/-8 years (54% male) and mean HbA(1c) of 6.7+/-1.3%. Patients with an HbA(1c) >8% had a >2-fold higher risk of sudden death compared with those with an HbA(1c) < or =6% (hazard ratio, 2.14; 95% confidence interval, 1.33 to 3.44), persisting in multivariate models. With each 1% increase in HbA(1c), the risk of sudden death rose significantly by 18%; similarly, cardiovascular events and mortality increased by 8%. There was a trend for higher risks of stroke and deaths resulting from heart failure, whereas myocardial infarction was not affected. The increased risks of both cardiovascular events and mortality were explained mainly by the impact of HbA(1c) on sudden death.
Poor glycemic control was strongly associated with sudden cardiac death in diabetic hemodialysis patients, which accounted for increased cardiovascular events and mortality. In contrast, myocardial infarction was not affected. Whether interventions achieving tight glycemic control decrease sudden death requires further evaluation. Clinical Trial Registration- URL: http://www.clinicalstudyresults.org. Unique identifier: CT-981-423-239.
接受维持性透析治疗的患者死亡率过高，主要是心源性猝死。血糖控制不佳与普通人群的心血管合并症有关。本研究调查了血糖控制对糖尿病血液透析患者心脏和血管结局的影响。
参加德国糖尿病和透析研究（4D 研究）的 1255 名 2 型糖尿病血液透析患者测量了糖化血红蛋白（HbA（1c）），中位随访时间为 4 年。使用 Cox 回归分析，根据基线时的 HbA（1c）水平确定达到预设的、经裁决的终点的风险比：心源性猝死（n=160）、心肌梗死（n=200）、中风（n=103）、心血管事件（n=469）、心力衰竭导致的死亡（n=41）和全因死亡率（n=617）。患者的平均年龄为 66+/-8 岁（54%为男性），平均 HbA（1c）为 6.7+/-1.3%。HbA（1c）>8%的患者心源性猝死的风险是 HbA（1c）<或=6%的患者的两倍以上（风险比，2.14；95%置信区间，1.33 至 3.44），在多变量模型中仍然存在。HbA（1c）每增加 1%，心源性猝死的风险显著增加 18%；同样，心血管事件和死亡率也增加了 8%。中风和心力衰竭导致的死亡风险呈上升趋势，而心肌梗死则没有影响。心血管事件和死亡率的风险增加主要归因于 HbA（1c）对心源性猝死的影响。
血糖控制不佳与糖尿病血液透析患者的心源性猝死密切相关，这导致心血管事件和死亡率增加。相比之下，心肌梗死不受影响。是否干预以实现严格的血糖控制会降低心源性猝死，这需要进一步评估。
临床试验注册- 网址：http://www.clinicalstudyresults.org。唯一标识符：CT-981-423-239。
