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• W1992605089 abstract "Diabetes mellitus (DM) constitutes a major end-stage renal disease (ESRD) health problem. Glycemic control is fundamental to the management of diabetes and its complications, and relies on monitoring of hyperglycemia. We therefore performed a primary data analysis of glycemic control and survival on a large national ESRD database. Ninety-five percent of patients with DM had type II diabetes (N=23 504), and five percent had type I diabetes (N=1 371). For the combined population, the mean hemoglobin A1c (HgbA1c) was 6.77%, and the mean random blood glucose was 168 mg/dl. Mean HgbA1c values were >7.0% in 35% and >8.5% in 14%. Mean HgbA1c values were below 5% in 11.3% of patients. Type I study patients tended to have higher HgbA1c values. Most patients (75.8%) had three or more random blood glucose determinations within 90 days preceding the HgbA1c measurement. The HgbA1c showed only a weak correlation with mean random glucose values (R2 0.3716; s.e.=1.36). The survival rates in the subsequent 12-month period ranged from 80 to 85% across different HgbA1c strata. Kaplan–Meier survival curves grouped by HgbA1c levels showed no correlation between HgbA1c and survival at 12 months. More studies are needed to refine recommendations for the role of HgbA1c and glycemic control in this patient population. Diabetes mellitus (DM) constitutes a major end-stage renal disease (ESRD) health problem. Glycemic control is fundamental to the management of diabetes and its complications, and relies on monitoring of hyperglycemia. We therefore performed a primary data analysis of glycemic control and survival on a large national ESRD database. Ninety-five percent of patients with DM had type II diabetes (N=23 504), and five percent had type I diabetes (N=1 371). For the combined population, the mean hemoglobin A1c (HgbA1c) was 6.77%, and the mean random blood glucose was 168 mg/dl. Mean HgbA1c values were >7.0% in 35% and >8.5% in 14%. Mean HgbA1c values were below 5% in 11.3% of patients. Type I study patients tended to have higher HgbA1c values. Most patients (75.8%) had three or more random blood glucose determinations within 90 days preceding the HgbA1c measurement. The HgbA1c showed only a weak correlation with mean random glucose values (R2 0.3716; s.e.=1.36). The survival rates in the subsequent 12-month period ranged from 80 to 85% across different HgbA1c strata. Kaplan–Meier survival curves grouped by HgbA1c levels showed no correlation between HgbA1c and survival at 12 months. More studies are needed to refine recommendations for the role of HgbA1c and glycemic control in this patient population. Patients with diabetes mellitus (DM) now account for 45 per cent of the prevalent end-stage renal disease (ESRD) population in the US, and the rate of ESRD caused by diabetes increased 86% between 1993 and 2003.1.System USRD: USRDS 2005 Annual Data Report Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2005Google Scholar Most incident patients with ESRD and diabetes carry multiple chronic comorbid conditions such as ischemic heart disease, congestive heart failure, and peripheral vascular disease when they begin dialysis. Macrovascular complications, including myocardial infarction, stroke, and peripheral vascular disease, are the major causes of morbidity and mortality in patients with ESRD and diabetes. Although only a minority of patients with diabetes achieve recommended goals for glycemic control,2.Koro C.E. Bowlin S.J. Bourgeois N. et al.Glycemic control from 1988 to 2000 among US adults diagnosed with type 2 diabetes: a preliminary report.Diabetes Care. 2004; 27: 17-20Crossref PubMed Scopus (568) Google Scholar, 3.Liebl A. Mata M. Eschwege E. Evaluation of risk factors for development of complications in Type II diabetes in Europe.Diabetologia. 2002; 45: S23-28Crossref PubMed Google Scholar, 4.Saydah S.H. Fradkin J. Cowie C.C. