Predictive ability of visit-to-visit variability in HbA1c and systolic blood pressure for the development of microalbuminuria and retinopathy in people with type 2 diabetes

Visit-to-visit variability of blood pressure and risk of diabetic retinopathy: a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM), a worldwide disease affecting more than 400 million people, is associated with high blood pressure (BP). In addition to macrovascular complications, high BP in DM patients is potentially linked to microvascular complications. More than 70% of DM patients have retinopathy. To our knowledge, no systematic review and meta-analysis has been conducted on the relationship between visit-to-visit variability in blood pressure and diabetic retinopathy risk.

METHODS

This systematic review and meta-analysis study was performed on the related articles. The search strategy, screening, and data selection were all checklist-based. A comprehensive search was done in three databases, including PubMed, Google Scholar, and Scopus. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were followed. English clinical studies published up to January 2023 contained diabetic patients as the population, retinopathy as the outcome, and visit-to-visit blood pressure as the intervention. Using the QUIPS technique, two authors independently quantify the risk of bias in included publications. The meta-analysis was conducted using R version 4.4.1. We calculated relative risk (RR) as the effect size, applying the random effect model. Standard deviation (SD) and coefficient of variation (CV), were used as measures of BP variability.

RESULTS

A total number of 8 studies with 743,315 participants were covered in this systematic review. After meta-analysis, we concluded that the group with higher SD of BP variability had 2 percent higher risk than the control group (RR = 1.02, 95% CI = 1.01-1.03, I-squared = 41%); however, results of our analysis for CV of BP variability showed no significant contrast with control group thus no increased risk was reported (RR = 1.04, 95% CI = 0.94-1.15, I-squared = 32%, P-value = 0.23).

CONCLUSION

In conclusion, an increased SD of BP variability significantly increased the relative risk for the development of retinopathy.

Variability of urinary albumin to creatinine ratio and eGFR are independently associated with eGFR slope in Japanese with type 2 diabetes: a three-year, single-center, retrospective cohort study

BACKGROUND

To evaluate the seasonal variability of urinary albumin to creatinine ratio (UACR) and eGFR and these effects on three-year eGFR slope in persons with type 2 diabetes (T2D).

METHODS

A total of 1135 persons with T2D were analyzed in this single-center, retrospective cohort study in Japan. The standard deviation (SD) of UACR (SD [UACR]) and SD of eGFR (SD [eGFR]) were calculated for each person's 10-point data during the three years, and a multiple linear regression analysis was performed to evaluate associations with eGFR slope. A sensitivity analysis was performed in a group with no medication changes (n = 801).

RESULTS

UACR exhibited seasonal variability, being higher in winter and lower in spring, early summer, and autumn especially in the UACR ≥ 30 mg/g subgroup, while eGFR showed no seasonal variability. The eGFR slope was significantly associated with SD (eGFR) (regression coefficient -0.170 [95% CI -0.189--0.151]) and SD (UACR) (0.000 [-0.001-0.000]). SGLT-2 inhibitors, baseline eGFR, and baseline systolic blood pressure (SBP) were also significantly associated. These associated factors, except baseline SBP, were still significant in the sensitivity analysis.

CONCLUSIONS

The UACR showed clear seasonal variability. Moreover, SD (UACR) and SD (eGFR) were independently associated with a three-year eGFR slope in persons with T2D.

TRIAL REGISTRATION

This study was not registered for clinical trial registration because it was a retrospective observational study.

HbA1c and systolic blood pressure variation to predict all-cause mortality in patients with type 2 diabetes mellitus

BACKGROUND

Glycated hemoglobin A1c (HbA1c) variation or blood pressure (BP) variation was known to be an independent predictor of all-cause mortality in patients with type 2 diabetes mellitus (T2DM). This study aimed to investigate the combined effect of HbA1c and systolic blood pressure (SBP) variation on all-cause mortality and if there was a gender difference in patients with T2DM.

METHODS

Patients with T2DM who had at least three HbA1c, SBP measurements within 12-24 months during 2001-2007 were included. Coefficient of variation (CV) was used to evaluate variation. The 75th percentile of HbA1c-CV and SBP-CV were set as a cutoff to define high and low variation. Hazard ratios (HRs) and 95% confidence intervals were estimated using Cox proportional hazard models.

RESULTS

A total of 2744 patients were included, of whom 769 died during the 11.7 observation years. The associated risk of all-cause mortality was 1.22 [1.01- 1.48], P = 0.044, for low HbA1c-CV & high SBP-CV; 1.28 [1.04-1.57], P = 0.020, for high HbA1c-CV & low SBP-CV; and 1.68 [1.31-2.17], P < 0.001, for high HbA1c-CV & high SBP-CV. The associated risk remained unchanged in either males or females older than 50 years old, although there is only numerically higher for high HbA1c-CV & low SBP-CV in females older than 50 years old.

CONCLUSIONS

Both HbA1c and SBP variation were significant predictors of all-cause mortality in patients with T2DM. The combined effect was higher than either alone and no gender difference in patients older than 50 years old.

Body Mass Index is related to short-term retinal worsening in type 2 diabetes mellitus patients treated with anticancer drugs

BACKGROUND

In cancer patients with diabetes, anticancer drugs (ADs) may negatively affect the course of diabetes vascular complications. The short-term effects of ADs on type 2 diabetes (T2DM) retinopathy are poorly known. This study evaluated the short-term effects of different classes of ADs on diabetic retinopathy (DR) and clinical risk factors for retinal worsening (RW) in cancer patients affected by T2DM.

METHODS

Retrospective single-center study evaluating 168 patients with T2DM and cancer. The diagnosis of T2DM preceded those of cancer in all patients. We evaluated the retinal short-term effects within the six months after the first-line ADs treatment.

RESULTS

After ADs, 6% of patients had a short-term RW. BMI is positively associated with the risk of RW (OR 1.45, 95% confidence interval: 1.1-1.9, P<0.005). Patients treated with alkylating agents and topoisomerase inhibitors have an increased risk of RW (P=0.049 and P=0.057, respectively) and a significantly higher HDL level (P<0.01).

CONCLUSIONS

To our knowledge, this study is the first investigating the short-term impact of ADs on DR of T2DM patients. Moreover, we provide information arose from a real-world setting. As confirmed by other studies, these findings could help to identify patients at risk for short-term RW, who should be promptly referred to the ophthalmologist for the prevention of visual impairment.

Association of fasting blood glucose variability with all-cause mortality in heart transplant recipients

BACKGROUND

Fasting blood glucose (FBG) variability, an emerging marker of glycemic control, has been shown to be related to the risk of cardiovascular events and all-cause mortality in subjects with or without diabetes. However, whether FBG variability is independently associated with a higher all-cause mortality in heart transplant recipients remains unknown.

METHODS

We performed a retrospective cohort study including 373 adult recipients who survived for at least 1 year after heart transplantation with a functioning graft and measured FBG more than three times within first year after transplantation. Multivariable adjusted Cox regression analyses were performed to assess the association between FBG variability and all-cause mortality.

