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Demirelli B, Boztepe B, Şenol EG, Boynueğri B, Bildacı YD, Gümrükçü G, Canbakan M, Öğütmen MB. Non-diabetic nephropathy in diabetic patients: incidence, HbA1c variability and other predictive factors, and implications. Int Urol Nephrol 2024:10.1007/s11255-024-04066-w. [PMID: 38662267 DOI: 10.1007/s11255-024-04066-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/18/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE Diabetes mellitus (DM) is the leading cause of chronic kidney disease (CKD) in the population. In patients with diabetes mellitus, the incidence of non-diabetic nephropathy (NDNP) has been estimated to range from 3% to 69.5%. Personal judgment is frequently employed while deciding whether or not to do a kidney biopsy (KB) on diabetic patients. NDNP alters the prognosis and course of treatment for people with DM. In our study, we examined the incidence of NDNP concurrent with the progression of diabetes mellitus, as well as the laboratory and clinical indicators that could be utilized to forecast it. METHODS A retrospective analysis of 76 diabetic patients who underwent KB was conducted. Based on the pathological diagnoses of these patients, they were categorized as DNP (diabetic nephropathy) or NDNP. The definition of HbA1c variability was determined by calculating the mean HbA1c and the average value of the HbA1c measurements, as well as the standard deviation (SD) for each participant. RESULTS NDNP was detected in 50% of 76 patients. Among patients with NDNP, 36.8% had focal segmental glomerulosclerosis (FSGS), 23.6% had membranous glomerulonephritis, and 7.8% had IgA nephritis. The NDNP group exhibited significantly higher rates of female gender, absence of diabetic retinopathy, shorter time to diagnosis of diabetes mellitus, chronic kidney disease, and proteinuria, less intensive medication for diabetes mellitus, presence of hematuria and leukociduria, immunological serological marker positivity, and non-HbA1C variability. Risk factors for predicting non-diabetic nephropathy, as determined by multivariate analysis, included female gender, the absence of diabetic retinopathy, non-HbA1c variability and a positive immunological serological test. CONCLUSION In this study, a significant number of diabetic patients with chronic kidney disease were diagnosed with NDNP. Identifying these patients allows for treatment of the specific underlying disease. Factors such as the absence of DR, non-HbA1c variability, female gender, and immunological serological test positivity can predict NDNP and guide the clinician's decision on kidney biopsy. Further prospective studies are warranted to validate the efficacy of potential predictive factors like HbA1c variability.
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Affiliation(s)
- Bülent Demirelli
- Department of Nephrology, Marmara Unıversity Pendik Training and Research Hospital, Nephrology Clinic, Fevzi Çakmak Quarter Muhsin Yazıcıoğlu Street No: 10 Üst Kaynarca, Pendik, İstanbul, Turkey.
| | - Burcu Boztepe
- Department of Nephrology, Haydarpaşa Numune Training and Research Hospital, Nephrology Clinic, İstanbul, Turkey
| | - Elif Gülcan Şenol
- Department of Nephrology, Haydarpaşa Numune Training and Research Hospital, Nephrology Clinic, İstanbul, Turkey
| | - Başak Boynueğri
- Department of Nephrology, Haydarpaşa Numune Training and Research Hospital, Nephrology Clinic, İstanbul, Turkey
| | - Yelda Deligöz Bildacı
- Department of Nephrology, Dokuz Eylül University Research and Application Hospital, Nephrology Clinic, İstanbul, Turkey
| | - Gülistan Gümrükçü
- Department of Pathology, Haydarpaşa Numune Training and Research Hospital, Izmir, Turkey
| | - Mustafa Canbakan
- Department of Nephrology, Haydarpaşa Numune Training and Research Hospital, Nephrology Clinic, İstanbul, Turkey
| | - Melike Betül Öğütmen
- Department of Nephrology, Haydarpaşa Numune Training and Research Hospital, Nephrology Clinic, İstanbul, Turkey
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Ahmad A, Lim LL, Morieri ML, Tam CHT, Cheng F, Chikowore T, Dudenhöffer-Pfeifer M, Fitipaldi H, Huang C, Kanbour S, Sarkar S, Koivula RW, Motala AA, Tye SC, Yu G, Zhang Y, Provenzano M, Sherifali D, de Souza RJ, Tobias DK, Gomez MF, Ma RCW, Mathioudakis N. Precision prognostics for cardiovascular disease in Type 2 diabetes: a systematic review and meta-analysis. COMMUNICATIONS MEDICINE 2024; 4:11. [PMID: 38253823 PMCID: PMC10803333 DOI: 10.1038/s43856-023-00429-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 12/14/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with Type 2 diabetes (T2D). METHODS We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies. RESULTS Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort. CONCLUSIONS Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.
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Affiliation(s)
- Abrar Ahmad
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
| | - Lee-Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Asia Diabetes Foundation, Hong Kong SAR, China
| | - Mario Luca Morieri
- Metabolic Disease Unit, University Hospital of Padova, Padova, Italy
- Department of Medicine, University of Padova, Padova, Italy
| | - Claudia Ha-Ting Tam
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Feifei Cheng
- Health Management Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China
| | - Tinashe Chikowore
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Hugo Fitipaldi
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
| | - Chuiguo Huang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Sudipa Sarkar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Robert Wilhelm Koivula
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, United Kingdom
| | - Ayesha A Motala
- Department of Diabetes and Endocrinology, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Sok Cin Tye
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
- Sections on Genetics and Epidemiology, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Gechang Yu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yingchai Zhang
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Michele Provenzano
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Diana Sherifali
- Heather M. Arthur Population Health Research Institute, McMaster University, Ontario, Canada
| | - Russell J de Souza
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton Health Sciences Corporation, Hamilton, Ontario, Canada
| | | | - Maria F Gomez
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden.
- Faculty of Health, Aarhus University, Aarhus, Denmark.
| | - Ronald C W Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China.
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China.
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | - Nestoras Mathioudakis
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Manosroi W, Phimphilai M, Waisayanand N, Buranapin S, Deerochanawong C, Gunaparn S, Phrommintikul A, Wongcharoen W. Glycated hemoglobin variability and the risk of cardiovascular events in patients with prediabetes and type 2 diabetes mellitus: A post-hoc analysis of a prospective and multicenter study. J Diabetes Investig 2023; 14:1391-1400. [PMID: 37610280 PMCID: PMC10688133 DOI: 10.1111/jdi.14073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/24/2023] Open
Abstract
AIMS/INTRODUCTION High glycated hemoglobin (HbA1c) variability has been reported to be linked with cardiovascular events in type 2 diabetes patients. Only a few studies have been carried out on Asian patients. This study aimed to investigate the association of prediabetes and type 2 diabetes in Asian patients by performing a post-hoc analysis of a multicenter, prospective, observational study. MATERIALS AND METHODS Data for prediabetes and type 2 diabetes patients were retrieved from a multicenter national registry entitled "CORE-Thailand study." The primary outcome was 4P-MACE (major adverse cardiovascular events, including non-fatal myocardial infarction, heart failure hospitalization, non-fatal stroke and all-cause death). Patients were stratified according to quartiles of HbA1c standard deviation. The Cox proportional hazards regression model was used to estimate the association of HbA1c variability with incident cardiovascular disease. RESULTS A total of 3,811 patients with prediabetes and type 2 diabetes were included. The median follow-up duration was 54 months. In the fully adjusted model, the highest quartile of HbA1c variability showed a statistically significant association with 4P-MACE (hazard ratio [HR] 2.77, 95% confidence interval [CI] 1.77-4.35), fatal and non-fatal myocardial infarction (HR 6.91, 95% CI 1.90-25.12), hospitalization for heart failure (HR 3.34, 95% CI 1.20-9.26) and all-cause death (HR 3.10, 95% CI 1.72-5.57). All these outcomes were statistically significantly different among four quartiles of HbA1c (log-rank P-value <0.05). Fatal and non-fatal stroke showed no statistically significant association with high HbA1c variability. CONCLUSION High HbA1c variability in the highest quartile showed a statistically significant association with multiple adverse cardiovascular events in an Asian population. Minimizing HbA1c fluctuation during long-term follow up should be another important objective for type 2 diabetes patients.
