A1C and survival in maintenance hemodialysis patients

Kamyar Kalantar-Zadeh, Joel D. Kopple, Deborah L. Regidor, Jennie Jing, Christian S. Shinaberger, Jason Aronovitz, Charles J. McAllister, David Whellan, Kumar Sharma

Research output: Contribution to journalArticle

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Abstract

OBJECTIVE - The optimal target for glycemic control has not been established in diabetic dialysis patients. RESEARCH DESIGN AND METHODS - To address this question, the national database of a large dialysis organization (DaVita) was analyzed via time-dependent survival models with repeated measures. RESULTS - Of 82,933 patients undergoing maintenance hemodialysis (MHD) in DaVita outpatient clinics over 3 years (July 2001 through June 2004), 23,618 diabetic MHD patients had A1C measurements at least once. Unadjusted survival analyses indicated paradoxically lower death hazard ratios (HRs) with higher A1C values. However, after adjusting for potential confounders (demographics, dialysis vintage, dose, comorbidity, anemia, and surrogates of malnutrition and inflammation), higher A1C values were incrementally associated with higher death risks. Compared with A1C in the 5-6% range, the adjusted all-cause and cardiovascular death HRs for A1C ≥10% were 1.41 (95% CI 1.25-1.60) and 1.73 (1.44-2.08), respectively (P < 0.001). The incremental increase in death risk for rising A1C values was monotonic and robust in nonanemic patients (hemoglobin >11.0 g/dl). In subgroup analyses, the association between A1C >6% and increased death risk was more prominent among younger patients, those who had undergone dialysis for >2 years, and those with higher protein intake (>1 g·kg-1·day-1), blood hemoglobin (>11 g/dl), or serum ferritin values (>500 ng/ml). CONCLUSIONS - In diabetic MHD patients, the apparently counterintuitive association between poor glycemic control and greater survival is explained by such confounders as malnutrition and anemia. All things equal, higher A1C is associated with increased death risk. Lower A1C levels not related to malnutrition or anemia appear to be associated with improved survival in MHD patients.

Original languageEnglish (US)
Pages (from-to)1049-1055
Number of pages7
JournalDiabetes Care
Volume30
Issue number5
DOIs
StatePublished - May 1 2007
Externally publishedYes

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Renal Dialysis
Maintenance
Survival
Dialysis
Malnutrition
Anemia
Survival Analysis
Ferritins
Ambulatory Care Facilities
Comorbidity
Cause of Death
Hemoglobins
Research Design
Demography
Organizations
Databases
Inflammation
Serum
Proteins

ASJC Scopus subject areas

  • Internal Medicine
  • Endocrinology, Diabetes and Metabolism
  • Advanced and Specialized Nursing

Cite this

Kalantar-Zadeh, K., Kopple, J. D., Regidor, D. L., Jing, J., Shinaberger, C. S., Aronovitz, J., ... Sharma, K. (2007). A1C and survival in maintenance hemodialysis patients. Diabetes Care, 30(5), 1049-1055. https://doi.org/10.2337/dc06-2127

A1C and survival in maintenance hemodialysis patients. / Kalantar-Zadeh, Kamyar; Kopple, Joel D.; Regidor, Deborah L.; Jing, Jennie; Shinaberger, Christian S.; Aronovitz, Jason; McAllister, Charles J.; Whellan, David; Sharma, Kumar.

In: Diabetes Care, Vol. 30, No. 5, 01.05.2007, p. 1049-1055.