RESULTS

Patients were categorized into three groups according to the coefficient of variation of FBG level: ≤7.0%, 7.0%-13.5%, and >13.5%. During a median follow-up of 44.4 months (interquartile range [IQR], 22.6-63.3 months), 31 (8.3%) participants died. In univariate analyses, FBG variability was associated with an increased all-cause mortality (hazard ratio [HR]: 3.00, 95% confidence interval [CI]: 1.67, 5.38; p < .001). This association remained materially unchanged in the multivariable model adjusted for components of demographics, cardiovascular history and lifestyle, hospital information, immunosuppressive therapy, and post-transplant renal function (HR: 2.75, 95% CI: 1.43, 5.28; p = .004).

CONCLUSIONS

After heart transplantation, high FBG variability is strongly and independently associated with an increased risk of all-cause mortality. Our findings suggest that FBG variability is a novel risk factor and prognostic marker for heart transplantation recipients in outpatient clinic.

Long-term HbA1c variability and macro-/micro-vascular complications in type 2 diabetes mellitus: a meta-analysis update

AIMS

The aim of the present study was to evaluate, by means of a meta-analysis approach, whether new available data, appeared on qualified literature, can support the effectiveness of an association of HbA1c variability with the risk of macro- and/or micro-vascular complications in type 2 diabetes mellitus (T2DM).

METHODS

The meta-analysis was conducted according to PRISMA Statement guidelines and considered published studies on T2DM, presenting HbA1c variability as standard deviation (SD) or its derived coefficient of variation (CV). Literature search was performed on PubMed in the time range 2015-July 2022, with no restrictions of language.

RESULTS

Twenty-three selected studies fulfilled the aims of the present investigation. Overall, the analysis of the risk as hazard ratios (HR) indicated a significant association between the HbA1c variability, expressed either as SD or CV, and the complications, except for neuropathy. Macro-vascular complications were all significantly associated with HbA1c variability, with HR 1.40 (95%CI 1.31-1.50, p < 0.0001) for stroke, 1.30 (95%CI 1.25-1.36, p < 0.0001) for transient ischaemic attack/coronary heart disease/myocardial infarction, and 1.32 (95%CI 1.13-1.56, p = 0.0007) for peripheral arterial disease. Micro-vascular complications yielded HR 1.29 (95%CI 1.22-1.36, p < 0.0001) for nephropathy, 1.03 (95%CI 0.99-1.08, p = 0.14) for neuropathy, and 1.15 (95%CI 1.08-1.24, p < 0.0001) for retinopathy. For all-cause mortality, HR was 1.33 (95%CI 1.27-1.39, p < 0.0001), and for cardiovascular mortality 1.25 (95%CI 1.17-1.34, p < 0.0001).

CONCLUSIONS

Our meta-analysis on HbA1c variability performed on the most recent published data since 2015 indicates positive association between HbA1c variability and macro-/micro-vascular complications, as well as mortality events, in T2DM, suggesting that this long-term glycaemic parameter merits further attention as a predictive, independent risk factor for T2DM population.

Association of visit-to-visit HbA1c variability with cardiovascular diseases in type 2 diabetes within or outside the target range of HbA1c

Background

Although a growing attention has been recently paid to the role of HbA1c variability in the risk of diabetic complications, the impact of HbA1c variability on cardiovascular diseases (CVD) in type 2 diabetes is still debated. The aim of the study is to investigate the association of HbA1c variability with CVD in individuals within or outside the target range of HbA1c.

Methods

Using data from Action in Diabetes and Vascular disease: preterAx and diamicroN-MR Controlled Evaluation (ADVANCE), we enrolled 855 patients with type 2 diabetes in China. The primary outcomes included major macrovascular events and major microvascular events. Visit-to-visit HbA1c variability was expressed as the coefficient of variation (CV) of five measurements of HbA1c taken 3-24 months after treatment. Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR).

Results

Among 855 patients in the intensive glucose treatment group, 563 and 292 patients were assigned to the group of "within the target range of HbA1c" (WTH) (updated mean HbA1c ≤ 7.0%) and "outside the target range of HbA1c" (OTH) (updated mean HbA1c > 7.0%), respectively. HbA1c variability was positively associated with the risk of major microvascular events in all patients and both the subgroups during a median follow-up period of 4.8 years. Particularly, the risk related to HbA1c variability was higher in patients in WTH group for the new or worsening nephropathy [aHR: 3.35; 95% confidence interval (CI): 1.05-10.74; P = 0.042].

Conclusions

This retrospective cohort study confirmed the positive correlation between HbA1c variability and major microvascular events, especially in subjects in WTH or OTH.

Joint effect of blood pressure and glycemic variation on the risk of cardiovascular morbidity and mortality in persons with type 2 diabetes

OBJECTIVE

Few studies have explored the association of visit-to-visit variation in blood pressure (BP) and glycemic factors with cardiovascular disease (CVD) morbidity and mortality. This study aimed to examine the independent and joint effect of visit-to-visit BP and glycemic variation on CVD morbidity and mortality in persons with T2DM.

METHODS

The present study consisted of two retrospective cohort studies. The Taiwan Diabetes Study was based on a database of the National Diabetes Care Management Program (DCMP) and linked with cardiovascular morbidity incidence. The Taichung Diabetes Study was based on the DCMP database of a medical center, which can be linked with the National Death Registry dataset. The outcomes were analyzed by using Cox's proportional hazard models.

RESULTS

A total of 13,280 and 10,894 persons with T2DM in Taiwan and Taichung Diabetes Study, respectively, were included. SBP-CV, FPG-CV, and HbA1c-CV were significant predictors of stroke, CVD event or death, all-cause mortality, and expanded CVD mortality, whereas DBP-CV was a significant predictor of all-cause mortality and expanded and non-expanded CVD mortality. The joint effect of SBP, FPG, and HbA1c predicted the incidence of stroke and CVD event or death with increased risks of 16 %-35 %. In addition, the joint effect of SBP, DBP, FPG, and HbA1c was associated with all-cause and expanded CVD mortality with increased risks of 29 %-81 %.

CONCLUSIONS

The joint effect of BP and glucose variation improved the prediction of cardiovascular morbidity and mortality. Moreover, simultaneous measurement of visit-to-visit BP and glycemic variation may stratify persons with cardiovascular risks and may be regarded as important therapeutic goals in the care of T2DM.

Do Nutrients and Nutraceuticals Play a Role in Diabetic Retinopathy? A Systematic Review

Diabetic retinopathy (DR) is a multifactorial neuro-microvascular disease, whose prevalence ranges from 25% to 60% of subjects affected by diabetes mellitus, representing the main cause of legal blindness in adults of industrialized countries. The treatment of advanced stage of DR is based on invasive and expensive therapies, while few strategies are available for the early stage or prevention. The mechanisms underlying DR involve a complex interplay between the detrimental effects of hyperglycemia, dyslipidemia, hypoxia, and oxidative stress, providing several pathways potentially targeted by nutrients and nutraceuticals. In this study, we conducted a systematic review of observational and interventional studies, evaluating the effect of nutrients and/or nutraceuticals on the risk of DR and their potential use for the treatment of patients with DR. The analysis of the 41 included studies (27 observational and 14 interventional studies) suggests a promising preventive role of some nutrients, in particular for vitamins B (i.e., B1 and B12), D, and E. However, further investigations are necessary to clarify the potential clinical application of nutraceuticals in the prevention and treatment of DR.