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Affiliation(s)
- Worapaka Manosroi
- Division of Endocrinology, Department of Internal Medicine, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
- Faculty of Medicine, Center for Clinical Epidemiology and Clinical StatisticsChiang Mai UniversityChiang MaiThailand
| | - Mattabhorn Phimphilai
- Division of Endocrinology, Department of Internal Medicine, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Nipawan Waisayanand
- Division of Endocrinology, Department of Internal Medicine, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Supawan Buranapin
- Division of Endocrinology, Department of Internal Medicine, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | | | - Siriluck Gunaparn
- Division of Cardiology, Department of Internal Medicine, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
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Ahmad A, Lim LL, Morieri ML, Tam CHT, Cheng F, Chikowore T, Dudenhöffer-Pfeifer M, Fitipaldi H, Huang C, Kanbour S, Sarkar S, Koivula RW, Motala AA, Tye SC, Yu G, Zhang Y, Provenzano M, Sherifali D, de Souza R, Tobias DK, Gomez MF, Ma RCW, Mathioudakis NN. Precision Prognostics for Cardiovascular Disease in Type 2 Diabetes: A Systematic Review and Meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.26.23289177. [PMID: 37162891 PMCID: PMC10168509 DOI: 10.1101/2023.04.26.23289177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background Precision medicine has the potential to improve cardiovascular disease (CVD) risk prediction in individuals with type 2 diabetes (T2D). Methods We conducted a systematic review and meta-analysis of longitudinal studies to identify potentially novel prognostic factors that may improve CVD risk prediction in T2D. Out of 9380 studies identified, 416 studies met inclusion criteria. Outcomes were reported for 321 biomarker studies, 48 genetic marker studies, and 47 risk score/model studies. Results Out of all evaluated biomarkers, only 13 showed improvement in prediction performance. Results of pooled meta-analyses, non-pooled analyses, and assessments of improvement in prediction performance and risk of bias, yielded the highest predictive utility for N-terminal pro b-type natriuretic peptide (NT-proBNP) (high-evidence), troponin-T (TnT) (moderate-evidence), triglyceride-glucose (TyG) index (moderate-evidence), Genetic Risk Score for Coronary Heart Disease (GRS-CHD) (moderate-evidence); moderate predictive utility for coronary computed tomography angiography (low-evidence), single-photon emission computed tomography (low-evidence), pulse wave velocity (moderate-evidence); and low predictive utility for C-reactive protein (moderate-evidence), coronary artery calcium score (low-evidence), galectin-3 (low-evidence), troponin-I (low-evidence), carotid plaque (low-evidence), and growth differentiation factor-15 (low-evidence). Risk scores showed modest discrimination, with lower performance in populations different from the original development cohort. Conclusions Despite high interest in this topic, very few studies conducted rigorous analyses to demonstrate incremental predictive utility beyond established CVD risk factors for T2D. The most promising markers identified were NT-proBNP, TnT, TyG and GRS-CHD, with the highest strength of evidence for NT-proBNP. Further research is needed to determine their clinical utility in risk stratification and management of CVD in T2D.
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Conlin PR, Zhang L, Li D, Nelson RE, Prentice JC, Mohr DC. Association of hemoglobin A1c stability with mortality and diabetes complications in older adults with diabetes. BMJ Open Diabetes Res Care 2023; 11:11/2/e003211. [PMID: 37024152 PMCID: PMC10083809 DOI: 10.1136/bmjdrc-2022-003211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 03/16/2023] [Indexed: 04/08/2023] Open
Abstract
INTRODUCTION Hemoglobin A1c (A1c) treatment goals in older adults should be individualized to balance risks and benefits. It is unclear if A1c stability over time within unique target ranges also affects adverse outcomes. RESEARCH DESIGN AND METHODS We conducted a retrospective observational cohort study from 2004 to 2016 of veterans with diabetes and at least four A1c tests during a 3-year baseline. We generated four distinct categories based on the percentage of time that baseline A1c levels were within patient-specific target ranges: ≥60% time in range (TIR), ≥60% time below range (TBR), ≥60% time above range (TAR), and a mixed group with all times <60%. We assessed associations of these categories with mortality, macrovascular, and microvascular complications. RESULTS We studied 397 634 patients (mean age 76.9 years, SD 5.7) with an average of 5.5 years of follow-up. In comparison to ≥60% A1c TIR, mortality was increased with ≥60% TBR, ≥60% TAR, and the mixed group, with HRs of 1.12 (95% CI 1.11 to 1.14), 1.10 (95% CI 1.08 to 1.12), and 1.06 (95% CI 1.04 to 1.07), respectively. Macrovascular complications were increased with ≥60% TBR and ≥60% TAR, with estimates of 1.04 (95% CI 1.01 to 1.06) and 1.06 (95% CI 1.03 to 1.09). Microvascular complications were lower with ≥60% TBR (HR 0.97, 95% CI 0.95 to 1.00) and higher with ≥60% TAR (HR 1.11, 95% CI 1.08 to 1.14). Results were similar with higher TIR thresholds, shorter follow-up, and competing risk of mortality. CONCLUSIONS In older adults with diabetes, mortality and macrovascular complications are associated with increased time above and below individualized A1c target ranges. Higher A1c TIR may identify patients with lower risk of adverse outcomes.
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Affiliation(s)
- Paul R Conlin
- Medical Service (111), VA Boston Health Care System West Roxbury Campus, West Roxbury, Massachusetts, USA
- Harvard Medical School, Boston, MA, USA
| | - Libin Zhang
- VA Center for Healthcare Organization and Implementation Research Boston Campus, Boston, Massachusetts, USA
| | - Donglin Li
- VA Center for Healthcare Organization and Implementation Research Boston Campus, Boston, Massachusetts, USA
| | - Richard E Nelson
- University of Utah Health, Salt Lake City, Utah, USA
- VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Julia C Prentice
- Boston University School of Medicine, Boston, Massachusetts, USA
- VA Boston Heatlhcare System, Boston, MA, USA
| | - David C Mohr
- VA Center for Healthcare Organization and Implementation Research Boston Campus, Boston, Massachusetts, USA
- Boston University School of Public Health, Boston, MA, USA
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Sartore G, Ragazzi E, Caprino R, Lapolla A. Long-term HbA1c variability and macro-/micro-vascular complications in type 2 diabetes mellitus: a meta-analysis update. Acta Diabetol 2023; 60:721-738. [PMID: 36715767 PMCID: PMC10148792 DOI: 10.1007/s00592-023-02037-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/17/2023] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Giovanni Sartore
- Department of Medicine - DIMED, University of Padua, Padua, Italy
| | - Eugenio Ragazzi
- Department of Pharmaceutical and Pharmacological Sciences - DSF, University of Padua, Padua, Italy.
| | - Rosaria Caprino
- Department of Medicine - DIMED, University of Padua, Padua, Italy
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HbA1c variability and diabetes complications: assessment and implications. DIABETES & METABOLISM 2023. [DOI: 10.1016/j.diabet.2022.101399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Long-term Outcomes Among Young Adults With Type 2 Diabetes Based on Durability of Glycemic Control: Results From the TODAY Cohort Study. Diabetes Care 2022; 45:2689-2697. [PMID: 36190810 PMCID: PMC9679266 DOI: 10.2337/dc22-0784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 08/19/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine the effect of different patterns of durable glycemic control on the development of comorbidities among youth with type 2 diabetes (T2D) and to assess the impact of fasting glucose (FG) variability on the clinical course of T2D. RESEARCH DESIGN AND METHODS From the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study, 457 participants (mean age, 14 years) with mean diabetes duration <2 years at entry and a minimum study follow-up of 10 years were included in these analyses. HbA1c, FG concentrations, and β-cell function estimates from oral glucose tolerance tests were measured longitudinally. Prevalence of comorbidities by glycemic control status after 10 years in the TODAY study was assessed. RESULTS Higher baseline HbA1c concentration, lower β-cell function, and maternal history of diabetes were strongly associated with loss of glycemic control in youth with T2D. Higher cumulative HbA1c concentration over 4 years and greater FG variability over a year within 3 years of diagnosis were related to higher prevalence of dyslipidemia, nephropathy, and retinopathy progression over the subsequent 10 years. A coefficient of variability in FG ≥8.3% predicted future loss of glycemic control and development of comorbidities. CONCLUSIONS Higher baseline HbA1c concentration and FG variability during year 1 accurately predicted youth with T2D who will experience metabolic decompensation and comorbidities. These values may be useful tools for clinicians when considering early intensification of therapy.
