Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Korea.
Medical Research Collaborating Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
Diabetes Metab J. 2023 Jul;47(4):535-546. doi: 10.4093/dmj.2022.0112. Epub 2023 Apr 25.
The optimal level of glycosylated hemoglobin (HbA1c) to prevent adverse clinical outcomes is unknown in patients with chronic kidney disease (CKD) and type 2 diabetes mellitus (T2DM).
We analyzed 707 patients with CKD G1-G5 without kidney replacement therapy and T2DM from the KoreaN Cohort Study for Outcome in Patients With Chronic Kidney Disease (KNOW-CKD), a nationwide prospective cohort study. The main predictor was time-varying HbA1c level at each visit. The primary outcome was a composite of development of major adverse cardiovascular events (MACEs) or all-cause mortality. Secondary outcomes included the individual endpoint of MACEs, all-cause mortality, and CKD progression. CKD progression was defined as a ≥50% decline in the estimated glomerular filtration rate from baseline or the onset of end-stage kidney disease.
During a median follow-up of 4.8 years, the primary outcome occurred in 129 (18.2%) patients. In time-varying Cox model, the adjusted hazard ratios (aHRs) for the primary outcome were 1.59 (95% confidence interval [CI], 1.01 to 2.49) and 1.99 (95% CI, 1.24 to 3.19) for HbA1c levels of 7.0%-7.9% and ≥8.0%, respectively, compared with <7.0%. Additional analysis of baseline HbA1c levels yielded a similar graded association. In secondary outcome analyses, the aHRs for the corresponding HbA1c categories were 2.17 (95% CI, 1.20 to 3.95) and 2.26 (95% CI, 1.17 to 4.37) for MACE, and 1.36 (95% CI, 0.68 to 2.72) and 2.08 (95% CI, 1.06 to 4.05) for all-cause mortality. However, the risk of CKD progression did not differ between the three groups.
This study showed that higher HbA1c levels were associated with an increased risk of MACE and mortality in patients with CKD and T2DM.
在患有慢性肾脏病（CKD）和 2 型糖尿病（T2DM）的患者中，预防不良临床结局的糖化血红蛋白（HbA1c）最佳水平尚不清楚。
我们分析了来自韩国慢性肾脏病患者结局的全国性前瞻性队列研究（KNOW-CKD）的 707 名无肾脏替代治疗的 CKD G1-G5 患者和 T2DM 患者。主要预测指标是每次就诊时 HbA1c 水平的时间变化。主要结局是主要不良心血管事件（MACE）或全因死亡率的复合终点。次要结局包括 MACE、全因死亡率和 CKD 进展的单独终点。CKD 进展定义为估计肾小球滤过率从基线下降≥50%或终末期肾病的发生。
在中位随访 4.8 年期间，129 名（18.2%）患者发生主要结局。在时变 Cox 模型中，HbA1c 水平为 7.0%-7.9%和≥8.0%时，主要结局的校正风险比（aHR）分别为 1.59（95%置信区间 [CI]，1.01 至 2.49）和 1.99（95%CI，1.24 至 3.19），与<7.0%相比。对基线 HbA1c 水平的进一步分析得出了类似的分级关联。在次要结局分析中，相应 HbA1c 类别的 aHR 分别为 2.17（95%CI，1.20 至 3.95）和 2.26（95%CI，1.17 至 4.37）用于 MACE，1.36（95%CI，0.68 至 2.72）和 2.08（95%CI，1.06 至 4.05）用于全因死亡率。然而，三组之间 CKD 进展的风险没有差异。
这项研究表明，较高的 HbA1c 水平与 CKD 和 T2DM 患者的 MACE 和死亡率风险增加相关。
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