Association Between HbA1c Levels and Diabetic Peripheral Neuropathy: A Case-Control Study of Patients with Type 2 Diabetes Using Claims Data

BACKGROUND

Evidence on the efficacy of glycemic control for diabetic peripheral neuropathy (DPN) is limited in patients with type 2 diabetes mellitus. Despite the known relationship between hemoglobin A1c (HbA1c) and DPN, the parameters (e.g., mean values or variability) that play an important role have not been elucidated.

OBJECTIVE

The objective of this study was to explore factors associated with DPN, including long-term HbA1c parameters, among patients with type 2 diabetes, in a large-scale longitudinal study.

METHODS

We conducted a case-control study using a medical claims database. We extracted data of patients with type 2 diabetes and disease records of DPN (indicating that they received treatment for DPN) and those without DPN records (controls), and matched for age, sex, index year, and duration since the first type 2 diabetes record. A logistic regression analysis was performed to explore factors associated with DPN, and a receiver-operating characteristic analysis to estimate the optimal mean HbA1c target.

RESULTS

Of 1,792,037 patients with type 2 diabetes, data from 1632 patients (816 per group) were analyzed. The mean HbA1c levels in the 3-year observation period were 7.2 ± 1.0% in the DPN group and 6.9 ± 1.1% in the control group. Elevated 3-year mean HbA1c levels were significantly associated with DPN records (adjusted odds ratio: 1.23, 95% confidence interval 1.06-1.42), while HbA1c variability was not significantly associated. The mean HbA1c levels that discriminated between patients with and without DPN records were 6.5% (unadjusted) and 7.1% (adjusted).

CONCLUSIONS

The development or progression of DPN in patients with type 2 diabetes was associated with the 3-year mean HbA1c level in real-world data.

Visit-to-visit variability in albuminuria predicts renal function deterioration in patients with type 2 diabetes

Aims/Introduction

We aimed to study the predictive ability of visit‐to‐visit variability in albuminuria for changes in renal function in patients with type 2 diabetes mellitus.

Materials and Methods

The cohort study was carried out in a single medical center. In the model development cohort of 1008 subjects, we developed the albuminuria variability score (AVS) to evaluate the visit‐to‐visit variability in albuminuria, which was the percentage of the number of changes in the urine albumin : creatinine ratio ≥3.39 mg/mmol among all visit‐to‐visit urine albumin : creatinine ratio differences within an individual. Multivariate logistic regression was applied to predict the influence of AVS levels on the occurrence of study end‐points. In another independent validation cohort of 310 participants, survival analysis was carried out to evaluate the ability of AVS in predicting the study end‐point.

Results

In the model development cohort, a higher AVS was associated with higher adjusted odds of having a declined or rapidly declined estimated glomerular filtration rate (eGFR) trajectory (1.84, 95% confidence interval 1.23–2.76 and 5.70, 95% confidence interval 2.28–14.25, respectively), a resultant eGFR <60 mL/min/1.73 m² (2.61, 95% confidence interval 1.63–4.16) and a >40% decline in eGFR from baseline (6.44, 95% confidence interval 2.15–19.26). In the validation cohort, a higher AVS independently predicted a 5‐year decrease of >40% in eGFR to <60 mL/min/1.73 m² (adjusted hazard ratio 3.33, 95% confidence interval 1.10–10.05). Integrated discrimination index and concordance statistics showed that AVS significantly improved the predictive ability of the models.

Conclusions

Visit‐to‐visit variability in albuminuria can independently predict long‐term renal function deterioration in patients with type 2 diabetes mellitus. Further investigations are warranted to elucidate the potential clinical applications.

Predictive Ability of Visit-to-Visit Variability of HbA1c Measurements for the Development of Diabetic Kidney Disease: A Retrospective Longitudinal Observational Study

AIMS

This study is aimed at clarifying the relationship between visit-to-visit variability of glycated hemoglobin (HbA1c) and the risk of diabetic kidney disease (DKD) and to identifying the most useful index of visit-to-visit variability of HbA1c.

METHODS

This clinic-based retrospective longitudinal study included 699 Japanese type 2 diabetes mellitus patients. Visit-to-visit variability of HbA1c was calculated as the internal standard deviation of HbA1c (HbA1c-SD), the coefficient of variation of HbA1c (HbA1c-CV), the HbA1c change score (HbA1c-HVS), and the area under the HbA1c curve (HbA1c-AUC) with 3-year serial HbA1c measurement data, and the associations between these indices and the development/progression of DKD were examined.

RESULTS

Cox proportional hazards models showed that the HbA1c-SD and HbA1c-AUC were associated with the incidence of microalbuminuria, independently of the HbA1c level. These results were verified and replicated in propensity score (PS) matching and bootstrap analyses. Moreover, the HbA1c-SD and HbA1c-AUC were also associated with oxidized human serum albumin (HSA), an oxidative stress marker.

CONCLUSIONS

Visit-to-visit variability of HbA1c was an independent risk factor of microalbuminuria in association with oxidative stress among type 2 diabetes mellitus patients. HbA1c-AUC, a novel index of HbA1c variability, may be a potent prognostic indicator in predicting the risk of microalbuminuria.

Artificial Intelligence (AI) approach to identifying factors that determine systolic blood pressure in type 2 diabetes (study from the LOOK AHEAD cohort)

BACKGROUND AND AIMS

Artificial Intelligence (AI) methods have recently become critical for research in diabetes in the era of big-data science.

METHODS

In this study, we used the data from the LOOK AHEAD and applied Random Forest to examine the factors determining SBP in persons with diabetes using the software R (version 4.0.3).

RESULTS

Our analysis (that included 4723 participants) showed that maximal exercise capacity, age, albumin to creatinine ratio, and serum creatinine were the key variables that determined systolic blood pressure.

CONCLUSIONS

Maximum exercise capacity is an important predictor of systolic blood pressure in patients with type 2 diabetes.

The Association Between Mean Glycated Haemoglobin or Glycaemic Variability and the Development of Retinopathy in People with Diabetes: A Retrospective Observational Cohort Study

INTRODUCTION

To determine the association between mean glycated haemoglobin (HbA_1c) or glycaemic variability and the development of diabetic retinopathy (DR) in people with diabetes.

METHODS

An observational cohort study with people registered with a DR eye screening service between October 2012 and October 2017. Those who had no DR at the start of the study were followed for a maximum of 5 years. HbA_1c measures were used to calculate HbA_1c variability and mean HbA_1c to assess any relationship between these and the risk of developing new onset DR.