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Lin CC, Li CI, Juan YL, Liu CS, Lin CH, Yang SY, Li TC. Joint effect of blood pressure and glycemic variation on the risk of cardiovascular morbidity and mortality in persons with type 2 diabetes. Metabolism 2022; 136:155308. [PMID: 36058287 DOI: 10.1016/j.metabol.2022.155308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/16/2022] [Accepted: 08/29/2022] [Indexed: 10/31/2022]
Abstract
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.
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Affiliation(s)
- Cheng-Chieh Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Ing Li
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Ya-Ling Juan
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Chiu-Shong Liu
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsueh Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Shing-Yu Yang
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Tsai-Chung Li
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan; Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan.
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Yeh ST, Ooi SW, Chang YH, Li CY, Chen HF. Age and sex-specific associations of visit-to-visit variability of glycated hemoglobin A1c with all-cause mortality in patients with diabetes. Medicine (Baltimore) 2022; 101:e29942. [PMID: 35984136 PMCID: PMC9387953 DOI: 10.1097/md.0000000000029942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Visit-to-visit variability (VVV) of glycated hemoglobin (HbA1c) levels have been found to be associated with prognosis of diabetes. However, little is known about whether or to what extent sex and age may modify the effects of VVV. METHODS To investigate age- and sex-specific rates of mortality from all causes and relative hazards of mortality in association with VVV of HbA1c levels, 47,145 patients with diabetes and prescription of any antidiabetic agents >6 months were identified from outpatient visits of a tertiary medical center in northern Taiwan during 2003-2018. VVV of HbA1c was measured by quartiles of standard deviation (SD), coefficient of variation (CV), and average real variability (ARV), respectively. The study subjects were linked to Taiwan's National Death Registry to identify all-cause mortality. The person-year approach with the Poisson assumption was used to assess the all-cause mortality rates, and Cox proportional hazard regression model was used to evaluate the relative hazards of all-cause mortality concerning various levels of VVV of HbA1c. RESULTS The lowest all-cause mortality rate was found in either the first or second quartile of various measures for VVV of HbA1c, but the highest mortality rate was consistently observed in the fourth quartile of VVV, regardless of SD, CV, or ARV across ages and sexes. Increased hazards of overall all-cause mortality were noticed from the second to fourth quartile of VVV of HbA1c. In detailed age- and sex-stratified analyses, elevated risk of mortality was seen in the fourth quartile of those aged <50 years while in those aged >69 years, increased risk of mortality was noticed in the third and fourth quartiles of any VVV of HbA1c irrespective of sex. In those aged 50-69 years, incremental increased hazards of mortality were consistently observed in the second to fourth quartiles of VVV of HbA1c. CONCLUSION HbA1c variability whether it was SD, CV, or ARV could strongly predict the risks of all-cause mortality. The extent of the relationship between VVV of HbA1c and all-cause mortality in different age groups was comparable between both sexes. Given the importance of long-term glucose fluctuation, the inclusion of HbA1c variability calculated from the standardized method should be considered by clinical guideline policymakers as part of the biochemical panel in daily diabetes management.
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Affiliation(s)
- Shu-Tin Yeh
- Department of Endocrinology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Seng-Wei Ooi
- Department of Endocrinology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Ya-Hui Chang
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan City, Taiwan
- Department of Public Health, College of Public Health, China Medical University, Taichung City, Taiwan
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung City, Taiwan
| | - Hua-Fen Chen
- Department of Endocrinology, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- *Correspondence: Hua-Fen Chen, Department of Endocrinology, Far Eastern Memorial Hospital, No.21, Sec. 2, Nanya S. Rd., Banciao Dist., New Taipei City 220, Taiwan (e-mail: )
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11
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Yan Y, Kondo N, Oniki K, Watanabe H, Imafuku T, Sakamoto Y, Shigaki T, Maruyama A, Nakazawa H, Kaneko T, Morita A, Yoshida A, Maeda H, Maruyama T, Jinnouchi H, Saruwatari J. Predictive Ability of Visit-to-Visit Variability of HbA1c Measurements for the Development of Diabetic Kidney Disease: A Retrospective Longitudinal Observational Study. J Diabetes Res 2022; 2022:6934188. [PMID: 35103243 PMCID: PMC8800606 DOI: 10.1155/2022/6934188] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/02/2021] [Accepted: 12/28/2021] [Indexed: 01/17/2023] Open
Abstract
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.
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Affiliation(s)
- Yunyi Yan
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Nozomi Kondo
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kentaro Oniki
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hiroshi Watanabe
- Department of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tadashi Imafuku
- Department of Molecular Pathophysiology, Institute of Advanced Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yuki Sakamoto
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takuro Shigaki
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Akari Maruyama
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hitomi Nakazawa
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tetsuya Kaneko
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Ayami Morita
- Diabetes Care Center, Jinnouchi Hospital, Kumamoto, Japan
| | - Akira Yoshida
- Diabetes Care Center, Jinnouchi Hospital, Kumamoto, Japan
| | - Hitoshi Maeda
- Department of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Toru Maruyama
- Department of Biopharmaceutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | | | - Junji Saruwatari
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
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12
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Zhou H, Wang W, Shen Q, Feng Z, Zhang Z, Lei H, Yang X, Liu J, Lu B, Shao J, Gu P. Time in range, assessed with continuous glucose monitoring, is associated with brachial-ankle pulse wave velocity in type 2 diabetes: A retrospective single-center analysis. Front Endocrinol (Lausanne) 2022; 13:1014568. [PMID: 36325447 PMCID: PMC9618671 DOI: 10.3389/fendo.2022.1014568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022] Open
Abstract
AIMS The aim of this retrospective single-center is to research the relationship between time in range(TIR), an important novel metric of glycemic control, assessed with continuous glucose monitoring(CGM) and brachial-ankle pulse wave velocity(BaPWV), a unique index of systemic arterial stiffness in type 2 diabetes. METHODS Study participants included 469 hospitalized patients with type 2 diabetes and no history of serious cardiovascular disease who underwent CGM and BaPWV measurements. TIR of 3.9-10.0 mmol/L was evaluated with CGM. BaPWV was measured by non-invasive arteriosclerosis detector and high baPWV was defined as a mean baPWV≧1800m/s. The spearman correlation and the partial correlation analysis were applied to analyze the correlation between TIR and baPWV. The binary logistic regression was used to examine the independent association of TIR and high BaPWV. RESULTS The presence of high baPWV was 32.2%. Compared with patients of low baPWV, those with high baPWV had significantly reduced TIR(P<0.001). With the increase of TIR tertiles, the prevalence of high BaPWV progressively decreased. Correlation analysis showed that TIR is inversely correlated with BaPWV. In a fully adjusted model controlling for traditional risk factor of CVD, TIR is associated with the presence of high BaPWV independent of HbA1c. CONCLUSION TIR is correlated with BaPWV independent of HbA1c in patients with type 2 diabetes, confirming a link between TIR and arterial stiffness.