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes.JAMA. 2004; 291: 335-342Crossref PubMed Scopus (1184) Google Scholar glycemic control is fundamental to the management of diabetes5.American Diabetes Association Tests of glycemia in diabetes (position statement).Diabetes Care. 2004; 27: S91-S93Crossref PubMed Google Scholar and its complications. Poor glycemic control is increasingly considered as an independent cardiovascular risk factor in diabetes.4.Saydah S.H. Fradkin J. Cowie C.C. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes.JAMA. 2004; 291: 335-342Crossref PubMed Scopus (1184) Google Scholar, 6.Wei M. Gaskill S.P. Haffner S.M. et al.Effects of diabetes and level of glycemia on all-cause and cardiovascular mortality. The San Antonio Heart Study.Diabetes Care. 1998; 21: 1167-1172Crossref PubMed Scopus (370) Google Scholar, 7.Hanefeld M. Fischer S. Julius U. et al.Risk factors for myocardial infarction and death in newly detected NIDDM: the Diabetes Intervention Study, 11-year follow-up.Diabetologia. 1996; 39: 1577-1583Crossref PubMed Scopus (905) Google Scholar, 8.Kuusisto J. Mykkanen L. Pyorala K. et al.NIDDM and its metabolic control predict coronary heart disease in elderly subjects.Diabetes. 1994; 43: 960-967Crossref PubMed Google Scholar, 9.Andersson D.K. Svardsudd K. Long-term glycemic control relates to mortality in type II diabetes.Diabetes Care. 1995; 18: 1534-1543Crossref PubMed Scopus (230) Google Scholar Among patients with diabetes in a large prospective study, high blood glucose concentrations were associated with a greater incidence of cardiovascular disease.10.Engelgau M.M. Geiss L.S. Saaddine J.B. et al.The evolving diabetes burden in the United States.Ann Intern Med. 2004; 140: 945-950Crossref PubMed Scopus (506) Google Scholar Recent data suggest that glycosylated hemoglobin levels are related to coronary heart disease risk in persons with type I and II diabetes.11.Selvin E. Marinopoulos S. Berkenblit G. et al.Meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitus.Ann Intern Med. 2004; 141: 421-431Crossref PubMed Scopus (1147) Google Scholar In fact, chronic hyperglycemia has been hypothesized to contribute to coronary disease in individuals without diabetes as well.12.Menon V. Greene T. Pereira A.A. et al.Glycosylated hemoglobin and mortality in patients with nondiabetic chronic kidney disease.J Am Soc Nephrol. 2005; 16: 3411-3417Crossref PubMed Scopus (47) Google Scholar, 13.Selvin E. Coresh J. Golden S.H. et al.Glycemic control and coronary heart disease risk in persons with and without diabetes: the atherosclerosis risk in communities study.Arch Intern Med. 2005; 165: 1910-1916Crossref PubMed Scopus (223) Google Scholar Limited data suggest that poor glycemic control in patients with diabetes on dialysis may be associated with increased morbidity from diabetic vascular complications.14.Manske C.L. Hyperglycemia and intensive glycemic control in diabetic patients with chronic renal disease.Am J Kidney Dis. 1998; 32: S157-S171Abstract Full Text PDF PubMed Scopus (35) Google Scholar, 15.Tzamaloukas A.H. Murata G.H. Zager P.G. et al.The relationship between glycemic control and morbidity and mortality for diabetics on dialysis.Asaio J. 1993; 39: 880-885Crossref PubMed Scopus (33) Google Scholar Recent data demonstrate that glycemic control may benefit patients with diabetes who have established coronary disease.16.Malmberg K. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group.BMJ. 1997; 314: 1512-1515Crossref PubMed Scopus (1168) Google Scholar, 17.Malmberg K. Norhammar A. Wedel H. et al.Glycometabolic state at admission: important risk marker of mortality in conventionally treated patients with diabetes mellitus and acute myocardial infarction: long-term results from the Diabetes and Insulin–Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study.Circulation. 