RESULTS

A total of 2511 individuals were followed up for up to 5 years. Of these, 542 (21.6%) developed DR. After adjustment, HbA_1c variability was not significantly associated with the development of DR (p = 0.3435). However, the mean HbA_1c was (p < 0.0001). Those with type 1 diabetes had an odds of 1.63 (95% CI 1.11-2.40) of a retinopathy diagnosis compared to those with type 2 diabetes.

CONCLUSIONS

We have shown that mean HbA_1c is associated with an increased risk of developing diabetic retinopathy. However, after adjustment for sex, age, diabetes type and the mean, the HbA_1c variability no longer remained significant. Our data suggest that optimizing long-term glycaemic control remains paramount.

Association between visit-to-visit variability of glycated albumin and diabetic retinopathy among patients with type 2 diabetes - A prospective cohort study

AIM

There is a paucity of studies regarding the association between long-term glycemic variability with the risk of diabetic retinopathy (DR) in patients with type 2 diabetes. Therefore, the purpose of this study is to explore the association of glycated albumin (GA) variability and HbA1c variability with the risk of DR in patients with type 2 diabetes.

METHODS

This prospective cohort study included 315 inpatients with type 2 diabetes (191 males and 124 females) with at least 3 measurements of GA and HbA1c within 2years prior to the baseline investigation. Different GA and HbA1c variability markers were calculated, including CV, variability independent of the mean (VIM), and the average real variability (ARV). Cox proportional hazard regression models were used to explore the association between visit-to-visit variability of GA and HbA1c and the risk of DR.

RESULTS

After an average follow-up of 3.42years, 81 patients developed incident DR. Multivariable-adjusted (diabetes duration, smoking status, systolic blood pressure, albumin to creatinine ratio, triglycerides, using fibrates, and mean HbA1c) hazard ratios of DR associated with each unit increase in GA-CV, GA-VIM, and GA-ARV were 1.05 (95% CI 1.02-1.09), 1.69 (95% CI 1.24-2.32), and 1.13 (95%CI 1.04-1.23), respectively. However, there was no significant association between visit-to-visit HbA1c variability and the risk of DR.

CONCLUSIONS

The present study indicated that visit-to-visit variability of GA can predict the risk of incident DR in patients with type 2 diabetes, and the prediction ability is independent of the average HbA1c levels.

Changes over Time in Hemoglobin A1C (HbA1C) Levels Predict Long-Term Survival Following Acute Myocardial Infarction among Patients with Diabetes Mellitus

Frequent fluctuations of hemoglobin A1c (HbA1C) values predict patient outcomes. However, data regarding prognoses depending on the long-term changes in HbA1C among patients after acute myocardial infarction (AMI) are scarce. We evaluated the prognostic significance of HbA1C levels and changes among diabetic patients (n = 4066) after non-fatal AMI. All the results of HbA1C tests up to the 10-year follow-up were obtained. The changes (∆) of HbA1C were calculated in each patient. The time intervals of ∆HbA1C values were classified as rapid ( Collapse

Key Words

• acute myocardial infarction
• diabetes mellitus
• hemoglobin A1c
• mortality
• prognosis

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Affiliation(s)

Ygal Plakht Department of Nursing, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel Department of Emergency Medicine, Soroka University Medical Center, Beer Sheva 84101, Israel
Harel Gilutz Goldman Medical School, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva 8410501, Israel;
Arthur Shiyovich Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;

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The Effect of HbA1c Variability as a Risk Measure for Microangiopathy in Type 1 Diabetes Mellitus

Background: To measure the relationship between variability in HbA_1c and microalbuminuria (MA) and diabetic retinopathy (DR) in the long term. Methods: A prospective case-series study, was conducted on 366 Type 1 Diabetes Mellitus patients with normoalbuminuria and without diabetic retinopathy at inclusion. The cohort was followed for a period of 12 years. The Cox survival analysis was used for the multivariate statistical study. The effect of variability in microangiopathy (retinopathy and nephropathy) was evaluated by calculating the standard deviation of HbA_1c (SD-HbA_1c), the coefficient of variation of HbA_1c (CV-HbA_1c), average real variability (ARV-HbA_1c) and variability irrespective of the mean (VIM-HbA_1c) adjusted for the other known variables. Results: A total of 106 patients developed diabetic retinopathy (29%) and 73 microalbuminuria (19.9%). Overt diabetic nephropathy, by our definition, affected only five patients (1.36%). Statistical results show that the current age, mean HbA_1c, SD-HbA_1c and ARV-HbA_1c are significant in the development of diabetic retinopathy. Microalbuminuria was significant for current age, mean HbA_1c, CV-HbA_1c and ARV-HbA_1c. Conclusions: By measuring the variability in HbA_1c, we can use SD-HbA_1c and ARV-HbA_1c as possible targets for judging which patients are at risk of developing DR and MA, and CV-HbA_1c as the target for severe DR.

Thresholds for postprandial hyperglycemia and hypertriglyceridemia associated with increased mortality risk in type 2 diabetes patients: A real-world longitudinal study

AIMS/INTRODUCTION

To identify thresholds for postprandial hyperglycemia and hypertriglyceridemia predictive of all-cause mortality in patients with type 2 diabetes.

MATERIALS AND METHODS

A total of 1,928 patients with type 2 diabetes visited our clinic for the first time from 1995 to 1999 and were followed up for ≥1 year. During the first year, 2-h post-breakfast blood glucose (2h-BG) levels were measured in 1,122 patients (BG cohort) and postprandial serum triglyceride (ppTG) levels were measured in 1,826 patients (TG cohort). Patients were retrospectively followed until 2017 and administered questionnaires. Associations between 2h-BG and ppTG levels and mortality risk were assessed by the multivariate Cox regression analysis.

RESULTS

Over of 17,429 person-years, 162 deaths occurred in the BG cohort, and over 28,026 person-years, 253 deaths occurred in the TG cohort. Hazard ratios (HRs) with 95% confidence intervals for all-cause mortality per 1-standard deviation increases in 2h-BG and ppTG were 1.34 (1.08-1.67) and 1.24 (1.06-1.45), respectively. HRs showed increasing trends across quintiles of 2h-BG (P = 0.034) and ppTG (P = 0.007). The HR was significantly elevated (2.37, 1.26-4.47) in the fifth quintile of 2h-BG (≥13.8 mmol/L) compared with the first quintile (<7.0 mmol/L; P = 0.008). The HR was also significantly elevated (1.63, 1.03-2.60) in the fifth quintile of ppTG (≥2.30 mmol/L) compared with the first quintile (<0.91 mmol/L; P = 0.038).

CONCLUSIONS

Postprandial hyperglycemia and hypertriglyceridemia were associated with all-cause mortality in patients with type 2 diabetes. We propose thresholds of 13.8 mmol/L 2h-BG and 2.30 mmol/L ppTG to identify patients at increased risk of mortality.

Visit-to-visit variability of clinical risk markers in relation to long-term complications in type 1 diabetes

BACKGROUND

Clinical characteristics such as HbA_1c , systolic blood pressure (SBP), albuminuria and estimated glomerular filtration rate (eGFR) are important when treating type 1 diabetes. We investigated the variability in these measures as risk markers for micro- and macrovascular complications.