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Affiliation(s)
- Hui Zhou
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Wei Wang
- Department of Endocrinology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Qiuyue Shen
- Department of Endocrinology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Zhouqin Feng
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Zhen Zhang
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Haiyan Lei
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
| | - Xinyi Yang
- Department of Endocrinology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Jun Liu
- Department of Endocrinology, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Bin Lu
- Department of Endocrinology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Jiaqing Shao
- Department of Endocrinology, Jinling Hospital, Southern Medical University, Nanjing, China
- *Correspondence: Jiaqing Shao, ;Ping Gu,
| | - Ping Gu
- Department of Endocrinology, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
- *Correspondence: Jiaqing Shao, ;Ping Gu,
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13
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Huang D, Huang YQ, Zhang QY, Cui Y, Mu TY, Huang Y. Association Between Long-Term Visit-to-Visit Hemoglobin A1c and Cardiovascular Risk in Type 2 Diabetes: The ACCORD Trial. Front Cardiovasc Med 2021; 8:777233. [PMID: 34901237 PMCID: PMC8652081 DOI: 10.3389/fcvm.2021.777233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/26/2021] [Indexed: 11/24/2022] Open
Abstract
Background: To explore the association between visit-to-visit variability of glycated hemoglobin (HbA1c) and cardiovascular outcomes in the patients with type 2 diabetes mellitus (T2DM) of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study. Methods: We conducted a post-hoc analysis on the ACCORD population including 9,544 participants with T2DM. Visit-to-visit variability of HbA1c was defined as the individual SD, coefficient of variation (CV), and variability independent of the mean (VIM) across HbA1c measurements. The clinical measurements included primary outcome [the first occurrence of non-fatal myocardial infarction (MI), non-fatal stroke or cardiovascular death], total mortality, cardiovascular death, non-fatal MI event, non-fatal stroke, total stroke, heart failure, macrovascular events, and major coronary events (CHD). Results: Over a median follow-up of 4.85 years, 594 and 268 participants experienced all-cause mortality and cardiovascular mortality, respectively. After adjusting for baseline HbA1c levels and confounding factors, the adjusted hazard ratio (HR) comparing patients in the highest vs. the lowest quartile CV of HbA1c variability was 1.61 (95% CI 1.29–2.00) for the primary outcome. Similar trends for secondary outcome were also observed. There was no association between HbA1c fluctuation and non-fatal stroke. Noticeably, there was 66% greater risk for the all-cause mortality among patients in the highest vs. the lowest quartile (HR 1.66, 95% CI 1.27–2.17). Conclusions: Greater variability of HbA1c is associated with higher risk for cardiovascular complications and all-cause death in T2DM. Our study stresses the significance of well-controlled glycemic levels for improving cardiovascular outcomes. Further randomized clinical trials are required to confirm these findings.
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Affiliation(s)
- Dan Huang
- Emergency Department, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yong-Quan Huang
- Department of Ultrasound, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Qun-Ying Zhang
- Department of Geriatrics, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
| | - Yan Cui
- Emergency Department, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Tian-Yi Mu
- Emergency Department, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Yin Huang
- Department of Cardiology, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, China
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14
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Dhatariya K, Humberstone A, Hasnat A, Wright R, Lujan M, Nunney I. The Association Between Mean Glycated Haemoglobin or Glycaemic Variability and the Development of Retinopathy in People with Diabetes: A Retrospective Observational Cohort Study. Diabetes Ther 2021; 12:2755-2766. [PMID: 34491530 PMCID: PMC8479058 DOI: 10.1007/s13300-021-01146-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 08/24/2021] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION To determine the association between mean glycated haemoglobin (HbA1c) 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. HbA1c measures were used to calculate HbA1c variability and mean HbA1c 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, HbA1c variability was not significantly associated with the development of DR (p = 0.3435). However, the mean HbA1c 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 HbA1c is associated with an increased risk of developing diabetic retinopathy. However, after adjustment for sex, age, diabetes type and the mean, the HbA1c variability no longer remained significant. Our data suggest that optimizing long-term glycaemic control remains paramount.
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Affiliation(s)
- Ketan Dhatariya
- Norwich Medical School, University of East Anglia, Medical Building, Norwich, Norfolk, NR4 7TJ, UK.
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
| | - Alexander Humberstone
- Norwich Medical School, University of East Anglia, Medical Building, Norwich, Norfolk, NR4 7TJ, UK
| | - Abul Hasnat
- Norwich Medical School, University of East Anglia, Medical Building, Norwich, Norfolk, NR4 7TJ, UK
| | - Rebecca Wright
- Norwich Medical School, University of East Anglia, Medical Building, Norwich, Norfolk, NR4 7TJ, UK
| | - Morgan Lujan
- Norwich Medical School, University of East Anglia, Medical Building, Norwich, Norfolk, NR4 7TJ, UK
| | - Ian Nunney
- Department of Medical Statistics, Norwich Medical School, Norwich, Norfolk, UK
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15
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Akselrod D, Friger M, Biderman A. HbA1C variability among type 2 diabetic patients: a retrospective cohort study. Diabetol Metab Syndr 2021; 13:101. [PMID: 34537062 PMCID: PMC8449921 DOI: 10.1186/s13098-021-00717-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/31/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Studies have found that HbA1C variability is an independent risk factor for diabetic complications in type 2 diabetic patients. This study aims to find factors contributing to higher HbA1C variability in the community. METHODS The study was conducted in the southern district of Israel, in Clalit Health Services (CHS). The study population was type 2 diabetic individuals aged 40-70 years in 2005, with a follow-up period of 11 years, until 2015. The definition of HbA1C variability was done by the standard deviation from the average HbA1C value of the entire study period, which was calculated for each participant. The study population was divided into two groups, "variability group" with HbA1C SD > 1.2, and "comparison group" of participants with HbA1C SD ≤ 1.2. In the univariate analysis we used X2 or Fisher test for categorical variables and independent t-test for numeric continuous variables. In the multivariate analysis we used logistic regression as well as assessing for possible interactions. Statistical analysis was ascribed for p < 0.05. All the data was drawn from the computerized medical system used by all primary care physicians and nurses in CHS working in the community. RESULTS The study population included 2866 participants, the average age was 58.6 years, 43.3% men and 56.7% women. Each participant had an average of 20.9 HbA1C measures in their computerized medical record during the 11 years of follow up. The mean HbA1C value was 7.8%. We found 632 patients (22%) with a high variability, whereas 2234 (78%) had a low variability of HbA1C. In the "variability group" there was a higher percentage of smokers, BMI ≥ 30 and a higher rate of visits to diabetic clinics compared to the "no variability" group. In the "variability group" we found a much higher use of insulin and ACE inhibitors. The highest frequency of variability was between HbA1c values of 8.1-8.5. The multivariate analysis showed that HbA1C variability was associated with insulin use (OR = 4.1, p < 0.001), with age (OR = 0.939, p < 0.001), and Ischemic heart disease (OR = 1.258, p = 0.03). BMI ≥ 30 was almost statistically significant (OR = 1.206, p = 0.063). Gender was statistically insignificant. CONCLUSIONS In conclusion, HbA1C variability might be used as an additional marker in Diabetes Mellitus type 2, reflecting the disease complexity characteristics and the patient's lifestyle profile.
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Affiliation(s)
- Dikla Akselrod
- Internal Medicine Department, Soroka University Medical Centre, Beersheba, Israel
| | - Michael Friger
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Aya Biderman
- Department of Family Medicine and Siaal Center for Community Research, Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 653, 84105 Beersheba, Israel
- Clalit Health Services, Southern District, Beersheba, Israel
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16
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Lee CH, Lui DTW, Cheung CYY, Woo YC, Fong CHY, Yuen MMA, Shea YF, Siu DCW, Chan KH, Chow WS, Lam KSL. Different glycaemia-related risk factors for incident Alzheimer's disease in men and women with type 2 diabetes-A sex-specific analysis of the Hong Kong diabetes database. Diabetes Metab Res Rev 2021; 37:e3401. [PMID: 32870568 DOI: 10.1002/dmrr.3401] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 06/01/2020] [Accepted: 08/19/2020] [Indexed: 12/14/2022]
Abstract
AIMS Sexual dimorphism has been reported in the epidemiology, neurobiologic susceptibility and clinical presentation of Alzheimer's disease (AD). As poor glycaemic control is associated with increased risks of AD, we aimed to investigate whether glycaemia-related risk factors also differ between men and women, using a retrospective, sex-specific analysis of a large Chinese cohort with diabetes. MATERIALS & METHODS A total of 85,514 Chinese individuals with type 2 diabetes (T2D; 46,783 women and 38,731 men), aged ≥60 years, were identified from electronic health records and observed for incident AD. Multivariable Cox regression analysis was used to evaluate the associations with incident AD of several glycaemia-related risk factors, including severe hypoglycaemia, mean HbA1c and indices of HbA1c variability, in men and women separately. RESULTS Over a median follow-up of 6 years, women had a higher incidence of AD than men (2.3% vs. 1.2%, p < 0.001). Both men and women shared the same independent non-glycaemic clinical predictors, which included older age, lower body mass index and longer duration of diabetes. However, for glycaemia-related risk factors, we observed that severe hypoglycaemia and indices of HbA1c variability were independent predictors of incident AD in women but not in men, and the associations were irrespective of their baseline glycaemic control and duration of diabetes. CONCLUSIONS Our findings highlighted that glycaemia-related risk factors for incident AD differ between men and women with T2D. Strategies to maintain glycaemic stability and avoid severe hypoglycaemia might be especially important to preserve healthy cognition in older women with diabetes.
