Association of glycemic status during progression of chronic kidney diseasewithearly dialysis mortality in patients with diabetes

Connie M. Rhee, Csaba P. Kovesdy, Vanessa A. Ravel, Elani Streja, Steven M. Brunelli, Melissa Soohoo, Keiichi Sumida, Miklos Z. Molnar, Gregory A. Brent, Danh V. Nguyen, Kamyar Kalantar-Zadeh

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

OBJECTIVE Although early trials suggested that intensive glycemic targets reduce the number of complications with diabetes, contemporary trials indicate no cardiovascular benefit and potentially higher mortality risk. As patients with advanced chronic kidney disease (CKD) transitioning to treatment with dialysis were excluded from these studies, the optimal glycemic level in this population remains uncertain.We hypothesized that glycemic status, defined by hemoglobin A1c (HbA1c) and random glucose levels, in the pre-end-stage renal disease (ESRD) period is associated with higher 1-year post-ESRD mortality among patients with incident diabetes who have ESRD. RESEARCH DESIGN AND METHODS Among 17,819 U.S. veterans with diabetic CKD transitioning to dialysis fromOctober 2007 to September 2011, we examined the association of mean HbA1c and random glucose levels averaged over the 1-year pre-ESRD transition period with mortality in the first year after dialysis initiation. All-cause mortality hazard ratios (HRs) were estimated using multivariable survivalmodels. Secondary analyses examined cardiovascular mortality using competing risks methods. RESULTS HbA1c levels 8% (64mmol/mol) were associated with higher mortality in the first year after dialysis initiation (reference value 6%to <7%[42-53mmol/mol]): adjusted HRs [aHRs] 1.19 [95% CI 1.07-1.32] and 1.48 (1.31-1.67) for HbA1c 8% to <9% [64-75 mmol/mol] and 9% [75 mmol/mol], respectively). Random glucose levels 200 mg/dL were associated with higher mortality (reference value 100 to <125 mg/dL): aHR 1.34 [95% CI 1.20-1.49]). Cumulative incidence curves showed that incrementally higher mean HbA1c and random glucose levels were associated with increasingly higher cardiovascular mortality. CONCLUSIONS In patients with diabetes and CKD transitioning to dialysis, higher mean HbA1c and random glucose levels during the pre-ESRD prelude period were associated with higher 1-year post-ESRD mortality. Clinical trials are warranted to examine whether modulating glycemic status improves survival in this population.

Original languageEnglish (US)
Pages (from-to)1050-1057
Number of pages8
JournalDiabetes Care
Volume40
Issue number8
DOIs
StatePublished - Aug 1 2017

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Dialysis
Kidney
Chronic Kidney Failure
Mortality
Hemoglobins
Glucose
Chronic Renal Insufficiency
Reference Values
Diabetic Nephropathies
Veterans
Diabetes Complications
Population
Research Design
Clinical Trials
Survival
Incidence

ASJC Scopus subject areas

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

Cite this

Rhee, C. M., Kovesdy, C. P., Ravel, V. A., Streja, E., Brunelli, S. M., Soohoo, M., ... Kalantar-Zadeh, K. (2017). Association of glycemic status during progression of chronic kidney diseasewithearly dialysis mortality in patients with diabetes. Diabetes Care, 40(8), 1050-1057. https://doi.org/10.2337/dc17-0110

Association of glycemic status during progression of chronic kidney diseasewithearly dialysis mortality in patients with diabetes. / Rhee, Connie M.; Kovesdy, Csaba P.; Ravel, Vanessa A.; Streja, Elani; Brunelli, Steven M.; Soohoo, Melissa; Sumida, Keiichi; Molnar, Miklos Z.; Brent, Gregory A.; Nguyen, Danh V.; Kalantar-Zadeh, Kamyar.

In: Diabetes Care, Vol. 40, No. 8, 01.08.2017, p. 1050-1057.

Research output: Contribution to journalArticle

Rhee, CM, Kovesdy, CP, Ravel, VA, Streja, E, Brunelli, SM, Soohoo, M, Sumida, K, Molnar, MZ, Brent, GA, Nguyen, DV & Kalantar-Zadeh, K 2017, 'Association of glycemic status during progression of chronic kidney diseasewithearly dialysis mortality in patients with diabetes', Diabetes Care, vol. 40, no. 8, pp. 1050-1057. https://doi.org/10.2337/dc17-0110
Rhee, Connie M. ; Kovesdy, Csaba P. ; Ravel, Vanessa A. ; Streja, Elani ; Brunelli, Steven M. ; Soohoo, Melissa ; Sumida, Keiichi ; Molnar, Miklos Z. ; Brent, Gregory A. ; Nguyen, Danh V. ; Kalantar-Zadeh, Kamyar. / Association of glycemic status during progression of chronic kidney diseasewithearly dialysis mortality in patients with diabetes. In: Diabetes Care. 2017 ; Vol. 40, No. 8. pp. 1050-1057.
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abstract = "OBJECTIVE Although early trials suggested that intensive glycemic targets reduce the number of complications with diabetes, contemporary trials indicate no cardiovascular benefit and potentially higher mortality risk. As patients with advanced chronic kidney disease (CKD) transitioning to treatment with dialysis were excluded from these studies, the optimal glycemic level in this population remains uncertain.We hypothesized that glycemic status, defined by hemoglobin A1c (HbA1c) and random glucose levels, in the pre-end-stage renal disease (ESRD) period is associated with higher 1-year post-ESRD mortality among patients with incident diabetes who have ESRD. RESEARCH DESIGN AND METHODS Among 17,819 U.S. veterans with diabetic CKD transitioning to dialysis fromOctober 2007 to September 2011, we examined the association of mean HbA1c and random glucose levels averaged over the 1-year pre-ESRD transition period with mortality in the first year after dialysis initiation. All-cause mortality hazard ratios (HRs) were estimated using multivariable survivalmodels. Secondary analyses examined cardiovascular mortality using competing risks methods. RESULTS HbA1c levels 8{\%} (64mmol/mol) were associated with higher mortality in the first year after dialysis initiation (reference value 6{\%}to <7{\%}[42-53mmol/mol]): adjusted HRs [aHRs] 1.19 [95{\%} CI 1.07-1.32] and 1.48 (1.31-1.67) for HbA1c 8{\%} to <9{\%} [64-75 mmol/mol] and 9{\%} [75 mmol/mol], respectively). Random glucose levels 200 mg/dL were associated with higher mortality (reference value 100 to <125 mg/dL): aHR 1.34 [95{\%} CI 1.20-1.49]). Cumulative incidence curves showed that incrementally higher mean HbA1c and random glucose levels were associated with increasingly higher cardiovascular mortality. CONCLUSIONS In patients with diabetes and CKD transitioning to dialysis, higher mean HbA1c and random glucose levels during the pre-ESRD prelude period were associated with higher 1-year post-ESRD mortality. Clinical trials are warranted to examine whether modulating glycemic status improves survival in this population.",
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AU - Kovesdy, Csaba P.