METHODS

This prospective study included 1062 individuals with type 1 diabetes. Visit-to-visit variability of HbA_1c , SBP, albuminuria and eGFR was calculated as the SD of the residuals in individual linear regression models using all available measures in a specified period of 3 years (VV). Endpoints included were as follows: cardiovascular events (CVE) defined as myocardial infarction, non-fatal stroke, or coronary or peripheral arterial intervention; end-stage kidney disease (ESKD) defined as eGFR <15 ml/min/1.73 m² , chronic dialysis or kidney transplantation; eGFR decline ≥30%; and mortality. Adjustment included age, sex, cholesterol, HbA_1c , SBP, body mass index, smoking, albuminuria, eGFR, and mean, intercept, slope of respective exposure variables and regression models.

RESULTS

SBP VV was significantly associated with CVE (adjusted hazard ratio per 50% increase, (CI 95%); p: 1.21 [1.05-1.39]; p = 0.008), ESKD (1.51 [1.16-1.96]; p = 0.002) and mortality (1.25 [1.09-1.44]; p = 0.002). HbA_1c VV was significantly associated with mortality (1.51 [1.30-1.75]; p < 0.001); albuminuria VV with eGFR decline (1.14 [1.08-1.20]; p = 0.024) and ESKD (1.14 [1.02-1.27]; p < 0.001), but neither CVE nor mortality. Adjusted eGFR VV was not associated with endpoints.

CONCLUSION

In type 1 diabetes, higher variability of basic clinical risk markers adds important risk stratification information for the development of micro- and macrovascular complications.

Habitual Miso (Fermented Soybean Paste) Consumption Is Associated with Glycemic Variability in Patients with Type 2 Diabetes: A Cross-Sectional Study

Glycemic control, including glycemic variability, is important for the prevention of diabetic vascular complications in patients with type 2 diabetes mellitus (T2DM). There was an association between miso soup intake and insulin resistance. However, the relationship between habitual miso consumption and glycemic control, including glycemic variability, in patients with T2DM remains unknown. We defined people without habitual miso consumption if they did not consume miso soup at all in a day. The average, standard deviation (SD), and coefficient of variation (CV), calculated as CV = (SD/average HbA1c) × 100 (%), of hemoglobin (Hb) A1c levels were evaluated. The proportions of habitual miso consumption of male and female were 88.1% and 82.3%, respectively. The average (7.0 [6.4-7.5] vs. 7.3 [6.8-8.4] %, p = 0.009), SD (0.21 [0.12-0.32] vs. 0.37 [0.20-0.72], p = 0.004), and CV (0.03 [0.02-0.04] vs. 0.05 [0.03-0.09], p = 0.005) of HbA1c levels in female with habitual miso consumption were lower than those of female without. Moreover, habitual miso consumption correlated with average (β = -0.251, p = 0.009), SD (β = -0.175, p = 0.016), and CV (β = -0.185, p = 0.022) of HbA1c levels after adjusting for covariates. However, no association between habitual miso consumption and any glycemic parameters was shown among male. This study clarified the association between habitual miso consumption and good glycemic control, including glycemic variability, in female, but not in male.

Fasting Glucose Variation Predicts Microvascular Risk in ACCORD and VADT

AIMS

The association of glycemic variability with microvascular disease complications in type 2 diabetes (T2D) has been under-studied and remains unclear. We investigated this relationship using both Action to Control Cardiovascular Risk in Diabetes (ACCORD) and the Veteran Affairs Diabetes Trial (VADT).

METHODS

In ACCORD, fasting plasma glucose (FPG) was measured 1 to 3 times/year for up to 84 months in 10 251 individuals. In the VADT, FPG was measured every 3 months for up to 87 months in 1791 individuals. Variability measures included coefficient of variation (CV) and average real variability (ARV) for fasting glucose. The primary composite outcome was time to either severe nephropathy or retinopathy event and secondary outcomes included each outcome individually. To assess the association, we considered variability measures as time-dependent covariates in Cox proportional hazard models. We conducted a meta-analysis across the 2 trials to estimate the risk of fasting glucose variability as well as to assess the heterogenous effects of FPG variability across treatment arms.

RESULTS

In both ACCORD and the VADT, the CV and ARV of FPG were associated with development of future microvascular outcomes even after adjusting for other risk factors, including measures of average glycemic control (ie, cumulative average of HbA1c). Meta-analyses of these 2 trials confirmed these findings and indicated FPG variation may be more harmful in those with less intensive glucose control.

CONCLUSIONS

This post hoc analysis indicates that variability of FPG plays a role in, and/or is an independent and readily available marker of, development of microvascular complications in T2D.

Systemic risk factors contribute differently to the development of proliferative diabetic retinopathy and clinically significant macular oedema

AIMS/HYPOTHESIS

The purpose of screening for diabetic retinopathy is to detect either of the two sight-threatening complications: proliferative diabetic retinopathy (PDR) or clinically significant diabetic macular oedema (DME). The aim of the study was to evaluate whether systemic risk factors affect the risk of developing these two complications differently.

METHODS

Survival analysis with death as a competing risk was used to describe the effect of sex, age and time of onset of diabetes, systolic (SBP) and diastolic (DBP) BPs, and the weighted exposure and CV of HbA_1c for the development of PDR and DME from all 2773 patients treated for diabetic retinopathy in a defined population from the Aarhus area, Denmark, between 1 July 1994 and 1 July 2019.

RESULTS

Increasing HbA_1c above normal increased the risk of developing both PDR and DME (p < 0.04), and values below normal increased the risk of developing PDR (p < 0.013). Increasing DBP increased the risk of developing both PDR and DME (p < 0.0001), whereas increasing SBP increased the risk of developing DME (p < 0.0001), but not PDR (p > 0.08). The risk of developing PDR increased with decreasing age of onset of diabetes (p < 0.0001), whereas the risk of developing DME was maximal for a known onset of diabetes at about 30 years of age and decreased significantly for both lower and higher ages of onset (p < 0.0001). The risk of developing both PDR and DME was lower in women than in men (p < 0.004) and was reduced with lower variability of repeated HbA_1c measurements (p < 0.0001).

CONCLUSIONS/INTERPRETATION

Systemic risk factors such as metabolic regulation, arterial BP and the age of onset of diabetes contribute differently to the development of PDR and DME. The overall risk of developing treatment-requiring diabetic retinopathy should be calculated from the risks of reaching each of the two complications separately.

Comparative predictive ability of visit-to-visit HbA1c variability measures for microvascular disease risk in type 2 diabetes

BACKGROUND

To assess the associations of various HbA1c measures, including a single baseline HbA1c value, overall mean, yearly updated means, standard deviation (HbA1c-SD), coefficient of variation (HbA1c-CV), and HbA1c variability score (HVS), with microvascular disease (MVD) risk in patients with type 2 diabetes.

