Association of Glycemic Status During Progression of Chronic Kidney Disease With Early Dialysis Mortality in Patients With Diabetes

Abstract

OBJECTIVEAlthough 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 METHODSAmong 17,819 U.S. veterans with diabetic CKD transitioning to dialysis from October 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 survival models. Secondary analyses examined cardiovascular mortality using competing risks methods.RESULTSHbA­­1c levels ≥8% (≥64 mmol/mol) were associated with higher mortality in the first year after dialysis initiation (reference value 6% to <7% [42–53 mmol/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.CONCLUSIONSIn 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.

Association of Continuation of Statin Therapy Initiated Before Transition to Chronic Dialysis Therapy With Mortality After Dialysis Initiation

“…We retrospectively examined data from the USRDS Transition of Care in Chronic Kidney Disease study, 11 which focused on investigating patients transitioning to ESRD. 15 , 16 In the present cohort study, we used the USRDS to identify the source cohort of 85 505 veterans who transitioned to ESRD between October 1, 2007, and March 30, 2014. Data analysis was conducted between August 2, 2017, and June 28, 2018.…”

Mortality Risk in Chronic Kidney Disease Patients Transitioning to Dialysis: Impact of Opiate and Non-Opiate Use

“…We conducted a cohort study with longitudinal data from the Transition of Care in CKD (TC-CKD) study [25][26][27][28][29], a retrospective cohort study examining US Veterans transitioning to renal replacement therapy over the period of October 1, 2007, through September 30, 2014. Our source population consisted of 85,505 patients from the national VA database who transitioned to dialysis over the period of October 1, 2007, to March 31, 2014.…”

An easy-to-operate web-based calculator for predicting the progression of chronic kidney disease

“…CKD is multifactorial and is defined as glomerular filtration rate (GFR) < 60 mL/min per 1.73 m 2 or abnormalities in kidney structure or function present for more than 3 months [ 3 , 4 ]. Diabetic nephropathy is the leading cause of CKD, accounting for approximately 40% of patients with non-dialysis-dependent CKD and ESRD [ 5 ]. Other pathological processes for CKD include chronic glomerulonephritis, ureteral obstruction, and renal fibrosis [ 6 – 8 ].…”