1999; 99: 2626-2632Crossref PubMed Scopus (755) Google Scholar Epidemiologic studies suggest the potential for improved glycemic control to reduce cardiovascular complications in diabetes, hence the benefit of hyperglycemia control on cardiovascular damage in patients with diabetes continues to be studied.18.Ceriello A. Hanefeld M. Leiter L. et al.Postprandial glucose regulation and diabetic complications.Arch Intern Med. 2004; 164: 2090-2095Crossref PubMed Scopus (273) Google Scholar, 19.Joy M.S. Cefalu W.T. Hogan S.L. et al.Long-term glycemic control measurements in diabetic patients receiving hemodialysis.Am J Kidney Dis. 2002; 39: 297-307Abstract Full Text Full Text PDF PubMed Scopus (122) Google Scholar American Diabetes Association (ADA) guidelines indicate that improved glycemic control may lower the risk of myocardial infarction and cardiovascular death.20.American Diabetes Association Standards of medical care in diabetes (position statement).Diabetes Care. 2004; 27: S15-S35Crossref PubMed Google Scholar Among risk factor reductions for mortality in dialysis patients with diabetes, improved glycemic control is widely recommended.21.Akmal M. Hemodialysis in diabetic patients.Am J Kidney Dis. 2001; 38: S195-199Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar However, whether glycemic control affects survival in diabetic ESRD patients remains unclear.22.Morioka T. Emoto M. Tabata T. et al.Glycemic control is a predictor of survival for diabetic patients on hemodialysis.Diabetes Care. 2001; 24: 909-913Crossref PubMed Scopus (184) Google Scholar Monitoring of hyperglycemia is at the center of management of diabetes.23.Goldstein D.E. Little R.R. Lorenz R.A. et al.Tests of glycemia in diabetes.Diabetes Care. 2004; 27: 1761-1773Crossref PubMed Scopus (439) Google Scholar, 24.Larsen M.L. Horder M. Mogensen E.F. Effect of long-term monitoring of glycosylated hemoglobin levels in insulin-dependent diabetes mellitus.N Engl J Med. 1990; 323: 1021-1025Crossref PubMed Scopus (206) Google Scholar The hemoglobin A1c (HgbA1c) concentration is a marker of hyperglycemia and reflects average blood glucose concentration over 3 months in diabetic individuals.25.Dunn P.J. Cole R.A. Soeldner J.S. et al.Reproducibility of hemoglobin AIc and sensitivity to various degrees of glucose intolerance.Ann Intern Med. 1979; 91: 390-396Crossref PubMed Scopus (79) Google Scholar HgbA1c tracks well in individuals over time.26.Meigs J.B. Nathan D.M. Cupples L.A. et al.Tracking of glycated hemoglobin in the original cohort of the Framingham Heart Study.J Clin Epidemiol. 1996; 49: 411-417Abstract Full Text PDF PubMed Scopus (77) Google Scholar The ADA recommends using point-of-care glycohemoglobin (HgbA1c) values to track glycemic control, make timely decisions on treatment, and to reduce risks of adverse outcomes by lowering A1c levels to below 7%.27.American Diabetes Association Standards of medical care in diabetes (position statement).Diabetes Care. 2005; 28: S4-S36Crossref PubMed Scopus (1067) Google Scholar, 28.American Diabetes Association Clinical practice recommendations.Diabetes Care. 2006; 29: S3PubMed Google Scholar However, less than half of patients with ESRD and diabetes fulfill the recommendations of the ADA to undergo at least four glycohemoglobin tests per year, and up to a quarter receive no testing.1.System USRD: USRDS 2005 Annual Data Report Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2005Google Scholar Monitoring of capillary blood glucose is also recommended, with a frequency and timing dependent on the patient's medical condition. However, half of chronic kidney patients with diabetes have not had glycosylated hemoglobin testing in the year before dialysis initiation.29.Collins A.J. Li S. Gilbertson D.T. et al.Chronic kidney disease and cardiovascular disease in the Medicare population.Kidney Int Suppl. 2003: S24-S31Abstract Full Text Full Text PDF Scopus (268) Google Scholar Diabetic monitoring in the ESRD population is also suboptimal, with over 60% not prescribed any diabetic test strips and less than half receiving the four or more HgbA1c tests per year recommended by the ADA1.System USRD: USRDS 2005 Annual Data Report Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2005Google Scholar. The apparent variability in HgbA1c testing practices in ESRD may derive from the lack of consensus on HgbA1c testing to reflect accurately glycemic control in ESRD patients with diabetes,30.Morgan L. Marenah C.B. Jeffcoate W.J. et al.Glycated proteins as indices of glycaemic control in diabetic patients with chronic renal failure.Diabet Med. 1996; 13: 514-519Crossref PubMed Scopus (32) Google Scholar, 31.Stettler C. Mueller B. Diem P. What you always wanted to know about HbA1c.Schweiz Med Wochenschr. 