METHODS

Linked data between National Cheng Kung University Hospital and Taiwan's National Health Insurance Research Database were utilized to identify the study cohort. The primary outcome was the composite MVD events (retinopathy, nephropathy, or neuropathy) occurring during the study follow-up. Cox model analyses were performed to assess the associations between HbA1c measures and MVD risk, with adjustment for patients' baseline HbA1c, demographics, comorbidities/complications, and treatments.

RESULTS

In the models without adjustment for baseline HbA1c, all HbA1c variability and mean measures were significantly associated with MVD risk, except HVS. With adjustment for baseline HbA1c, HbA1c-CV had the strongest association with MVD risk. For every unit of increase in HbA1c-CV, the MVD risk significantly increased by 3.42- and 2.81-fold based on the models without and with adjustment for baseline HbA1c, respectively. The associations of HbA1c variability and mean measures with MVD risk in patients with baseline HbA1c < 7.5% (58 mmol/mol) were stronger compared with those in patients with baseline HbA1c ≥ 7.5% (58 mmol/mol).

CONCLUSIONS

HbA1c variability, especially HbA1c-CV, can supplement conventional baseline HbA1c measure for explaining MVD risk. HbA1c variability may play a greater role in MVD outcomes among patients with relatively optimal baseline glycemic control compared to those with relatively poor baseline glycemic control.

Effect of postprandial hyperglycemia at clinic visits on the incidence of retinopathy in patients with type 2 diabetes: An analysis using real-world long-term follow-up data

AIMS/INTRODUCTION

There is little evidence on the role of postprandial glycemia in the incidence of diabetic retinopathy (DR) in a real-world setting. We aimed to assess the effect of postprandial hyperglycemia at clinic visits on the incidence of DR in patients with type 2 diabetes, and whether its effect differs depending on glycated hemoglobin (HbA1c) values and age.

MATERIALS AND METHODS

Intrapersonal mean blood glucose levels at 1-2 h post-breakfast (1-2h-PBBG), post-lunch (1-2 h-PLBG) and both (1-2h-PBLBG) during 2 years from the first visit were used as baseline data. This retrospective cohort study enrolled 487, 323 and 406 patients who had 1-2h-PBLBG, 1-2h-PBBG and 1-2h-PLBG measurements, respectively. These three groups were followed from 1999 up through 2017.

RESULTS

DR occurred in 145, 92 and 126 patients in the 1-2h-PBLBG, 1-2h-PBBG and 1-2h-PLBG groups, respectively. Multivariate Cox regression analysis showed that the mean 1-2h-PBLBG, 1-2h-PBBG and 1-2h-PLBG levels were significant predictors of DR, independent of mean HbA1c. In patients with mean HbA1c <7.0% and those with a baseline age <60 years, the mean 1-2h-PBLBG, 1-2h-PBBG and 1-2h-PLBG levels were significant predictors.

CONCLUSIONS

Postprandial hyperglycemia at clinic visits might predict the incidence of DR, independent of HbA1c. The effect of postprandial hyperglycemia on DR is obvious in patients with well-controlled HbA1c and in younger patients. Even with the lower HbA1c level, correcting postprandial hyperglycemia is important for preventing DR, especially in middle-aged adults with type 2 diabetes.

Visit-to-visit blood pressure variability and risk of chronic kidney disease: A systematic review and meta-analyses

Objective

Previous studies have shown that visit-to-visit blood pressure variability (BPV) is associated with chronic kidney disease (CKD). However, the results have not been consistent among studies. This systematic review and meta-analysis was conducted to comprehensively assess the association between visit-to-visit BPV and the risk of CKD.

Methods

Medline, Embase, and the Cochrane Library were searched from the date of inception through 1 August 2019 using the terms “blood pressure variability,” “chronic kidney disease,” “nephropathy,” and other comparable terms. The primary outcome was the development of CKD. Two reviewers extracted the data independently. Meta-analysis was performed using a random effects model.

Results

Fourteen studies were included in the systematic review and meta-analysis. The risk of CKD was significantly greater in patients with high baseline systolic blood pressure variability (SBPV) than in patients with low baseline SBPV: the standard deviation (SD) showed relative risk (RR) of 1.69 and 95% CI of 1.38–2.08, the coefficient of variation (CV) showed RR of 1.23 and 95% CI of 1.12–1.36, and variance independent of mean (VIM) showed RR of 1.40 and 95% CI of 1.15–1.71. RRs for each unit increase in visit-to-visit SBPV and risk of CKD were 1.05 (95% CI: 1.03–1.07) for SD, 1.06 (95% CI: 1.03–1.09) for CV, and 1.1 (95% CI: 0.96–1.25) for VIM. Diastolic BPV was similarly predictive of CKD based on SD and CV.

Conclusions

Increased visit-to-visit BPV might be an independent risk factor for CKD. However, significant heterogeneity was present; thus, future prospective studies are needed to confirm our findings. Our results indicate that treatment of hypertension should control blood pressure levels and prevent abnormal fluctuations in blood pressure to reduce the risk of CKD.

An Observational Registry to Assess Urinary Albumin Evolution in Saudi Hypertensive Patients with the Current Treatment Local algorithm: Results of the RATIONAL Study

Introduction

Hypertension causes microalbuminuria, which if left uncontrolled could progress to kidney damage. Antihypertensive treatment primarily aims at controlling blood pressure (BP), but is also shown to control urine albumin excretion. This renoprotective role of antihypertensive medications consists of halting or reverting albuminuria progression.

Patients and Methods

A national Kingdom of Saudi Arabia (KSA), multicenter, observational, longitudinal study (RATIONAL), evaluated the correlation between BP control and microalbuminuria evolution over 1 year. Adult hypertensive patients with kidney damage were enrolled, after giving written consent.

Results

Of 409 patients, 60% had uncontrolled BP at baseline, down to 34% at 12 months. Over 80% of patients were on mono or double antihypertensive therapy, and angiotensin-receptor blockers (ARB) topped the list of medication classes. Albumin–creatinine ratio (ACR) significantly decreased throughout the study, indicating that BP control is paramount to prevent target organ damage. BP change most strongly correlated with ACR change upon triple therapy (ARB + calcium channel blocker + β-blocker). Importantly, 25% (at 6 months) and 38% (at 12 months) of patients reverted back to normoalbuminuria, mostly upon renin-angiotensin system blockers. Around 80% of study patients had also diabetes, a common condition in KSA, which significantly hindered achievement of normoalbuminuria at 12 months.

Conclusion

A modest but solid correlation between BP control and ACR reduction was identified. Results underline proper BP management in KSA and success of antihypertensive treatment in reverting microalbuminuria or delaying its progress. The study duration might be insufficient to reflect conclusively the beneficial effect of longer-term BP control on microalbuminuria evolution.

Prognostic importance of visit-to-visit blood pressure variability for micro- and macrovascular outcomes in patients with type 2 diabetes: The Rio de Janeiro Type 2 Diabetes Cohort Study

BACKGROUND

The prognostic importance of an increased visit-to-visit blood pressure variability (BP-VVV) for the future development of micro- and macrovascular complications in type 2 diabetes has been scarcely investigated and is largely unsettled. We aimed to evaluate it in a prospective long-term follow-up study with 632 individuals with type 2 diabetes.