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Affiliation(s)
- Chi-Ho Lee
- State Key Laboratory of Pharmaceutical Biotechnology, University of Hong Kong, Hong Kong, China
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - David T W Lui
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Chloe Y Y Cheung
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Yu-Cho Woo
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Carol H Y Fong
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Michele M A Yuen
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Yat-Fung Shea
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - David C W Siu
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Koon-Ho Chan
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Wing-Sun Chow
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Karen S L Lam
- State Key Laboratory of Pharmaceutical Biotechnology, University of Hong Kong, Hong Kong, China
- Department of Medicine, University of Hong Kong, Hong Kong, China
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Prentice JC, Mohr DC, Zhang L, Li D, Legler A, Nelson RE, Conlin PR. Increased Hemoglobin A 1c Time in Range Reduces Adverse Health Outcomes in Older Adults With Diabetes. Diabetes Care 2021; 44:1750-1756. [PMID: 34127496 PMCID: PMC8385473 DOI: 10.2337/dc21-0292] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/29/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Short- and long-term glycemic variability are risk factors for diabetes complications. However, there are no validated A1C target ranges or measures of A1C stability in older adults. We evaluated the association of a patient-specific A1C variability measure, A1C time in range (A1C TIR), on major adverse outcomes. RESEARCH DESIGN AND METHODS We conducted a retrospective observational study using administrative data from the Department of Veterans Affairs and Medicare from 2004 to 2016. Patients were ≥65 years old, had diabetes, and had at least four A1C tests during a 3-year baseline period. A1C TIR was the percentage of days during the baseline in which A1C was in an individualized target range (6.0-7.0% up to 8.0-9.0%) on the basis of clinical characteristics and predicted life expectancy. Increasing A1C TIR was divided into categories of 20% increments and linked to mortality and cardiovascular disease (CVD) (i.e., myocardial infarction, stroke). RESULTS The study included 402,043 veterans (mean [SD] age 76.9 [5.7] years, 98.8% male). During an average of 5.5 years of follow-up, A1C TIR had a graded relationship with mortality and CVD. Cox proportional hazards models showed that lower A1C TIR was associated with increased mortality (A1C TIR 0 to <20%: hazard ratio [HR] 1.22 [95% CI 1.20-1.25]) and CVD (A1C TIR 0 to <20%: HR 1.14 [95% CI 1.11-1.19]) compared with A1C TIR 80-100%. Competing risk models and shorter follow-up (e.g., 24 months) showed similar results. CONCLUSIONS In older adults with diabetes, maintaining A1C levels within individualized target ranges is associated with lower risk of mortality and CVD.
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Affiliation(s)
- Julia C Prentice
- VA Boston Healthcare System, Boston, MA .,Boston University School of Medicine, Boston, MA
| | - David C Mohr
- VA Boston Healthcare System, Boston, MA.,Boston University School of Public Health, Boston, MA
| | | | | | | | - Richard E Nelson
- VA Salt Lake City Healthcare System, Salt Lake City, UT.,University of Utah, Salt Lake City, UT
| | - Paul R Conlin
- VA Boston Healthcare System, Boston, MA.,Harvard Medical School, Boston, MA
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18
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Mellergård E, Johnsson P, Eek F. Effects of perceived competence, negative appraisal, and motivation orientation on glycemic stability in individuals with type 2 diabetes :A prospective cohort study. Prim Care Diabetes 2021; 15:269-274. [PMID: 33041216 DOI: 10.1016/j.pcd.2020.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/23/2020] [Accepted: 09/25/2020] [Indexed: 11/21/2022]
Abstract
AIMS HbA1c variability is targeted as a part of clinical risk assessment in type 2 diabetes. Psychological factors such as patient competence, adjustment to diabetes, and motivation, may influence glycemic control. The objective of the present study was to determine if perceived competence, diabetes appraisal, and motivation predicted HbA1c variability, and to examine differences regarding these factors in relation to diabetes duration, in individuals with type 2 diabetes. METHODS Data on perceived competence, appraisal of diabetes, and motivation orientation from 158 individuals with type 2 diabetes were analyzed as potential predictors of HbA1c at five measurement points over a time period of 24 months. Associations between psychological factors and HbA1c variability were examined through multiple linear regression analyses, and differences in psychological measures between groups with different diabetes duration were examined using ANOVA. RESULTS Negative appraisal of diabetes predicted higher HbA1c variability and was associated with higher baseline HbA1c, and greater perceived competence predicted lower HbA1c variability. CONCLUSIONS The results indicate that lower levels of diabetes distress, as well as confidence in one's ability to manage diabetes, could potentially predict better glycemic control.
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Affiliation(s)
- Emelia Mellergård
- Department of Health Sciences, Margaretavägen 1B, 222 40, Faculty of Medicine, Lund University, Lund, Sweden.
| | - Per Johnsson
- Department of Psychology, Allhelgona Kyrkogata 16a, 223 62, Faculty of Social Sciences, Lund University, Lund, Sweden.
| | - Frida Eek
- Department of Health Sciences, Margaretavägen 1B, 222 40, Faculty of Medicine, Lund University, Lund, Sweden.
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19
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Zhou JJ, Koska J, Bahn G, Reaven P. Fasting Glucose Variation Predicts Microvascular Risk in ACCORD and VADT. J Clin Endocrinol Metab 2021; 106:1150-1162. [PMID: 33367811 PMCID: PMC7993576 DOI: 10.1210/clinem/dgaa941] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Jin J Zhou
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ, USA
- Carl T. Hayden Phoenix VA Health Care System (111E), Phoenix, AZ, USA
- Correspondence: Jin J. Zhou, PhD, Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, 1295 N. Martin Ave., Tucson, AZ 85724, USA.
| | - Juraj Koska
- Carl T. Hayden Phoenix VA Health Care System (111E), Phoenix, AZ, USA
| | - Gideon Bahn
- Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Peter Reaven
- Carl T. Hayden Phoenix VA Health Care System (111E), Phoenix, AZ, USA
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Zhao MJY, Prentice JC, Mohr DC, Conlin PR. Association between hemoglobin A1c variability and hypoglycemia-related hospitalizations in veterans with diabetes mellitus. BMJ Open Diabetes Res Care 2021; 9:9/1/e001797. [PMID: 33431600 PMCID: PMC7802724 DOI: 10.1136/bmjdrc-2020-001797] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 11/10/2020] [Accepted: 12/14/2020] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION To study the impact of hemoglobin A1c (A1c) variability on the risk of hypoglycemia-related hospitalization (HRH) in veterans with diabetes mellitus. RESEARCH DESIGN AND METHODS 342 059 veterans with diabetes aged 65 years or older were identified for a retrospective cohort study. All participants had a 3-year baseline period from January 1, 2005 to December 31, 2016, during which they had at least four A1c tests. A1c variability measures included coefficient of variation (A1c CV), A1c SD, and adjusted A1c SD. HRH was identified during a 2-year follow-up period from Medicare and the Veterans Health Administration through validated algorithms of International Classification of Diseases (ICD)-9 and ICD-10 codes. Logistic regression modeling was used to evaluate the relationship between A1c variability and HRH risk while controlling for relevant clinical covariates. RESULTS 2871 patients had one or more HRH in the 2-year follow-up period. HRH risk increased with greater A1c variability, and this was consistent across A1c CV, A1c SD, and adjusted A1c SD. Average A1c levels were also independently associated with HRH, with levels <7.0% (53 mmol/mol) having lower risk and >9% (75 mmol/mol) with greater risk. The relationships between A1c variability remained significant after controlling for average A1c levels and prior HRH during the baseline period. CONCLUSION Increasing A1c variability and elevated A1c levels are associated with a greater risk of HRH in older adults with diabetes. Clinicians should consider A1c variability when assessing patients for risk of severe hypoglycemia.
