Hsiao Ching-Chung, Tu Hui-Tzu, Lin Chi-Hung, Chen Kuan-Hsing, Yeh Yung-Hsin, See Lai-Chu
Kidney Research Center and Department of Nephrology, Chang Gung Memorial Hospital, Taipei 333, Taiwan.
Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan.
J Clin Med. 2019 Mar 27;8(4):420. doi: 10.3390/jcm8040420.
Patients with diabetic kidney disease (DKD) are at higher risk of hypoglycemia than diabetic patients without DKD. We aimed to investigate the temporal trends of severe hypoglycemia in advanced DKD patients transitioning to dialysis and examine risk factors associated with severe hypoglycemia. We also investigated the association of severe hypoglycemia episodes with one-year mortality after initiation of dialysis in patients with advanced DKD.
Using the Taiwan National Health Insurance Research Database, 46,779 advanced DKD patients transitioning to dialysis (Peritoneal dialysis 4216, hemodialysis 42,563) between 1997 and 2011 were enrolled. We calculated the rates of severe hypoglycemia from 5 years before dialysis until 10 years after dialysis. Cox proportional hazard model was used to examine the risk factors of post end stage renal disease (ESRD) one-year hypoglycemia and post ESRD one-year mortality in advanced DKD patients transitioning to dialysis.
We found that 11.5% of advanced DKD patients had at least one episode of severe hypoglycemia the year leading up to dialysis initiation. Multivariate analysis revealed hemodialysis compared with peritoneal dialysis, stroke, use of sulfonylurea, glinide, and insulin were associated with higher risk of severe hypoglycemia one year after transitioning to dialysis. Increased frequency of severe hypoglycemia-related hospitalizations was associated with incrementally higher mortality risk one year after transitioning to dialysis (Pre-ESRD hypoglycemia: Hazard ratios: 1.28 (1.18⁻1.38, < 0.001), 1.64 (1.49⁻1.81, < 0.001) for one, two hypoglycemia-related hospitalizations, respectively; post-ESRD hypoglycemia: HRs of 1.56 (1.40⁻1.73, < 0.001), 1.72 (1.39⁻2.12, < 0.001) for one, two hypoglycemia-related hospitalizations, respectively (reference group: no hypoglycemia related hospitalization)).
Among advanced DKD patients, we observed a progressive elevated risk of hypoglycemia during the critical dialysis transition period. Increased frequency of severe hypoglycemia-related hospitalizations was associated with higher mortality risk one year after transitioning to dialysis. Further study of glycemic management strategies which prevent hypoglycemia during the critical transition period are warranted.
与无糖尿病肾病（DKD）的糖尿病患者相比，DKD患者发生低血糖的风险更高。我们旨在调查晚期DKD患者转为透析时严重低血糖的时间趋势，并研究与严重低血糖相关的危险因素。我们还研究了晚期DKD患者开始透析后严重低血糖发作与一年死亡率之间的关联。
利用台湾国民健康保险研究数据库，纳入了1997年至2011年间46779例转为透析的晚期DKD患者（腹膜透析4216例，血液透析42563例）。我们计算了从透析前5年到透析后10年的严重低血糖发生率。采用Cox比例风险模型研究晚期DKD患者转为透析后终末期肾病（ESRD）一年低血糖和ESRD一年死亡率的危险因素。
我们发现，11.5%的晚期DKD患者在开始透析前一年至少有一次严重低血糖发作。多变量分析显示，与腹膜透析相比，血液透析、中风、使用磺脲类药物、格列奈类药物和胰岛素与转为透析一年后严重低血糖的风险较高有关。转为透析一年后，严重低血糖相关住院频率增加与死亡风险逐步升高相关（ESRD前低血糖：风险比：1.28（1.18⁻1.38，<0.001），1.64（1.49⁻1.81，<0.001）分别对应一次、两次低血糖相关住院；ESRD后低血糖：一次、两次低血糖相关住院的风险比分别为1.56（1.40⁻1.73，<0.001），1.72（1.39⁻2.12，<0.001）（参照组：无低血糖相关住院））。
在晚期DKD患者中，我们观察到在关键的透析过渡期低血糖风险逐渐升高。转为透析一年后，严重低血糖相关住院频率增加与死亡风险较高有关。有必要进一步研究在关键过渡期预防低血糖的血糖管理策略。
