Transcript Hemoglobin A1c in Hemodialysis Patients

Hemoglobin A1c in Hemodialysis
Patients
Source: Ix JH. Hemoglobin A1c in
hemodialysis patients: Should one size
fit all? Clin J Am Soc Nephrol.
2010;5:1539–1541.
Overview
• Diabetes mellitus is one of the major causes behind endstage renal
disease (ESRD) in the United States.
• It has been observed that, on average, four out of ten patients seen
on dialysis rounds has diabetes mellitus, among whom the levels of
hemoglobin A1c (HbA1c) are frequently measured quarterly.
• At present, the kidney disease: Improving Global Outcomes
foundation does not offer clinical practice guidelines for HbA1c
management.
• According to the kidney disease outcomes quality initiative (KDOQI)
recommendations (updated in 2007), “Target HbA1c for people
with diabetes should be <7%, irrespective of the presence or the
absence of chronic kidney disease.”
• This recommendation aligns with the diabetes management in the
general population.
• Recent data across randomized studies on
statins provides caution about the extension
of data from the general population to ESRD,
including therapies with significant
established benefits in the general population.
• There have also been heightened concerns
regarding the association of drugs used for
treating diabetes in ESRD patients, with the
risk of cardiovascular disease events.
• A study was conducted evaluating the link between HbA1c levels
and mortality in hemodialysis patients with diabetes.
• The observed HbA1c levels were less than KDOQI
recommendations.
• The association of HbA1c with mortality differed significantly with
the adjustment for demographic and confounding variables.
• The unadjusted analyses showed that patients with HbA1c levels
between 7 and 9% had the least overall mortality, and those with
HbA1c levels <5% had the greatest mortality.
• Similar results were observed in another study; however, patients
with HbA1c levels <5% or 􀁴7% showed statistically significantly
higher risk of mortality than individuals with intermediate HbA1c
levels.
• Through a post hoc analysis of the 4-D study it was shown
that higher HbA1c levels were related with sudden death
but not myocardial infarction or stroke.
• Hemoglobin A1c values <7% were similarly linked with an
average level of blood glucose in ESRD as in the general
population, however, in the ESRD patients, at higher levels,
the average serum glucose levels were lesser at any given
HbA1c.
• Some other small studies have shown that HbA1c remains
associated with fasting and post challenge glucose levels in
ESRD; however, the correlations are not so significant than
those observed in the general population.
Conclusion
• Several important aspects are required to be addressed to support
HbA1c in dialysis patients. The control of HbA1c can influence the
risk of peripheral arterial disease and amputation, an extremely
common and morbid event seen in ESRD patients.
• Glycemic control may affect the patency of permanent dialysis access
and the risk of infection.
• Tighter control might reduce the development of neuropathy and
retinopathy in ESRD as observed in the general population.
• Proper assessment of association of HbA1c with these outcomes in
ESRD patients should be considered for future research to find the
risks and benefits linked with various HbA1c targets.
• Individualized HbA1c targets with the consideration of the extent of
life expectancy, age, comorbidity and the patient’s ability and their
caregivers to act in response to hypoglycemic events might be more
accurate than a “one size fits all” target designed using studies in the
general population.
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