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Affiliation(s)
- Molly J Y Zhao
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Health Care System, Boston, Massachusetts, USA
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Julia C Prentice
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Health Care System, Boston, Massachusetts, USA
- Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Health Care System, Boston, Massachusetts, USA
- Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Paul R Conlin
- Medical Service (111), VA Boston Healthcare System, West Roxbury, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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21
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Tseng JY, Chen HH, Huang KC, Hsu SP, Chen CC. Effect of mean HbA1c on the association of HbA1c variability and all-cause mortality in patients with type 2 diabetes. Diabetes Obes Metab 2020; 22:680-687. [PMID: 31903705 DOI: 10.1111/dom.13951] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 12/20/2019] [Accepted: 12/28/2019] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Juei-Yu Tseng
- Division of Endocrinology and Metabolism, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, China Medical University, Taichung, Taiwan
| | - Hsin-Hung Chen
- Intelligent Diabetes Metabolism and Exercise Center, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Institute of Public Health, Chung Shan Medical University, Taichung, Taiwan
| | - Kuo-Chin Huang
- Integration of Traditional Chinese-Western Medicine, Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Sheng-Pang Hsu
- Division of Endocrinology and Metabolism, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, China Medical University, Taichung, Taiwan
| | - Ching-Chu Chen
- Division of Endocrinology and Metabolism, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Chinese Medicine, China Medical University, Taichung, Taiwan
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22
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Slieker RC, van der Heijden AAWH, Nijpels G, Elders PJM, 't Hart LM, Beulens JWJ. Visit-to-visit variability of glycemia and vascular complications: the Hoorn Diabetes Care System cohort. Cardiovasc Diabetol 2019; 18:170. [PMID: 31830993 PMCID: PMC6909524 DOI: 10.1186/s12933-019-0975-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 12/03/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Glycemic variation has been suggested to be a risk factor for diabetes-related complications. Previous studies did not address confounding of diabetes duration, number of visits and length of follow-up. Here, we characterize glycemic variability over time and whether its relation to diabetes-related complications and mortality is independent from diabetes- and follow-up duration. MATERIALS AND METHODS Individuals with type 2 diabetes (n = 6770) from the Hoorn Diabetes Care System cohort were included in this study. The coefficient of variation (CV) was calculated over 5-year sliding intervals. People divided in quintiles based on their CV. Cox proportional hazard models were used to investigate the role of glycemic CV as risk factor in diabetes-related complications and mortality. RESULTS The coefficient of variation of glucose (FG-CV) increased with time, in contrast to HbA1c (HbA1c-CV). People with a high FG-CV were those with an early age of diabetes onset (ΔQ5-Q1 = - 2.39 years), a higher BMI (ΔQ5-Q1 = + 0.92 kg/m2), an unfavorable lipid profile, i.e. lower levels of HDL-C (ΔQ5-Q1 = - 0.06 mmol/mol) and higher triglycerides (ΔQ5-Q1 =+ 1.20 mmol/mol). People with the highest FG-CV in the first 5-year interval showed an increased risk of insulin initiation, retinopathy, macrovascular complications and mortality independent of mean glycemia, classical risk factors and medication use. For HbA1c, the associations were weaker and less consistent. CONCLUSIONS Individuals with a higher FG-CV have an unfavorable metabolic profile and have an increased risk of developing micro- and macrovascular complications and mortality. The association of HbA1c-CV with metabolic outcomes and complications was less consistent in comparison to FG-CV.
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Affiliation(s)
- Roderick C Slieker
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Institute, Amsterdam UMC, Location VUMC, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands. .,Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, The Netherlands.
| | - Amber A W H van der Heijden
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Institute, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Giel Nijpels
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Institute, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Petra J M Elders
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Institute, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Leen M 't Hart
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Institute, Amsterdam UMC, Location VUMC, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands.,Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, The Netherlands.,Molecular Epidemiology Section, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Joline W J Beulens
- Department of Epidemiology and Biostatistics, Amsterdam Public Health Institute, Amsterdam UMC, Location VUMC, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Critchley JA, Carey IM, Harris T, DeWilde S, Cook DG. Variability in Glycated Hemoglobin and Risk of Poor Outcomes Among People With Type 2 Diabetes in a Large Primary Care Cohort Study. Diabetes Care 2019; 42:2237-2246. [PMID: 31582426 DOI: 10.2337/dc19-0848] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/01/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes guidelines focus on target glycated hemoglobin (HbA1c) levels. Long-term variability in HbA1c may be predictive of hospitalization or mortality, but its importance at different average levels or trajectories is unclear. RESEARCH DESIGN AND METHODS Using English primary care data, 58,832 patients with type 2 diabetes had HbA1c average (mean of annual means), variability (coefficient of variation), and trajectory (annual regression slope) estimated during 2006-2009. Hazard ratios (HRs) for mortality and emergency hospitalization during 2010-2015, with adjustment for age, sex, smoking, BMI, duration of diabetes, and deprivation, were estimated using Cox regression. The simultaneous impact of HbA1c average, variability, and trajectory was estimated using percentiles. RESULTS In mutually adjusted models, HbA1c variability showed a consistent dose-response relationship with all-cause mortality, while average level was only important among individuals in the highest or lowest 10% of the distribution, and trajectory had no independent effect. Individuals with the most unstable HbA1c (top 10%) were almost twice as likely to die (HR 1.93 [95% CI 1.72-2.16]) than were those with the most stable (bottom 10%)-an association attenuated but not explained by hypoglycemia. For emergency hospitalizations, similar trends were seen except for coronary artery disease (CAD) and ischemic stroke (IS), where increasing average rather than variability was predictive. CONCLUSIONS HbA1c variability was strongly associated with overall mortality and emergency hospitalization and not explained by average HbA1c or hypoglycemic episodes. Only for CAD and IS hospitalizations was no association found, with average HbA1c strongly predictive. Targets should focus on both stability and absolute level of HbA1c.
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Affiliation(s)
- Julia A Critchley
- Population Health Research Institute, St. George's, University of London, London, U.K.
| | - Iain M Carey
- Population Health Research Institute, St. George's, University of London, London, U.K
| | - Tess Harris
- Population Health Research Institute, St. George's, University of London, London, U.K
| | - Stephen DeWilde
- Population Health Research Institute, St. George's, University of London, London, U.K
| | - Derek G Cook
- Population Health Research Institute, St. George's, University of London, London, U.K
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24
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Zhou JJ, Koska J, Bahn G, Reaven P. Glycaemic variation is a predictor of all-cause mortality in the Veteran Affairs Diabetes Trial. Diab Vasc Dis Res 2019; 16:178-185. [PMID: 31014099 PMCID: PMC7380497 DOI: 10.1177/1479164119827598] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Diabetes is associated with substantially increased mortality. Classic risk factors explain a portion of the excess of mortality in type 2 diabetes. The aim of this study was to examine whether visit-to-visit variation in fasting glucose and haemoglobin A1c values in the Veteran Affairs Diabetes Trial were associated with all-cause mortality in patients with type 2 diabetes in addition to other comorbidity conditions, hypoglycaemic events and adverse lifestyle behaviours. The Veteran Affairs Diabetes Trial was a randomized trial that enrolled 1791 military veterans who had a suboptimal response to therapy for type 2 diabetes to receive either intensive or standard glucose control. During the Veteran Affairs Diabetes Trial, fasting glucose and haemoglobin A1c were measured quarterly for up to 84 months. Variability measures included coefficient of variation and average real variability. We found that variability measures (coefficient of variation and average real variability) of fasting glucose were predictors of all-cause mortality, even after adjusting for comorbidity index, mean fasting glucose and adverse lifestyle behaviour during the study. Accounting for severe hypoglycaemia did not weaken this association. Our analysis indicates that in the Veteran Affairs Diabetes Trial, longitudinal variation in fasting glucose was associated with all-cause mortality, even when accounting for standard measures of glucose control as well as comorbidity and lifestyle factors.