Research output: Contribution to journalArticle

Kalantar-Zadeh, K, Kopple, JD, Regidor, DL, Jing, J, Shinaberger, CS, Aronovitz, J, McAllister, CJ, Whellan, D & Sharma, K 2007, 'A1C and survival in maintenance hemodialysis patients', Diabetes Care, vol. 30, no. 5, pp. 1049-1055. https://doi.org/10.2337/dc06-2127
Kalantar-Zadeh K, Kopple JD, Regidor DL, Jing J, Shinaberger CS, Aronovitz J et al. A1C and survival in maintenance hemodialysis patients. Diabetes Care. 2007 May 1;30(5):1049-1055. https://doi.org/10.2337/dc06-2127
Kalantar-Zadeh, Kamyar ; Kopple, Joel D. ; Regidor, Deborah L. ; Jing, Jennie ; Shinaberger, Christian S. ; Aronovitz, Jason ; McAllister, Charles J. ; Whellan, David ; Sharma, Kumar. / A1C and survival in maintenance hemodialysis patients. In: Diabetes Care. 2007 ; Vol. 30, No. 5. pp. 1049-1055.
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abstract = "OBJECTIVE - The optimal target for glycemic control has not been established in diabetic dialysis patients. RESEARCH DESIGN AND METHODS - To address this question, the national database of a large dialysis organization (DaVita) was analyzed via time-dependent survival models with repeated measures. RESULTS - Of 82,933 patients undergoing maintenance hemodialysis (MHD) in DaVita outpatient clinics over 3 years (July 2001 through June 2004), 23,618 diabetic MHD patients had A1C measurements at least once. Unadjusted survival analyses indicated paradoxically lower death hazard ratios (HRs) with higher A1C values. However, after adjusting for potential confounders (demographics, dialysis vintage, dose, comorbidity, anemia, and surrogates of malnutrition and inflammation), higher A1C values were incrementally associated with higher death risks. Compared with A1C in the 5-6{\%} range, the adjusted all-cause and cardiovascular death HRs for A1C ≥10{\%} were 1.41 (95{\%} CI 1.25-1.60) and 1.73 (1.44-2.08), respectively (P < 0.001). The incremental increase in death risk for rising A1C values was monotonic and robust in nonanemic patients (hemoglobin >11.0 g/dl). In subgroup analyses, the association between A1C >6{\%} and increased death risk was more prominent among younger patients, those who had undergone dialysis for >2 years, and those with higher protein intake (>1 g·kg-1·day-1), blood hemoglobin (>11 g/dl), or serum ferritin values (>500 ng/ml). CONCLUSIONS - In diabetic MHD patients, the apparently counterintuitive association between poor glycemic control and greater survival is explained by such confounders as malnutrition and anemia. All things equal, higher A1C is associated with increased death risk. Lower A1C levels not related to malnutrition or anemia appear to be associated with improved survival in MHD patients.",
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AU - Shinaberger, Christian S.

AU - Aronovitz, Jason

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AB - OBJECTIVE - The optimal target for glycemic control has not been established in diabetic dialysis patients. RESEARCH DESIGN AND METHODS - To address this question, the national database of a large dialysis organization (DaVita) was analyzed via time-dependent survival models with repeated measures. RESULTS - Of 82,933 patients undergoing maintenance hemodialysis (MHD) in DaVita outpatient clinics over 3 years (July 2001 through June 2004), 23,618 diabetic MHD patients had A1C measurements at least once. Unadjusted survival analyses indicated paradoxically lower death hazard ratios (HRs) with higher A1C values. However, after adjusting for potential confounders (demographics, dialysis vintage, dose, comorbidity, anemia, and surrogates of malnutrition and inflammation), higher A1C values were incrementally associated with higher death risks. Compared with A1C in the 5-6% range, the adjusted all-cause and cardiovascular death HRs for A1C ≥10% were 1.41 (95% CI 1.25-1.60) and 1.73 (1.44-2.08), respectively (P < 0.001). The incremental increase in death risk for rising A1C values was monotonic and robust in nonanemic patients (hemoglobin >11.0 g/dl). In subgroup analyses, the association between A1C >6% and increased death risk was more prominent among younger patients, those who had undergone dialysis for >2 years, and those with higher protein intake (>1 g·kg-1·day-1), blood hemoglobin (>11 g/dl), or serum ferritin values (>500 ng/ml). CONCLUSIONS - In diabetic MHD patients, the apparently counterintuitive association between poor glycemic control and greater survival is explained by such confounders as malnutrition and anemia. All things equal, higher A1C is associated with increased death risk. Lower A1C levels not related to malnutrition or anemia appear to be associated with improved survival in MHD patients.

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