METHODS

BP-VVV parameters (systolic and diastolic standard deviations [SD] and variation coefficients) were measured during the first 24-months. Multivariate Cox analysis, adjusted for risk factors and mean BP levels, examined the associations between BP-VVV and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration, peripheral neuropathy) and macrovascular complications (total cardiovascular events [CVEs], major adverse CVEs [MACE] and cardiovascular and all-cause mortality). Improvement in risk discrimination was assessed by the C-statistic and integrated discrimination improvement (IDI) index.

RESULTS

Over a median follow-up of 11.3 years, 162 patients had a CVE (132 MACE), and 212 patients died (95 from cardiovascular diseases); 153 newly-developed or worsened diabetic retinopathy, 193 achieved the renal composite outcome (121 newly-developed microalbuminuria and 95 deteriorated renal function), and 171 newly-developed or worsened peripheral neuropathy. Systolic BP-VVV was an independent predictor of MACE (hazard ratio: 1.25, 95% CI 1.03-1.51 for a 1-SD increase in 24-month SD), but not of total CVEs, cardiovascular and all-cause mortality, and of any microvascular outcome. However, no BP-VVV parameter significantly improved cardiovascular risk discrimination (increase in C-statistic 0.001, relative IDI 0.9%).

CONCLUSIONS

Systolic BP-VVV was an independent predictor of MACE, but it did not improve cardiovascular risk stratification. The goal of anti-hypertensive treatment in patients with type 2 diabetes shall remain in controlling mean BP levels, not on decreasing their visit-to-visit variability.

Effect of mean HbA1c on the association of HbA1c variability and all-cause mortality in patients with type 2 diabetes

AIM

To evaluate the effect of mean HbA1c on the correlation between HbA1c variability and all-cause mortality, and the risks associated with different levels of HbA1c and glycaemic control status in patients with type 2 diabetes.

MATERIALS AND METHODS

Patients with type 2 diabetes and at least three HbA1c measurements within 12-24 months were included. HbA1c variability score, coefficient of variation (CV) and standard deviation (SD) were used to evaluate variability. A variability score of 50 was set as a cutoff to define low and high variability.

RESULTS

A total of 4216 patients were included, of whom 1196 died during the observation period (11.1 ± 3.2 years). All-cause mortality increased with HbA1c variability score and the quartiles of HbA1c CV and SD. The strength of this association was attenuated after adjustment for mean HbA1c, and the risks associated with HbA1c variability and glycaemic control status were similar. The highest associated risk was observed with an HbA1c variability score of >50 and mean HbA1c of ≥7.5%. Mortality risk was significantly higher with a mean HbA1c of ≤6.0% and >8.5% and of ≤6.0% and >8.0% for low and high HbA1c variability, respectively.

CONCLUSIONS

Mean HbA1c contributed to the correlation between HbA1c variability and all-cause mortality. The risks associated with HbA1c variability and glycaemic control status were similar. The relationship between mean HbA1c and mortality presented a J-shaped distribution for both low and high HbA1c variability.

Preoperative outpatient blood pressure variability predicts postoperative mortality, readmission and morbidity after surgery

BACKGROUND

Outpatient blood pressure variability (BPV) predicts hospitalization and death in non-surgical patients independently of hypertension. We hypothesized that preoperative BPV predicts postoperative outcomes.

METHODS

We assessed 22,233 veterans undergoing CABG, colectomy, hip replacement, pancreatectomy, carotid endarterectomy or AV-fistula with ≥10 outpatient BP's over three preoperative years. Calculating BPV as SD of systolic or diastolic BP, we used logistic regression considering demographics, comorbidities, and pre-admission cardiovascular medications to estimate odds ratios for 90-day mortality or readmission, MI, CVA, renal failure, and wound infection, choosing the lowest 5%ile of systolic/diastolic BPV for reference.

RESULTS

Covariate-adjusted ORs for adverse outcomes increased as BPV increased. For instance, the highest 5%ile of systolic BPV had covariate-adjusted ORs of 2.96 and 1.78 for 90-day mortality and readmission. Systolic and diastolic BPV trended together but affected outcomes independently.

CONCLUSIONS

Preoperative BPV predicts postoperative outcomes. BPV should be considered in individualized risk assessment and subgroup risk stratification.

Blood Pressure Variability and Incidence of New-Onset Atrial Fibrillation

Blood pressure variability is a well-known risk factor for cardiovascular disease, but its association with atrial fibrillation (AF) is uncertain. We aimed to evaluate the association between visit-to-visit blood pressure variability and incident AF. This population-based cohort study used database from the Health Screening Cohort, which contained a complete set of medical claims and a biannual health checkup information of the Koran population. A total of 8 063 922 individuals who had at least 3 health checkups with blood pressure measurement between 2004 and 2010 were collected after excluding subjects with preexisting AF. Blood pressure variability was defined as variability independence of the mean and was divided into 4 quartiles. During a mean follow-up of 6.8 years, 140 086 subjects were newly diagnosed with AF. The highest blood pressure variability (fourth quartile) was associated with an increased risk of AF (hazard ratio, 95% CI; systolic blood pressure: 1.06, 1.05–1.08; diastolic blood pressure: 1.07, 1.05–1.08) compared with the lowest (first quartile). Among subjects in the fourth quartile in both systolic and diastolic blood pressure variability, the risk of AF was 7.6% higher than those in the first quartile. Moreover, this result was consistent in both patients with or without prevalent hypertension. In subgroup analysis, the impact of high blood pressure variability on AF development was stronger in high-risk subjects, who were older (≥65 years), with diabetes mellitus or chronic kidney disease. Our findings demonstrated that higher blood pressure variability was associated with a modestly increased risk of AF.

Association between blood pressure variability, cardiovascular disease and mortality in type 2 diabetes: A systematic review and meta-analysis

AIM

To investigate the associations of blood pressure variability (BPV), expressed as long-term (visit-to-visit) and short-term (ambulatory blood pressure monitoring [ABPM] and home blood pressure monitoring [HBPM]) and all-cause mortality, major adverse cardiovascular events (MACEs), extended MACEs, microvascular complications (MiCs) and hypertension-mediated organ damage (HMOD) in adult patients with type 2 diabetes.

MATERIALS AND METHODS

PubMed, Medline, Embase, Cinahl, Web of Science, ClinicalTrials.gov and grey literature databases were searched for studies including patients with type 2 diabetes, at least one variable of BPV (visit-to-visit, HBPM, ABPM) and evaluation of the incidence of at least one of the following outcomes: all-cause mortality, MACEs, extended MACEs and/or MiCs and/or HMOD. The extracted information was analyzed using random effects meta-analysis and meta-regression.