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Affiliation(s)
- Jin J Zhou
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, USA
- Carl T. Hayden Phoenix VA Health Care System, Phoenix, AZ, USA
| | - Juraj Koska
- Carl T. Hayden Phoenix VA Health Care System, Phoenix, AZ, USA
| | - Gideon Bahn
- Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Peter Reaven
- Carl T. Hayden Phoenix VA Health Care System, Phoenix, AZ, USA
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25
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Zhou JJ, Schwenke DC, Bahn G, Reaven P. Glycemic Variation and Cardiovascular Risk in the Veterans Affairs Diabetes Trial. Diabetes Care 2018; 41:2187-2194. [PMID: 30082325 PMCID: PMC6150432 DOI: 10.2337/dc18-0548] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/20/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE There is uncertainty about the importance of glycemic variability in cardiovascular complications in patients with type 2 diabetes. Using the Veterans Affairs Diabetes Trial (VADT), we investigated the association between variation in fasting glucose and glycated hemoglobin (HbA1c) over time and the incidence of cardiovascular disease (CVD) and assessed whether this is influenced by intensive or standard glycemic control. RESEARCH DESIGN AND METHODS During the VADT, fasting glucose and HbA1c were measured every 3 months for up to 84 months in 1,791 individuals. Variability measures included coefficient of variation (CV) and average real variability (ARV) for fasting glucose and HbA1c. Overall mean glucose and HbA1c measures as well as their maximum and the most recent measurement were also examined. RESULTS Variability measures (CV and ARV) of fasting glucose were significantly associated with CVD even after adjusting for other risk factors, including mean fasting glucose. When considering separately groups receiving intensive and standard glycemic control, this relationship was evident in the intensive treatment group but not in the standard group. Additional adjustment for severe hypoglycemic episodes did not alter the relationship between fasting glucose variability and CVD. Interestingly, no HbA1c measures were associated with CVD after adjusting for multiple baseline risk factors. CONCLUSIONS Our analysis indicates that in the VADT, variability of fasting glucose plays a role in the development of CVD complications beyond the influence of standard fasting glucose measures. The adverse consequences of fasting glucose variability on CVD appear greatest in those receiving intensive glucose control.
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Affiliation(s)
- Jin J Zhou
- Department of Epidemiology and Biostatistics, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
| | | | - Gideon Bahn
- Hines VA Cooperative Studies Program Coordinating Center, Edward Hines, Jr. VA Hospital, Hines, IL
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26
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Sakamoto M. Type 2 Diabetes and Glycemic Variability: Various Parameters in Clinical Practice. J Clin Med Res 2018; 10:737-742. [PMID: 30214644 PMCID: PMC6135001 DOI: 10.14740/jocmr3556w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/14/2018] [Indexed: 01/09/2023] Open
Abstract
It has become possible to measure blood glucose levels continuously from 24 h to approximately 2 weeks due to the recent development of relevant devices such as continuous glucose monitoring and flash glucose monitoring systems. This has enabled not only medical professionals but also patients to monitor details of glycemic variability (GV) which was not possible in the past. Details of GV for both short and intermediate periods can now be obtained, and it is important in patient care to appropriately evaluate the data obtained. Types of GV in terms of time frame vary from short-term to long-term. Several studies reported that long-term GV was related to micro- and macro-angiopathies in patients with type 2 diabetes mellitus (T2DM). However, there are still unknown aspects regarding the relationships of various durations of GV with prognosis. Further clinical trials are required to examine the mechanism of GV and to evaluate whether GV can be a valuable therapeutic target in treatment of patients with T2DM.
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Affiliation(s)
- Masaya Sakamoto
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
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Mo Y, Zhou J, Ma X, Zhu W, Zhang L, Li J, Lu J, Hu C, Bao Y, Jia W. Haemoglobin A1c variability as an independent correlate of atherosclerosis and cardiovascular disease in Chinese type 2 diabetes. Diab Vasc Dis Res 2018; 15:402-408. [PMID: 29848065 DOI: 10.1177/1479164118778850] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To examine the association between haemoglobin A1c variability and macrovascular complication in type 2 diabetes. METHODS We retrospectively enrolled 5278 diabetes patients with no history of cardiovascular disease and atherosclerosis by ultrasound at their first visit to the hospital from 1999 to 2010. Patients had a median of 4 haemoglobin A1c (range = 3-9) measurements during follow-up. Average haemoglobin A1c and haemoglobin A1c variability were calculated as intra-individual mean, standard deviation, coefficient of variation and adjusted standard deviation. Cardiovascular disease events and ultrasound results were re-evaluated from the medical history at the end of the study. RESULTS A total of 972 patients had macrovascular complication. Compared to those without atherosclerosis/cardiovascular disease (n = 4306), haemoglobin A1c intra-individual mean and haemoglobin A1c variability levels were significantly higher in patients with macrovascular complication ( p < 0.001). Multivariable logistic regression analysis showed that haemoglobin A1c variability was associated with macrovascular complication. Moreover, 488 patients with only atherosclerosis had significantly higher haemoglobin A1c intra-individual mean and haemoglobin A1c variability values than those without atherosclerosis/cardiovascular disease ( p < 0.001), but in 484 patients with cardiovascular disease incidents, only higher haemoglobin A1c intra-individual mean level was found ( p = 0.004). CONCLUSIONS In Chinese type 2 diabetes, haemoglobin A1c variability was associated with macrovascular complication. Long-term stabilization of glucose is important in diabetes management, especially in the early stage of atherosclerosis.
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Affiliation(s)
- Yifei Mo
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jian Zhou
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaojing Ma
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wei Zhu
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Lei Zhang
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jie Li
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jingyi Lu
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cheng Hu
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yuqian Bao
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Weiping Jia
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Key Clinical Center for Metabolic Disease, Shanghai Diabetes Institute, Shanghai Key Laboratory of Diabetes Mellitus, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Li TC, Li CI, Liu CS, Lin WY, Lin CH, Yang SY, Chiang JH, Lin CC. Development and validation of prediction models for the risks of diabetes-related hospitalization and in-hospital mortality in patients with type 2 diabetes. Metabolism 2018; 85:38-47. [PMID: 29452177 DOI: 10.1016/j.metabol.2018.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 02/07/2018] [Accepted: 02/09/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Diabetes is a major cause of hospitalization and in-hospital mortality. However, a scoring system that can be used to identify diabetic patients at risk of diabetes-related hospitalization and in-hospital mortality is lacking. METHODS We included 32,653 patients in this retrospective cohort study. All recruited patients had type 2 diabetes, were 30-84 years of age, and were enrolled in the National Diabetes Care Management Program over the period of 2001-2003. We used the Cox proportional hazard regression model to derive risk scores. The predictive accuracy of the models was evaluated using receiver operating characteristic curves. We conducted the Hosmer-Lemeshow test to assess the agreement between predicted and observed risks. RESULTS Over a follow-up period of eight years, 6243 patients were hospitalized for diabetes-related events, and 2048 deaths were registered in hospital records. For the one-, three-, five-, and eight-year periods, the areas under the curve (AUC) for diabetes-related hospitalization in the validation set were 0.80, 077, 0.76, and 0.74, respectively. The corresponding values for in-hospital mortality in the validation set were 0.87, 080, 0.77, and 0.76. The goodness-of-fit test showed that the predicted and observed probabilities in the one-, three-, five-, and eight-year periods were similar for diabetes-related hospitalization and in-hospital mortality in the validation set (all p values > 0.05). CONCLUSION We developed models for the estimation of the risks of diabetes-related hospitalization and in-hospital mortality in patients with type 2 diabetes. The models may be used to identify diabetic patients who are at high risk for hospital admission and in-hospital mortality.
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Affiliation(s)
- Tsai-Chung Li
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan; Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Chia-Ing Li
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Chiu-Shong Liu
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wen-Yuan Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsueh Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Sing-Yu Yang
- Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Jen-Huai Chiang
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Chieh Lin
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan; Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan.
