Rhee Jinnie J, Zheng Yuanchao, Liu Sai, Montez-Rath Maria E, Hamill Richard J, Ishida Julie H, Winkelmayer Wolfgang C
Department of Medicine, Division of Nephrology, Stanford University School of Medicine, Stanford, California, USA.
Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, California, USA.
Kidney Int Rep. 2020 Apr 29;5(7):1014-1025. doi: 10.1016/j.ekir.2020.04.020. eCollection 2020 Jul.
Patients with diabetes mellitus (DM) on hemodialysis (HD) may be particularly vulnerable to infections.
We used merged data from the United States Renal Data System and electronic health records data from a large US dialysis provider to retrospectively examine the association between glycemic control and infections in these patients. Adult patients with DM aged ≥18 years who initiated in-center maintenance HD treatment from 2006 to 2011 and survived >90 days were included. Quarterly mean time-averaged hemoglobin A1c (HbA1c) values were categorized into <5.5%, 5.5 to <6.5%, 6.5 to <7.5%, 7.5 to <8.5%, and ≥8.5%. We used Medicare claims to ascertain infection-related outcomes and the ESRD Death Notification to identify death from infectious cause. We used Cox proportional hazards models to estimate multivariable-adjusted hazard ratios and 95% confidence intervals (CIs) for the associations between time-averaged HbA1c categories and infectious events.
In a cohort of 33,753 eligible patients, those with higher HbA1c levels had higher rates of diabetic foot infections and skin and soft tissue infections, with patients with HbA1c ≥8.5% having 23% (95% CI, 5%, 45%) and 22% (95% CI, 5%, 42%) higher rates, respectively, compared with HbA1c 5.5 to <6.5%. Patients in the lower HbA1c categories had higher rates of infection-related and all-cause mortality (-for-trend <0.001).
This study highlights the need for greater attention to foot evaluation and skin and soft tissue infections among patients on HD with less than optimal diabetes control.
接受血液透析（HD）的糖尿病（DM）患者可能特别容易感染。
我们使用了来自美国肾脏数据系统的合并数据以及来自美国一家大型透析服务提供商的电子健康记录数据，以回顾性研究这些患者血糖控制与感染之间的关联。纳入了2006年至2011年开始接受中心内维持性HD治疗且存活超过90天的年龄≥18岁的成年DM患者。将季度平均时间加权糖化血红蛋白（HbA1c）值分为<5.5%、5.5至<6.5%、6.5至<7.5%、7.5至<8.5%和≥8.5%。我们使用医疗保险理赔数据确定与感染相关的结局，并使用终末期肾病死亡通知来识别因感染导致的死亡。我们使用Cox比例风险模型来估计时间加权HbA1c类别与感染事件之间关联的多变量调整风险比和95%置信区间（CI）。
在33753名符合条件的患者队列中，HbA1c水平较高的患者糖尿病足感染和皮肤及软组织感染的发生率较高，与HbA1c为5.5至<6.5%的患者相比，HbA1c≥8.5%的患者发生率分别高23%（95%CI，5%，45%）和22%（95%CI，5%，42%）。HbA1c类别较低的患者感染相关死亡率和全因死亡率较高（趋势P<0.001）。
本研究强调，对于糖尿病控制欠佳的HD患者，需要更加关注足部评估以及皮肤和软组织感染。