RESULTS

Data from a total of 377 305 patients were analyzed. Systolic blood pressure (SBP) variability was associated with a significantly increased risk of all-cause mortality (HR 1.12, 95% CI 1.04-1.21), MACEs (HR 1.01, 95% CI 1.04-1.17), extended MACEs (HR 1.07, 95% CI 1.03-1.11) and MiCs (HR 1. 12, 95% CI 1.01-1.24), while diastolic blood pressure was not. Associations were mainly driven from studies on long-term SBP variability. Qualitative analysis showed that BPV was associated with the presence of HMOD expressed as carotid intima-media thickness, pulse wave velocity and left ventricular hypertrophy. Results were independent of mean blood pressure, glycaemic control and serum creatinine levels.

CONCLUSIONS

Our results suggest that BPV might provide additional information rather than mean blood pressure on the risk of cardiovascular disease in patients with type 2 diabetes.

The effect of long-term past glycemic control on executive function among patients with type 2 diabetes mellitus

Objective

Patients with type 2 diabetes mellitus (T2DM) show more executive dysfunction than nondiabetics. However, how long poor glycemic control affects executive function remains unclear. Thus, we aimed to investigate the relationships in a cross-sectional study.

Methods

We studied 118 T2DM outpatients (age, ≥ 60 years; excluding history of stroke, dementia and severe hypoglycemia). HbA1c values were recorded every ≤ 12 weeks for ≥ 5 years. All patients underwent verbal-fluency tests (reflecting executive function) and Mini-Mental State Examination (MMSE). The correlation between past glycemic control values and both cognitive tests scores was investigated. As markers of past glycemic control, we used average hemoglobin A1c (HbA1c) values and glycemic control variability [coefficient of variation (CV) of HbA1c values (HbA1c-CV)].

Results

Verbal-fluency tests scores correlated with HbA1c-CV, but not with average HbA1c values, after adjusting for age, years of education and sex. Verbal-fluency tests scores correlated with HbA1c-CV for the past 5 years, best compared with HbA1c-CV for past < 5 years. MMSE scores were also related to only HbA1c-CV for the past 3 years in an adjustment model.

Conclusions

Five-year HbA1c variability affected executive function in T2DM patients, but not average HbA1c values. Long-term longitudinal studies may be required.

Overall Quality of Care Predicts the Variability of Key Risk Factors for Complications in Type 2 Diabetes: An Observational, Longitudinal Retrospective Study

OBJECTIVE

An association between variability in clinical parameters (HbA_1c, blood pressure, cholesterol, and uric acid) and risk of complications in type 2 diabetes has been reported. In this analysis, we investigated to what extent such variability is associated with overall quality of care.

RESEARCH DESIGN AND METHODS

The quality of care summary score (Q-score) represents a validated, overall quality of care indicator ranging between 0 and 40; the higher the score, the better the quality of care provided by the diabetes center. We identified patients with five or more measurements of clinical parameters after the assessment of the Q-score. Multiple linear regression analyses assessed the role of the Q-score in predicting the variability of the different parameters.

RESULTS

Overall, 273,888 patients were analyzed. The variability of all the parameters systematically increased with decreasing Q-score values. At multivariate linear regression analysis, compared with a Q-score >25, a score <15 was associated with a significantly larger variation in HbA_1c, blood pressure, uric acid, total cholesterol, and LDL cholesterol and a lower variation in HDL cholesterol. The analysis of standardized β coefficients show that the Q-score has a larger impact on the variability of HbA_1c (0.34; P < 0.0001), systolic blood pressure (0.21; P < 0.0001), total cholesterol (0.21; P < 0.0001), and LDL cholesterol (0.20; P < 0.0001).

CONCLUSIONS

The variability of risk factors for diabetic complications is associated with quality of care. Quality of care improvement initiatives should be targeted to increase the achievement of the recommended target while reducing such variability.

Visit-to-Visit Variability of Blood Pressure Is Associated With Hospitalization and Mortality in an Unselected Adult Population

BACKGROUND

Blood pressure variability (BPV) has been associated with poor health outcomes in high-risk patients, but its association with more general populations is poorly understood.

METHODS

We analyzed outcomes from 240,622 otherwise unselected patients who had 10 or more outpatient blood pressure readings recorded over a 3-year period and were aged from 20 to 100 years.

RESULTS

Whether calculated as SD, average change, or greatest change and systolic or diastolic blood pressure, we found that higher outpatient BPV was associated with subsequent hospitalization and mortality. Systolic pressure average change exceeding 10-12 mm Hg or diastolic exceeding 8 mm Hg significantly increased risk of hospitalization and death (odds ratios [ORs] from 2.0 to 4.5). Variability in the highest decile increased risks even more dramatically, with propensity-matched ORs from 4.4 to 42. A systolic change exceeding 35 mm Hg increased the relative risk of death 4.5-fold. Similarly, a diastolic change greater than 23-24 mm Hg almost tripled the risks of hospitalization and death. Neither stratification for hypertension nor propensity matching for risk factors within the database affected these associations.

CONCLUSIONS

Systolic and diastolic variabilities were each associated with subsequent adverse outcomes. Physicians should pay special attention to patients with swings in blood pressure between clinic visits. Electronic medical records should flag such variability.

Long-term visit-to-visit glycemic variability as predictor of micro- and macrovascular complications in patients with type 2 diabetes: The Rio de Janeiro Type 2 Diabetes Cohort Study

BACKGROUND

Long-term visit-to-visit glycemic variability is an additional measure of glycemic control. We aimed to evaluate the prognostic value of several measures of glycemic variability for the occurrence of micro- and macrovascular complications, and all-cause mortality in patients with type 2 diabetes.

METHODS

654 individuals were followed-up over a median of 9.3 years. Glycemic variability (SDs and coefficients of variation of HbA1c and fasting glycaemia) was measured during the first 12- and 24-months. Multivariate Cox analysis, adjusted for risk factors and mean HbA1c and fasting glycaemia levels, examined the associations between glycemic variability and the occurrence of microvascular (retinopathy, microalbuminuria, renal function deterioration, peripheral neuropathy) and macrovascular complications [total cardiovascular events (CVE), major adverse CVEs (MACE) and cardiovascular mortality], and of all-cause mortality.

RESULTS

During follow-up, 128 patients had a CVE (96 MACE), and 158 patients died (67 from cardiovascular diseases); 152 newly-developed or worsened diabetic retinopathy, 183 achieved the renal composite outcome (89 newly developed microalbuminuria and 91 deteriorated renal function), and 96 newly-developed or worsened peripheral neuropathy. Glycemic variability, particularly the 24-month parameters either estimated by HbA1c or by fasting glycemia, predicted all endpoints, except for retinopathy and peripheral neuropathy development/progression, and was a better predictor than mean HbA1c. Glycemic variability predicted retinopathy development/progression in patients with good glycemic control (HbA1c ≤ 7.5%, 58 mmol/mol) and predicted new-incident peripheral neuropathy.

CONCLUSIONS

Long-term visit-to-visit glycemic variability is an additional and frequently a better glycemic parameter than mean HbA1c levels for assessing the risk of future development of micro- and macrovascular complications in patients with type 2 diabetes.