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Walker GS, Chen JY, Hopkinson H, Sainsbury CAR, Jones GC. Structured education using Dose Adjustment for Normal Eating (DAFNE) reduces long-term HbA 1c and HbA 1c variability. Diabet Med 2018; 35:745-749. [PMID: 29573459 DOI: 10.1111/dme.13621] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2018] [Indexed: 11/30/2022]
Abstract
AIMS Previous evidence has demonstrated that participation in the Dose Adjustment for Normal Eating (DAFNE) education programme can reduce HbA1c and severe hypoglycaemia in people with Type 1 diabetes. In a number of studies, increased HbA1c variability has been associated with higher diabetic morbidity and mortality. No studies have examined the impact of structured education on HbA1c variability in Type 1 diabetes. METHODS People with Type 1 diabetes who had attended DAFNE were identified for inclusion from the Scottish Care Information-Diabetes dataset. HbA1c median and variability, expressed as coefficient of variation (CV) before and after DAFNE was calculated. RESULTS Some 1061 individuals participated in DAFNE education and 687 met the inclusion criteria. A significant median reduction in HbA1c [-3.5 mmol/mol (-0.3%)] was seen at 12 months with a significant reduction [-1.5 mmol/mol (-0.1%)] still seen at 60 months of follow-up. HbA1c variability as measured by CV was significantly lower during the post-DAFNE period: 0.08 (IQR 0.05-0.12) reduced to 0.07 (IQR 0.05-0.10); P = 0.002. CONCLUSION The data confirm that DAFNE participation improves glycaemic control in Type 1 diabetes with benefits being sustained for 5 years. This study is the first to demonstrate reduced HbA1c variability after completion of structured education. This is new evidence of the beneficial impact of DAFNE on glycaemic profile.
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Affiliation(s)
- G S Walker
- Diabetes Centre, Gartnavel General Hospital, Glasgow, UK
| | - J Y Chen
- Diabetes Centre, Gartnavel General Hospital, Glasgow, UK
| | - H Hopkinson
- Diabetes Centre, New Victoria Hospital, Glasgow, UK
| | | | - G C Jones
- Diabetes Centre, Gartnavel General Hospital, Glasgow, UK
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Cardoso CRL, Leite NC, Moram CBM, Salles GF. 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. Cardiovasc Diabetol 2018; 17:33. [PMID: 29477146 PMCID: PMC6389075 DOI: 10.1186/s12933-018-0677-0] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 02/16/2018] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- C. R. L. Cardoso
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro, RJ CEP: 22750-240 Brazil
| | - N. C. Leite
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro, RJ CEP: 22750-240 Brazil
| | - C. B. M. Moram
- Department of Occupational Therapy, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - G. F. Salles
- Department of Internal Medicine, University Hospital Clementino Fraga Filho, School of Medicine, Universidade Federal do Rio de Janeiro, Rua Croton, 72, Jacarepagua, Rio de Janeiro, RJ CEP: 22750-240 Brazil
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Dhatariya KK, Li Ping Wah-Pun Sin E, Cheng JOS, Li FYN, Yue AWY, Gooday C, Nunney I. The impact of glycaemic variability on wound healing in the diabetic foot - A retrospective study of new ulcers presenting to a specialist multidisciplinary foot clinic. Diabetes Res Clin Pract 2018; 135:23-29. [PMID: 29097286 DOI: 10.1016/j.diabres.2017.10.022] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/11/2017] [Accepted: 10/24/2017] [Indexed: 12/17/2022]
Abstract
AIMS Glycaemic variability - the visit-to-visit variation in HbA1c - plays a possible role in the development of micro and macrovascular disease in patients with diabetes. Whether HbA1c variability is a factor determining wound healing in diabetic foot ulcers remains unknown. We aimed to determine whether HbA1c variability is associated with foot ulcer healing time. METHODS A retrospective analysis of patients presenting to our specialist multidisciplinary foot clinic between July 2013 and March 2015, with at least three HbA1c measurements within five years of presentation and more than two follow-up reviews. HbA1c variation was measured by magnitude of standard deviation. RESULTS 629 new referrals were seen between July 2013 and March 2015. Of these, 172 patients had their number of days to healing recorded and sufficient numbers of HbA1c values to determine variability. The overall geometric mean days to heal was 91.1 days (SD 80.8-102.7). In the low HbA1c variability group the geometric mean days to heal was 78.0 days (60.2-101.2) vs 126.9 days (102.0-158.0) in the high Hb1Ac variability group (p = .032). Those with low HbA1c (<58 mmol/mol) and low variability healed faster than those with high HbA1c and high variability (73.5 days [59.5-90.8] vs 111.0 days [92.0-134.0], p = .007). Additionally, our results show that time to healing is more dependent on the mean HbA1c than the variability in HbA1c (p = .007). CONCLUSIONS/INTERPRETATION Our data suggest that there was a significant association between HbA1c variability and healing time in diabetic foot ulcers.
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Affiliation(s)
- Ketan K Dhatariya
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK; Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY, UK.
| | | | | | | | - Anson Wei Yue Yue
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Catherine Gooday
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK; Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk NR4 7UY, UK
| | - Ian Nunney
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
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Walker GS, Cunningham SG, Sainsbury CAR, Jones GC. HbA 1c variability is associated with increased mortality and earlier hospital admission in people with Type 1 diabetes. Diabet Med 2017; 34:1541-1545. [PMID: 28833535 DOI: 10.1111/dme.13455] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2017] [Indexed: 01/21/2023]
Abstract
AIM Despite evidence of morbidity, no evidence exists on the relationship between HbA1c variability and mortality in Type 1 diabetes. We performed an observational study to investigate whether the association between HbA1c variability and mortality exists in a population of people with Type 1 diabetes. As a secondary outcome, we compared onset of first hospital admission between groups. METHODS People with Type 1 diabetes were identified for inclusion from the Scottish Care Information - Diabetes data set. This database includes data of all people known to have diabetes who live within Scotland. A survival analysis was carried out over a 47-month period comparing two groups; group 1 with a HbA1c coefficient of variation (CV) above the median CV value, and group 2 with a CV below the median value. Time to death or first admission was also analysed. A Cox proportional hazard model was used to compare time to death, adjusting for appropriate covariables. RESULTS Some 6048 individuals with Type 1 diabetes were included in the analysis. Median HbA1c CV was 7.9. The hazard ratio (HR) for mortality for those with an HbA1c CV above the median value is 1.5 over 47 months of follow-up (P < 0.001). HR for survival to either the first admission to hospital or death for those with an HbA1c CV above the median value was 1.35 (95% confidence interval 1.25-1.45) over 730 days of follow-up (P < 0.001). CONCLUSION Our results show that people with greater HbA1c variability have a higher rate of mortality and earlier hospital admission in Type 1 diabetes.
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Affiliation(s)
- G S Walker
- Diabetes Centre, Gartnavel General Hospital, Glasgow
| | - S G Cunningham
- Clinical Technology Centre, Ninewells Hospital, Dundee, UK
| | | | - G C Jones
- Diabetes Centre, Gartnavel General Hospital, Glasgow
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The relationship between fasting blood glucose variability and coronary artery collateral formation in type 2 diabetes patients with coronary artery disease. Coron Artery Dis 2017. [PMID: 28644211 DOI: 10.1097/mca.0000000000000520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Coronary collaterals are an alternative source of blood supply to ischemic myocardium. Well-developed coronary collateral arteries in patients with coronary artery disease (CAD) limit the size of acute myocardial infarction and improves survival. The aim of this study was to investigate the relationship between glycemic variability and coronary collateral formation in patients with type 2 diabetes mellitus and CAD. METHODS Consecutive patients undergoing percutaneous coronary intervention or coronary artery bypass grafting procedures were studied. Multivariate logistic regression models were used to examine the association between coronary artery collateral formation graded by Rentrope classification and glycemic variability, measured by coefficient variation of fasting blood glucose. RESULTS In our study, we retrospectively enrolled 300 patients, of whom 239 were diabetic (age: 70.1±11.9, 56% men) and 61 were nondiabetic (age: 71.5±11.5, 72% men). Diabetic patients were further stratified as follows: those with poor coronary collateral artery development (n=171, age: 69.7±12.4, 55% men) and those with good coronary collateral artery development (n=68, age 71.1±10.8, 59% men) according to the Rentrope classification. Our findings did not show association between glycemic variability and coronary collateral vessels development after controlling for potential confounders (odds ratio: 2.51; 95% confidence interval: 0.57-11.03; P=0.22). The culprit lesion (≥75% stenosis) in the left anterior descending artery and the right coronary artery was more frequent in the good collateral group compared with the poor collateral group (66 vs. 50%, P=0.02; 63 vs. 45%, P=0.01 respectively). CONCLUSION Glycemic variability is not associated with coronary collateral artery formation in patients with type 2 diabetes mellitus and CAD.
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