Glycated Hemoglobin and Outcomes in Patients with Advanced Diabetic Chronic Kidney Disease
I-Ching Kuo1, Hugo You-Hsien Lin1,2, Sheng-Wen Niu1,2
1Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.
Insights
Higher HbA1c levels increase risks for kidney disease progression and mortality in diabetic patients with stage 3-4 chronic kidney disease (CKD). This association was not observed in patients with stage 5 CKD.
Area of Science:
- Nephrology
- Endocrinology
- Clinical Medicine
Background:
- Diabetes mellitus is a leading cause of end-stage renal disease (ESRD).
- The predictive value of glycated hemoglobin (HbA1c) for clinical outcomes in advanced chronic kidney disease (CKD) remains less understood.
- Understanding HbA1c's role is crucial for managing diabetic kidney disease.
Purpose of the Study:
- To investigate the association between baseline HbA1c levels and clinical outcomes in diabetic patients across different stages of CKD.
- To determine if HbA1c predicts ESRD, mortality, and cardiovascular events in CKD stages 3-5.
- To clarify the differential impact of HbA1c on kidney disease progression based on CKD stage.
Main Methods:
- Prospective cohort study involving 2401 diabetic patients with CKD stages 3-5.
- Patients were categorized into four baseline HbA1c groups: <6%, 6%-7%, 7%-9%, and >9%.
- Median follow-up of 3 years, assessing incidence of ESRD, all-cause mortality, and combined cardiovascular events with mortality. Cox regression analysis was employed.
Main Results:
- Higher HbA1c correlated with higher estimated glomerular filtration rate (eGFR) in stage 5 CKD, but not in stage 3-4 CKD.
- A trend towards worse outcomes was noted for HbA1c >6% in stage 3-4 CKD, with significance only for HbA1c >9%.
- For HbA1c >9% in stage 3-4 CKD, hazard ratios were 1.6 for ESRD, 1.52 for all-cause mortality, and 1.46 for combined CV events with mortality.
Conclusions:
- Elevated HbA1c levels are associated with increased risks of ESRD, mortality, and cardiovascular events in diabetic patients with stage 3-4 CKD.
- This association between higher HbA1c and adverse clinical outcomes was not significant in diabetic patients with stage 5 CKD.
- Glycemic control, as indicated by HbA1c, may play a more critical role in earlier stages of diabetic kidney disease progression.
Abstract:
Diabetes is the major risk factor for end-stage renal disease (ESRD) worldwide. In advanced chronic kidney disease (CKD), less is known about the predictive value of HbA1c. We enrolled 2401 diabetic patients with stage 3-4 and stage 5 CKD, who were classified into 4 groups according to their baseline HbA1c values (<6%, 6%-7%, 7%-9%, and >9%). During the median follow-up of 3 years, 895 patients developed ESRD, and 530 died. In linear regression analysis, higher HbA1c correlated with higher eGFR in patients with stage 5 CKD but not in stage 3-4 CKD. In Cox regression analysis, a trend toward worse clinical outcomes existed when the HbA1c level exceeded 6% in stage 3-4 CKD, but the significance was only observed for >9%. The hazard ratios (HRs) for ESRD, all-cause mortality and combined CV events with mortality in the group of HbA1c >9% were 1.6 (95% CI, 1.07 to 2.38), 1.52 (95% CI, 0.97 to 2.38) and 1.46 (95% CI, 1.02 to 2.09), respectively. This study demonstrates that the higher HbA1c level is associated higher risks for clinical outcomes in diabetic patients with stage 3-4 CKD but not in stage 5 CKD.
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