Rhee Connie M, Kovesdy Csaba P, Ravel Vanessa A, Streja Elani, Brunelli Steven M, Soohoo Melissa, Sumida Keiichi, Molnar Miklos Z, Brent Gregory A, Nguyen Danh V, Kalantar-Zadeh Kamyar
Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange, CA
Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN.
Diabetes Care. 2017 Aug;40(8):1050-1057. doi: 10.2337/dc17-0110. Epub 2017 Jun 7.
Although early trials suggested that intensive glycemic targets reduce the number of complications with diabetes, contemporary trials indicate no cardiovascular benefit and potentially higher mortality risk. As patients with advanced chronic kidney disease (CKD) transitioning to treatment with dialysis were excluded from these studies, the optimal glycemic level in this population remains uncertain. We hypothesized that glycemic status, defined by hemoglobin A (HbA--) and random glucose levels, in the pre-end-stage renal disease (ESRD) period is associated with higher 1-year post-ESRD mortality among patients with incident diabetes who have ESRD.
Among 17,819 U.S. veterans with diabetic CKD transitioning to dialysis from October 2007 to September 2011, we examined the association of mean HbA-- and random glucose levels averaged over the 1-year pre-ESRD transition period with mortality in the first year after dialysis initiation. All-cause mortality hazard ratios (HRs) were estimated using multivariable survival models. Secondary analyses examined cardiovascular mortality using competing risks methods.
HbA-- levels ≥8% (≥64 mmol/mol) were associated with higher mortality in the first year after dialysis initiation (reference value 6% to <7% [42-53 mmol/mol]): adjusted HRs [aHRs] 1.19 [95% CI 1.07-1.32] and 1.48 (1.31-1.67) for HbA-- 8% to <9% [64-75 mmol/mol] and ≥9% [≥75 mmol/mol], respectively). Random glucose levels ≥200 mg/dL were associated with higher mortality (reference value 100 to <125 mg/dL): aHR 1.34 [95% CI 1.20-1.49]). Cumulative incidence curves showed that incrementally higher mean HbA-- and random glucose levels were associated with increasingly higher cardiovascular mortality.
In patients with diabetes and CKD transitioning to dialysis, higher mean HbA-- and random glucose levels during the pre-ESRD prelude period were associated with higher 1-year post-ESRD mortality. Clinical trials are warranted to examine whether modulating glycemic status improves survival in this population.
尽管早期试验表明强化血糖目标可减少糖尿病并发症的数量，但当代试验表明并无心血管益处，且死亡风险可能更高。由于这些研究排除了晚期慢性肾脏病（CKD）患者向透析治疗过渡的情况，该人群的最佳血糖水平仍不确定。我们假设，在糖尿病合并终末期肾病（ESRD）的患者中，终末期肾病前期由糖化血红蛋白（HbA--）和随机血糖水平定义的血糖状态与ESRD后1年的较高死亡率相关。
在2007年10月至2011年9月期间从糖尿病性CKD过渡到透析的17819名美国退伍军人中，我们研究了ESRD过渡期前1年平均HbA--和随机血糖水平与透析开始后第一年死亡率之间的关联。使用多变量生存模型估计全因死亡风险比（HRs）。二级分析采用竞争风险方法检查心血管死亡率。
HbA--水平≥8%（≥64 mmol/mol）与透析开始后第一年的较高死亡率相关（参考值6%至<7%[42 - 53 mmol/mol]）：对于HbA-- 8%至<9%[64 - 75 mmol/mol]和≥9%[≥75 mmol/mol]，调整后的HRs [aHRs]分别为1.19 [95% CI 1.07 - 1.32]和1.48（1.31 - 1.67）。随机血糖水平≥200 mg/dL与较高死亡率相关（参考值100至<125 mg/dL）：aHR为1.34 [95% CI 1.20 - 1.49]）。累积发病率曲线显示，平均HbA--和随机血糖水平越高，心血管死亡率越高。
在糖尿病合并CKD并过渡到透析的患者中，ESRD前期较高的平均HbA--和随机血糖水平与ESRD后1年的较高死亡率相关。有必要进行临床试验以研究调节血糖状态是否能改善该人群的生存率。