AU - Ravel, Vanessa A.

AU - Streja, Elani

AU - Brunelli, Steven M.

AU - Soohoo, Melissa

AU - Sumida, Keiichi

AU - Molnar, Miklos Z.

AU - Brent, Gregory A.

AU - Nguyen, Danh V.

AU - Kalantar-Zadeh, Kamyar

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N2 - OBJECTIVE Although early trials suggested that intensive glycemic targets reduce the number of complications with diabetes, contemporary trials indicate no cardiovascular benefit and potentially higher mortality risk. As patients with advanced chronic kidney disease (CKD) transitioning to treatment with dialysis were excluded from these studies, the optimal glycemic level in this population remains uncertain.We hypothesized that glycemic status, defined by hemoglobin A1c (HbA1c) and random glucose levels, in the pre-end-stage renal disease (ESRD) period is associated with higher 1-year post-ESRD mortality among patients with incident diabetes who have ESRD. RESEARCH DESIGN AND METHODS Among 17,819 U.S. veterans with diabetic CKD transitioning to dialysis fromOctober 2007 to September 2011, we examined the association of mean HbA1c and random glucose levels averaged over the 1-year pre-ESRD transition period with mortality in the first year after dialysis initiation. All-cause mortality hazard ratios (HRs) were estimated using multivariable survivalmodels. Secondary analyses examined cardiovascular mortality using competing risks methods. RESULTS HbA1c levels 8% (64mmol/mol) were associated with higher mortality in the first year after dialysis initiation (reference value 6%to <7%[42-53mmol/mol]): adjusted HRs [aHRs] 1.19 [95% CI 1.07-1.32] and 1.48 (1.31-1.67) for HbA1c 8% to <9% [64-75 mmol/mol] and 9% [75 mmol/mol], respectively). Random glucose levels 200 mg/dL were associated with higher mortality (reference value 100 to <125 mg/dL): aHR 1.34 [95% CI 1.20-1.49]). Cumulative incidence curves showed that incrementally higher mean HbA1c and random glucose levels were associated with increasingly higher cardiovascular mortality. CONCLUSIONS In patients with diabetes and CKD transitioning to dialysis, higher mean HbA1c and random glucose levels during the pre-ESRD prelude period were associated with higher 1-year post-ESRD mortality. Clinical trials are warranted to examine whether modulating glycemic status improves survival in this population.

AB - OBJECTIVE Although early trials suggested that intensive glycemic targets reduce the number of complications with diabetes, contemporary trials indicate no cardiovascular benefit and potentially higher mortality risk. As patients with advanced chronic kidney disease (CKD) transitioning to treatment with dialysis were excluded from these studies, the optimal glycemic level in this population remains uncertain.We hypothesized that glycemic status, defined by hemoglobin A1c (HbA1c) and random glucose levels, in the pre-end-stage renal disease (ESRD) period is associated with higher 1-year post-ESRD mortality among patients with incident diabetes who have ESRD. RESEARCH DESIGN AND METHODS Among 17,819 U.S. veterans with diabetic CKD transitioning to dialysis fromOctober 2007 to September 2011, we examined the association of mean HbA1c and random glucose levels averaged over the 1-year pre-ESRD transition period with mortality in the first year after dialysis initiation. All-cause mortality hazard ratios (HRs) were estimated using multivariable survivalmodels. Secondary analyses examined cardiovascular mortality using competing risks methods. RESULTS HbA1c levels 8% (64mmol/mol) were associated with higher mortality in the first year after dialysis initiation (reference value 6%to <7%[42-53mmol/mol]): adjusted HRs [aHRs] 1.19 [95% CI 1.07-1.32] and 1.48 (1.31-1.67) for HbA1c 8% to <9% [64-75 mmol/mol] and 9% [75 mmol/mol], respectively). Random glucose levels 200 mg/dL were associated with higher mortality (reference value 100 to <125 mg/dL): aHR 1.34 [95% CI 1.20-1.49]). Cumulative incidence curves showed that incrementally higher mean HbA1c and random glucose levels were associated with increasingly higher cardiovascular mortality. CONCLUSIONS In patients with diabetes and CKD transitioning to dialysis, higher mean HbA1c and random glucose levels during the pre-ESRD prelude period were associated with higher 1-year post-ESRD mortality. Clinical trials are warranted to examine whether modulating glycemic status improves survival in this population.

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