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Correlates of low hemoglobin A1c in maintenance hemodialysis patients

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Abstract

Purpose

The optimal target for glycemic control has not been established for diabetic maintenance hemodialysis (MHD) patients.

Methods

A 6-year cohort (October 2001– December 2006) of 347 diabetic MHD patients with HbA1c data was examined for associations between HbA1c and mortality. Death hazard ratios (HR) were estimated using Cox regressions and cubic splines.

Results

In these 347 patients (age, 59 ± 11 years; 49 % women; 28 % African Americans; and 55 % Hispanics), each 0.5 % decline in HbA1c below 6 % was associated with a 4.7 times higher death risk (HR = 4.7; 95 % CI 1.7–12.7) in the fully adjusted model. Factors associated with lower HbA1c levels (<6 % compared to 6–7 %) were: Hispanic ethnicity (OR = 2.9; 95 % CI 1.1–7.9), higher mid-arm muscle circumstance (OR = 1.1; 95 % CI 1.0–1.3), higher total iron-binding capacity (OR = 1.03; 95 % CI 1.01–1.05), and higher iron saturation ratio (OR = 1.14; 95 % CI 1.03–1.26). HbA1c levels >7 % showed a consistent trend toward elevated mortality risk (HR = 1.18; 95 % CI 0.99–1.41) after multivariate adjustment.

Conclusions

In diabetic MHD patients with burnt-out diabetes, characterized by HbA1c <6 %, even lower HbA1c levels are associated with significantly higher death risk. Additional studies are needed to determine the optimal target for HbA1c levels in different subgroups of diabetic MHD patients.

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Acknowledgments

We thanks DaVita Clinical Research and DaVita dietitians in Wild West, Gold Coast, and Surf and Sun divisions for supporting the study and the staff at Harbor-UCLA General Clinic Research Center Core Laboratories for the management of blood samples and measuring inflammatory markers. The study was supported by KKZ’s research grant from the American Heart Association grant (0655776Y). KKZ’s other funding sources include the National Institute of Diabetes, Digestive and Kidney Disease of the National Institute of Health (R01 DK078106); a research grant from DaVita Clinical Research and a philanthropic grant from Mr. Harold Simmons. This study was supported by a National Institutes of Health grant (R21 DK078012) from NIH-NIDDK to Dr Kalantar-Zadeh and by the General Clinical Research Center grant M01-RR00425 from the NIH National Centers for Research Resources. MZM received grants from the National Developmental Agency (KTIA-OTKA-EU 7KP-HUMAN-MB08-A-81231) from the Research and Technological Innovation Fund and is recipient of the Hungarian Eötvös Scholarship (MÖB/77-2/2012).

Conflict of interests

Dr. Kalantar-Zadeh is the medical director of DaVita Harbor-UCLA/MFI in Long Beach, CA. Other authors have not declared any conflict of interest.

Author information

Correspondence to Kamyar Kalantar-Zadeh.

Additional information

Youngmee Kim and Jong Chan Park contributed equally to this work.

Electronic supplementary material

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Kim, Y., Park, J.C., Molnar, M.Z. et al. Correlates of low hemoglobin A1c in maintenance hemodialysis patients. Int Urol Nephrol 45, 1079–1090 (2013). https://doi.org/10.1007/s11255-012-0208-y

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Keywords

  • Diabetes mellitus
  • Burnt-out diabetes
  • Glucose
  • Hemoglobin A1c
  • Hemodialysis
  • Mortality
  • Malnutrition-inflammation complex syndrome