2000; 130: 993-1005PubMed Google Scholar especially those on erythropoietin therapy.32.Nakao T. Matsumoto H. Okada T. et al.Influence of erythropoietin treatment on hemoglobin A1c levels in patients with chronic renal failure on hemodialysis.Intern Med. 1998; 37: 826-830Crossref PubMed Scopus (111) Google Scholar The relationship between glycosylated hemoglobin and dialysis outcomes in DM has not been adequately characterized. Actual levels of glycemic control are not reported in the United States Renal Data Service Medicare database. The data on the impact of glycemic control on ESRD patient survival are limited to one retrospective15.Tzamaloukas A.H. Murata G.H. Zager P.G. et al.The relationship between glycemic control and morbidity and mortality for diabetics on dialysis.Asaio J. 1993; 39: 880-885Crossref PubMed Scopus (33) Google Scholar and one single-center observational study.22.Morioka T. Emoto M. Tabata T. et al.Glycemic control is a predictor of survival for diabetic patients on hemodialysis.Diabetes Care. 2001; 24: 909-913Crossref PubMed Scopus (184) Google Scholar We recently performed a primary data analysis of glycemic control and survival on a large national ESRD database.33.Williams ME L.E. Lazarus J.M. et al.Glycohemoglobin levels and the subsequent impact on mortality risk in diabetic hemodialysis (HD) patients.J Am Soc Nephrol. 2005; 16: 723A-724AGoogle Scholar The analysis also provided new information on patient characteristics of the type I and II diabetic subpopulations with ESRD.34.Williams M.E.L.E. Lazarus J.M. et al.Differences between Type 1 and Type 2 DM patients on hemodialysis.J Am Soc Nephrol. 2005; 16: 723AGoogle Scholar This report summarizes our findings. Patient characteristics are shown in Table 1. Among the 24 875 eligible patients, a total of 1371 (5.5%) had type I diabetes and 23 504 (94.5%) had type II diabetes. Type I study patients were significantly different from the type II study patients, with younger age (P<0.0001), different racial distribution with more white race (P<0.0001), longer dialysis vintage (P<0.0016), slightly lower body surface area (P<0.0001), and different distribution of vascular accesses (P=0.003). Type I study patients had higher serum phosphorus levels (P<0.0016).Table 1Study patient characteristics with a breakdown into types I and II DM (values in parenthesis are s.d.)DM patients with HgbA1c (drawn between 1 October 2002 and 31 December2002)CharacteristicsAll study patientsType I DMType II DMNo. of patients24 875137123 504Age*P<0.0001; (years)63.7 (12.1)49.3 (14.4)64.5 (11.4)% female51.549.551.6Race*P<0.0001;———White (%)53.060.652.6Black (%)36.432.536.6Other (%)10.66.910.8Vintage**P<0.0016; (days)1051 (951)1172 (1.075)1044 (943)Body surface area*P<0.0001; (m2)1.86 (0.25)1.82 (0.25)1.86 (0.25)% of patients on Erythropoietin99.098.799.0access type***P=0.003: All comparing type I vs type II DM patients only.———Fistula (%)30.034.429.7Graft (%)45.740.846.0Catheter (%)23.524.423.5Blank (%)0.80.40.8HD dose (eKt/V)1.41 (0.29)1.41 (0.32)1.41 (0.28)Albumin3.82 (0.38)3.83 (0.42)3.81 (0.38)Hemoglobin11.72 (1.10)11.71 (1.17)11.72 (1.09)Calcium9.29 (0.70)9.27 (0.73)9.29 (0.70)Phosphorus*P<0.0001;5.60 (1.44)5.89 (1.55)5.59 (1.44)Creatinine8.23 (2.67)8.60 (2.61)8.20 (2.67)White blood cell count**P<0.0016;7.77 (2.87)7.97 (2.39)7.76 (2.89)HgbA1c (%)6.77 (1.44)7.49 (1.99)6.73 (1.68)DM, diabetes mellitus; HD, hemodialysis; HgbA1c, hemoglobin A1c.