Glycated Hemoglobin and Risk of Death in Diabetic Patients Treated With Hemodialysis: A Meta-analysis

Christopher Hill, A.P. Maxwell, C.R. Cardwell, B.I. Freedman, M. Tonelli, M. Emoto, M. Inaba, Y. Hayashino, S. Fukuhara, T. Okada, C. Drechsler, C. Wanner, A. Casula, A.I. Adler, C. Lamina, F. Kronenberg, E. Streja, K. Kalantar-Zadeh, D.G. Fogarty

Research output: Contribution to journalArticlepeer-review

Abstract

Background: Studies investigating the association between glycated hemoglobin (HbA) level and mortality risk in diabetic patients receiving hemodialysis have shown conflicting results. 
Study Design: We conducted a systematic review and meta-analysis using MEDLINE, EMBASE, Web of Science, and the Cochrane Library. 
Setting & Population: Diabetic patients on maintenance hemodialysis therapy. 
Selection Criteria for Studies: Observational studies or randomized controlled trials investigating the association between HbA values and mortality risk. Study authors were asked to provide anonymized individual patient data or reanalyze results according to a standard template. 
Predictor: Single measurement or mean HbA values. Mean HbA values were calculated using all individual-patient HbA values during the follow-up period of contributing studies. 
Outcome: HR for mortality risk. 
Results: 10 studies (83,684 participants) were included: 9 observational studies and one secondary analysis of a randomized trial. After adjustment for confounders, patients with baseline HbA levels =8.5% (=69 mmol/mol) had increased mortality (7 studies; HR, 1.14; 95% CI, 1.09-1.19) compared with patients with HbA levels of 6.5%-7.4% (48-57 mmol/mol). Likewise, patients with a mean HbA value =8.5% also had a higher adjusted risk of mortality (6 studies; HR,1.29; 95% CI, 1.23-1.35). There was a small but nonsignificant increase in mortality associated with mean HbA levels =5.4% (=36 mmol/mol; 6 studies; HR, 1.09; 95% CI, 0.89-1.34). Sensitivity analyses in incident (=90 days of hemodialysis) and prevalent patients (>90 days of hemodialysis) showed a similar pattern. In incident patients, mean HbA levels =5.4% also were associated with increased mortality risk (4 studies; HR, 1.29; 95% CI, 1.23-1.35). 
Limitations: Observational study data and inability to adjust for diabetes type in all studies. 
Conclusions: Despite concerns about the utility of HbA measurement in hemodialysis patients, high levels (=8.5%) are associated with increased mortality risk. Very low HbA levels (=5.4%) also may be associated with increased mortality risk. 
Original languageEnglish
Pages (from-to)84-94
JournalAmerican Journal of Kidney Diseases
Volume63
Issue number1
Early online date19 Aug 2013
DOIs
Publication statusPublished - Jan 2014

Keywords

  • HbA1c;
  • diabetes mellitus
  • hemodialysis;
  • survival.

ASJC Scopus subject areas

  • Medicine(all)

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