The Association Between Hemoglobin A1c and Complications Among Individuals With Diabetes and Severe Chronic Kidney
Dea H Kofod1, Nicholas Carlson1, Thomas P Almdal1,2
1Department of Nephrology and Endocrinology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
Insights
For individuals with severe chronic kidney disease (CKD) and diabetes, an HbA1c level between 6.7-7.1% is most favorable. This target range helps reduce major adverse cardiovascular events and microvascular complications.
Area of Science:
- Nephrology
- Endocrinology
- Cardiology
Background:
- Optimal glycemic control in severe chronic kidney disease (CKD) is not well-defined.
- Individuals with diabetes and severe CKD face increased risks of complications.
Purpose of the Study:
- To investigate the association between HbA1c levels and complications in patients with diabetes and severe CKD.
- To determine the optimal HbA1c target for reducing adverse outcomes in this population.
Main Methods:
- Danish nationwide registry-based cohort study (2010-2022).
- Included 27,113 individuals with diabetes and severe CKD (eGFR <30 mL/min/1.73 m2).
- Used Cox regressions to analyze risks of MACE, microvascular complications, and hypoglycemia hospitalizations across HbA1c strata.
Main Results:
- For severe CKD patients, MACE risk increased at HbA1c ≥7.2% and <5.8%.
- Microvascular complication risk rose significantly at HbA1c ≥7.2%.
- Hypoglycemia hospitalization risk increased at HbA1c ≥6.7%.
Conclusions:
- An HbA1c range of 6.7-7.1% (50-54 mmol/mol) appears most favorable for this high-risk group.
- This target range may help reduce long-term complications in patients with diabetes and severe CKD.
Objective:
The optimal glycemic target for individuals with severe chronic kidney disease (CKD) remains unclear. We investigated the association between HbA1c and complications in individuals with diabetes and severe CKD.
Research Design And Methods:
In a Danish nationwide registry-based cohort study, we included 27,113 individuals ≥18 years old with diabetes and severe CKD (estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2) between 2010 and 2022. As reference groups, we included an age- and sex-matched cohort of 80,131 individuals with diabetes and mild-to-moderate CKD (eGFR 30-59 mL/min/1.73 m2) and 80,797 individuals with diabetes and no-to-mild CKD (eGFR ≥60 mL/min/1.73 m2). Multiple Cox regressions were used to estimate the standardized 1-year risk of major adverse cardiovascular events (MACE), microvascular complications, and hospitalizations due to hypoglycemia across strata of HbA1c levels.
Results:
For individuals with severe CKD, the risk of MACE significantly increased at HbA1c levels ≥7.2% (55 mmol/mol) (P < 0.01) and <5.8% (40 mmol/mol) (P < 0.001), compared with an HbA1c level of 6.3-6.6% (45-49 mmol/mol). The risk of microvascular complications significantly increased at HbA1c levels ≥7.2% (55 mmol/mol) (P < 0.001), and the risk of hospitalization due to hypoglycemia significantly increased at HbA1c levels ≥6.7% (50 mmol/mol) (P < 0.001). The association patterns between HbA1c and outcomes were similar in the severe CKD cohort compared with the matched cohorts with mild-to-moderate CKD and no-to-mild CKD.
Conclusions:
Our data suggest an HbA1c range of 6.7-7.1% (50-54 mmol/mol) to be most favorable for reducing long-term complications in this high-risk population.
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