* P<0.0001;** P<0.0016;*** P=0.003: All comparing type I vs type II DM patients only. Open table in a new tab DM, diabetes mellitus; HD, hemodialysis; HgbA1c, hemoglobin A1c. Type I study patients had higher mean HgbA1c values (7.5 vs 6.7%, P<0.0001). The frequency distribution of the HgbA1c results is shown in Figure 1. For all study patients, mean HgbA1c values were >7.0% in 35% and >8.5% in 14%; in 11.3% of patients, mean HgbA1c values were below 5%. Overall, patients with type I DM tended to have higher HgbA1c values, with mean HgbA1c>7.0% in 50% and >8.5% in >26% of type I study patients. Of the entire study cohort, 41% were treated with insulin, 20% with oral hypoglycemia agents, 16% with both, and 23% with neither. For those with HgbA1c<6%, 37% were on neither insulin nor oral hypoglycemic agents. Of the 24 744 hemodialysis patients with HgbA1c drawn, 89.6% (N=22 178) had random blood glucose measurements available from the previous 90 days. For the combined type I and type II population, the mean HgbA1c was 6.77%, and the mean random blood glucose was 168 mg/dl. A scatter plot (not shown) generated by plotting the mean blood glucose vs HgbA1c indicated that the HgbA1c correlated with the mean random blood glucose levels with an R2 value of 0.3716 and a s.e. of 1.36. The 12-month survival rates ranged from 80 to 85% between groups, corresponding to a 15–20% unadjusted 12-month mortality rate. Kaplan–Meier survival curves grouped by HgbA1c levels, shown in Figure 2a, did not reach statistical significance. This finding persisted when results from type I and type II DM patients were separately analyzed (Figure 2b and c). Multivariable models indicated that there were no clear patterns between HgbA1c and death risk for all study patients, shown in Figure 3. Despite the higher HgbA1c levels found in type I patients, the models from our subset analyses by DM type were similarly without any pattern (data not shown). For patients with diabetes excluded from the study for having no HgbA1c measured during the baseline period, 16.93% died in the subsequent year, compared to 16.15% who died in the study population.Figure 3Impact of varying levels of HgbA1c on all-cause mortality, using Cox proportional hazard models. Data are presented as unadjusted, case-mix adjusted, and case-mix plus laboratory adjusted. Line indicates frequency distribution of HgbA1c values as shown is Figure 1.View Large Image Figure ViewerDownload (PPT) The incidence of ESRD attributed to DM in the US continues to increase, linked to escalation in both the general diabetic and diabetic CKD populations. Insulin therapies remain the mainstay of glycemic control in ESRD patients with diabetes, used in about 60% of patients, up to twice that of non-ESRD Medicare patients.1.System USRD: USRDS 2005 Annual Data Report Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2005Google Scholar However, data on the differences between type I and type II patients with diabetes on dialysis are not available. Furthermore, there is currently limited evidence on the utility of glycohemoglobin (HgbA1c) levels in ESRD as correlated with improvement in outcomes, although such data are available in the non-ESRD population.23.Goldstein D.E. Little R.R. Lorenz R.A. et al.Tests of glycemia in diabetes.Diabetes Care. 2004; 27: 1761-1773Crossref PubMed Scopus (439) Google Scholar, 27.American Diabetes Association Standards of medical care in diabetes (position statement).Diabetes Care. 2005; 28: S4-S36Crossref PubMed Scopus (1067) Google Scholar This is the first study to characterize a large population of prevalent ESRD patients with diabetes. The majority were type II patients, a proportion similar to the general diabetes population. The smaller population of type I DM patients was younger, more predominantly white, longer on dialysis, had greater elevations of serum phosphorus, and had poorer glycemic control. There were no differences in dialysis adequacy, anemia correction, albumin levels, or serum calcium. Classification of diabetes type in the general population is known to be imperfect.35.Report of the expert committee on the diagnosis and classification of diabetes mellitus Diabetes Care. 2003; 26: S5-S20PubMed Google Scholar For this analysis, classification was based mainly on Medicare reporting from Form 2728 with a few de novo diagnoses of DM (newly added ICD-9 diagnoses) after the initiation of dialysis. The initial analysis revealed that 50% of type I and 34% of type II ESRD patients were above the ADA glycemic goal for HgbA1c of 7%, itself a value well above the normal range for nondiabetics.36.Feinglos M.N. Bethel M.A. Emerging care for type 2 diabetes: using insulin to reach lower glycemic goals.Cleveland Clin J Med. 2005; 72: 791-799Crossref PubMed Scopus (2) Google Scholar These data are better than or at least no different from the experience in the general population, where only 37% of adult patients with diabetes in the US are achieving the glycemic goal.4.Saydah S.H. Fradkin J. Cowie C.C. