Association between Glycemic Control and Survival in Patients with Type 2 Diabetes on Peritoneal Dialysis: Results...

Current clinical guidelines for glycemic control in patients on peritoneal dialysis lack a strong evidence base. In patients on peritoneal dialysis with diabetes, HbA1c >8% is associated with increased all-cause mortality. Younger patients with less comorbidity have the greatest potential survival benefit with improved glycemic control.

Diabetes is the leading cause of kidney failure globally affecting 40% of people receiving peritoneal dialysis (PD). High-quality data on the potential impact of improving glycemic control is needed to inform the current recommendations to individualize HbA 1C targets.

Data from 8 countries in the prospective cohort Peritoneal Dialysis Outcomes and Practice Patterns Study (2014-2022) were used to assess the association between baseline HbA 1C and all-cause mortality in people with type 2 diabetes on PD for at least 90 days. Cox proportional hazards model adjusted for potential confounders was used to assess the relationship in the whole cohort and subgroups. Using inverse probability weighting, an average treatment effect in the treated analysis further investigated potential implications of improved glycemic control.

HbA 1C was measured at least once in 8436 patients during a mean follow-up of 16 months. Compared with HbA 1C ≤8% (Diabetes Control and Complications Trial units), HbA 1C >8% was associated with higher risk of all-cause mortality in the cohort as a whole (hazard ratio [HR] 1.18 P = 0.02 95% confidence interval [CI], 1.03 to 1.35) and within subgroups: age younger than 65 years (HR, 1.28; P = 0.01; 95% CI, 1.05 to 1.56), average albumin >3.0 g/dl (HR, 1.25; P = 0.004; 95% CI, 1.07 to 1.46), no preexisting coronary artery disease (CAD; HR, 1.24; P = 0.008; 95% CI, 1.06 to 1.46), hemoglobin <10 g/L (HR, 1.50; P = 0.01; 95% CI, 1.09 to 2.07), and PD vintage <1 year (HR, 1.22; P = 0.02; 95% CI, 1.03 to 1.45). The projected survival advantage at 3 years for those with HbA 1C ≤8% compared with >8% was 7% overall, increasing to 12% in younger cohorts (age younger than 65 years). The largest predicted absolute survival advantage of 16% (78% versus 61%) was seen in those aged younger than 65 years, with a normal serum albumin level and no history of CAD.

Associations between HbA 1C and mortality argue for tighter individualized targets for patient subgroups (younger, noninflamed, and without established CAD). Our weighted analysis suggests improved glycemic control (reducing HbA 1C to <8%) may result in an absolute reduction in mortality at 3 years of up to 12% in younger cohorts.