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes.JAMA. 2004; 291: 335-342Crossref PubMed Scopus (1184) Google Scholar In the general diabetic population, there is no HgbA1c level below which the risk of complications does not continue to fall.27.American Diabetes Association Standards of medical care in diabetes (position statement).Diabetes Care. 2005; 28: S4-S36Crossref PubMed Scopus (1067) Google Scholar, 37.The absence of a glycemic threshold for the development of long-term complications: the perspective of the Diabetes Control and Complications Trial Diabetes. 1996; 45: 1289-1298Crossref PubMed Scopus (651) Google Scholar Therefore, it is not unexpected that in a recent survey on improving diabetic ESRD outcomes, nephrologists rated better glycemic control equal in importance to hypertension control, and more important than lipid control.38.Flauto R.P. Leon J.B. Sehgal A.R. The provision and outcomes of diabetic care of hemodialysis patients.Am J Kidney Dis. 2003; 41: 125-131Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The latest United States Renal Data Service report indicates that the cumulative use of insulin and oral agents in ESRD patients with diabetes increased between 2000 and 2003, which suggests a more aggressive treatment approach in diabetes management.1.System USRD: USRDS 2005 Annual Data Report Atlas of End-Stage Renal Disease in the United States. National Institutes of Health, National Institutes of Diabetes and Digestive and Kidney Diseases, Bethesda, MD2005Google Scholar Nonetheless, in this study, a large percentage of those with the lowest HgbA1c values were on neither insulin nor oral agents. Our data are the first indication that HgbA1c values in a large cohort of hemodialysis patients with diabetes are either similar to or range below that reported for the general diabetic population. HgbA1c correlated with mean random blood glucose levels with an R2 of 0.3716 in this study. However, the s.e. of 1.36 indicated considerable variability not explained by the random blood glucose measurements. Data from the Diabetes Control and Complication Control indicate that mean plasma glucose from multiple determinants of 170g/dl correlated with a HgbA1c of 7%,39.Rohlfing C.L. Wiedmeyer H.M. Little R.R. et al.Defining the relationship between plasma glucose and HbA(1c): analysis of glucose profiles and HbA(1c) in the Diabetes Control and Complications Trial.Diabetes Care. 2002; 25: 275-278Crossref PubMed Scopus (784) Google Scholar compared with our values of 1.68g/dl and 6.77%. This finding is interesting considering that the random blood glucose measurements in hemodialysis patients may vary considerably depending on their dialysis shift (because the blood specimens are typically drawn pre-dialysis), and on the confounding effect of timing relative to food intake and medications for diabetes. Several factors impacting on ESRD glycemic management are known to exist, including pharmacodynamic effects of uremia and/or the dialysis procedure on insulin and carbohydrate metabolism, pharmacokinetic influences on insulin and oral hypoglycemic agents used to treat hyperglycemia, and potential effects on HbgA1c, used as the basis of glycemic management.40.Tuohy K.W.M. Management of the diabetic ESRD Patient: Dialysis and transplantation. Elsevier, Philadelphia2005Google Scholar Glycohemoglobin measurements in this report utilized an immunoturbidimetric assay performed in a single laboratory. Unlike high-pressure liquid chromatography commonly used in routine laboratory determinations of HgbA1c, the immunoturbidimetric assay is not influenced by high urea levels or hemoglobin variants. In the general population of patients with diabetes, the HbA1c provides a glycemic history of the preceding 120 days, the average red blood cell lifespan.23.Goldstein D.E. Little R.R. Lorenz R.A. et al.Tests of glycemia in diabetes.Diabetes Care. 2004; 27: 1761-1773Crossref PubMed Scopus (439) Google Scholar However, several reports have indicated that erythrocyte survival is reduced in ESRD, which would be expected to lower HgbA1c levels.41.Little R.R. Tennill A.L. Rohlfing C. et al.Can glycohemoglobin be used to assess glycemic control in patients with chronic renal failure?.Clin Chem. 2002; 48: 784-786PubMed Google Scholar Furthermore, the widespread use of erythropoietin increases the proportion of reticulocytes and ‘younger’ red blood cells in circulation with less glycemic exposure time for glycosylation to occur.32.Nakao T. Matsumoto H. Okada T. et al.Influence of erythropoietin treatment on hemoglobin A1c levels in patients with chronic renal failure on hemodialysis.Intern Med. 1998; 37: 826-830Crossref PubMed Scopus (111) Google Scholar, 42.Uehlinger D.E. Gotch F.A. Sheiner L.B. A pharmacodynamic model of erythropoietin therapy for uremic anemia.Clin Pharmacol Ther. 1992; 51: 76-89Crossref PubMed Scopus (121) Google Scholar Current Medicare standards call for measurement of HgbA1c every 3 months, or monthly during dosing changes or poor glycemic control, as one of the regular laboratory evaluations considered standard of care for patients with diabetes, and some suggest that more frequent testing than four times annually may be necessary in complex patients.43www.cmms.hhs.gov. US Department of Health and Human Services.Google Scholar However, limited outcome-based evidence is available to support such a recommendation in ESRD. Issues related to poor glycemic control in the ESRD patient with DM would be expected to include acute management problems such as fluid overload, hyperkalemia, and ketoacidosis, and certain chronic manifestations such as refractory gastroparesis and malnutrition.40.Tuohy K.W.M. Management of the diabetic ESRD Patient: Dialysis and transplantation. Elsevier, Philadelphia2005Google Scholar, 44.Mak R.H. Impact of end-stage renal disease and dialysis on glycemic control.Semin Dial. 2000; 13: 4-8Crossref PubMed Scopus (80) Google Scholar, 45.Ifudu O. Dulin A.L. Friedman E.A. Interdialytic weight gain correlates with glycosylated hemoglobin in diabetic hemodialysis patients.Am J Kidney Dis. 1994; 23: 686-691Abstract Full Text PDF PubMed Scopus (27) Google Scholar Chronic hyperglycemia has been increasingly hypothesized to contribute to coronary heart disease, the major source of morbidity and mortality, in individuals with diabetes.13.Selvin E. Coresh J. Golden S.H. et al.Glycemic control and coronary heart disease risk in persons with and without diabetes: the atherosclerosis risk in communities study.Arch Intern Med. 2005; 165: 1910-1916Crossref PubMed Scopus (223) Google Scholar The United Kingdom Prospective Diabetes Study of patients with type II diabetes showed a 16% reduction (P=0.052) in myocardial infarction with intensive glycemic control after 10 years of follow-up, although the overall results for cardiovascular outcomes were considered negative.46.Stratton I.M. Adler A.I. Neil H.A. et al.Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study.BMJ. 2000; 321: 405-412Crossref PubMed Scopus (6410) Google Scholar The European Prospective Investigation of Cancer and Medicine (EPIC-Norfolk) reported a risk ratio for coronary heart disease of 1.40 for each 1% increase in HgbA1c after adjustment for known cardiovascular risk factors.47.Khaw K.T. Wareham N. Luben R. et al.Glycated haemoglobin, diabetes, and mortality in men in Norfolk cohort of european prospective investigation of cancer and nutrition (EPIC-Norfolk).BMJ. 2001; 322: 15-18Crossref PubMed Scopus (777) Google Scholar Other epidemiologic cohort studies have also suggested a positive association between HgbA1c levels and coronary risk.11.Selvin E. Marinopoulos S. Berkenblit G. et al.Meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitu" @default.
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• W1992605089 title "Hemodialyzed type I and type II diabetic patients in the US: Characteristics, glycemic control, and survival" @default.
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