Correlates of poor glycemic control among patients with diabetes initiating hemodialysis for end-stage renal disease

Inequalities in end-stage renal disease: underprivileged and ethnic minority members are at higher risk

BACKGROUND

Incidence of end-stage renal disease (ESRD) is higher in Israel than the European average. Socio-economic differences in ESRD have been reported globally, but many countries lack a national register. Using national data, we assessed which socio-demographic factors are associated with 5-year incidence of ESRD in Israel, where there is universal access to renal replacement therapy (RRT).

METHODS

Data on all incident ESRD cases aged ≥20 years receiving chronic RRT between 1 January 2014 and 31 December 2018 (N = 7883) were collected from Israel's National Dialysis & Renal Transplant Register. Individual-level data on ESRD cases requiring RRT included residential area, age, gender, ethnicity (Jewish or Arab) and ESRD cause (diabetes, other, unknown/missing). Area-level data included age and sex distribution, socio-economic status (SES) and proportion of Arab population. The associations between individual-level socio-demographic characteristics and ESRD cause were tested in bivariate comparisons. The risk of developing ESRD during the study period (from all and specific causes) was estimated using multiple Poisson regression models with negative binomial distribution, using four parameters, namely sex, ethnicity, SES category and age strata, based on area-level distribution of these parameters, and with the whole population (aged ≥20 years) as the denominator.

RESULTS

A socio-economic gradient was seen for ESRD from all causes, more marked for diabetic aetiology [rate ratio (RR)=0.45, 95% CI: 0.39-0.52 highest vs lowest SES categories] than from other (RR = 0.64, 95% CI: 0.55-0.75) or unknown cause (RR = 0.79, 95% CI: 0. 62-0.99). Based on population area-level data, predominantly Arab neighbourhoods showed higher risk for ESRD requiring RRT for all causes, with the strongest association for diabetes (RR = 1.69, 95% CI: 1.53-1.86) adjusted for SES, age and sex.

CONCLUSIONS

A strong socio-economic gradient was demonstrated for ESRD requiring RRT. Arab ethnicity was associated with higher risk for ESRD, especially due to diabetes. Our findings suggest the need for allocation of health resources according to needs and culturally appropriate interventions for improving control of modifiable risk factors for chronic renal failure.

Diabetes Prevalence, Treatment, Control, and Outcomes Among Hemodialysis Patients in the Gulf Cooperation Council Countries

INTRODUCTION

Diabetes mellitus (DM) is a leading cause of end-stage kidney disease (ESKD). We provide the first description of DM prevalence, related outcomes, and the hemoglobin A1c (HbA1c)/mortality relationship in national hemodialysis (HD) patient samples across the Gulf Cooperation Council (GCC) countries.

METHODS

We analyzed data from the prospective Dialysis Outcomes and Practice Patterns Study (DOPPS) in the GCC (2012-2018, N = 2274 HD patients ≥18 years old). Descriptive statistics were calculated, and all-cause mortality was analyzed for patients with DM versus without DM and by HbA1c levels in patients with DM by Cox regression with progressive confounder adjustments.

RESULTS

DM in the GCC ranged from 45% to 74% in patients with HD by country. Patients with DM were 13 years older (59.9 vs. 46.7 years) and had greater body mass index (BMI), shorter median years on dialysis (1.5 vs. 3.0 years), and higher comorbidity burden. In patients with DM, insulin use was 26% to 50% across countries, with variable oral antidiabetic drug use (2%-32%); median HbA1c levels were 6.1% to 7.5% across countries. Patients with DM (vs. without DM) had higher crude death rates (15.6 vs. 6.2 deaths per 100 patient-years, mean follow-up 1.3 years) and adjusted mortality (hazard ratio [HR] = 1.72 [95% CI 1.23-2.39]). In patients with DM, mortality was lowest at HbA1c 6.5% to 7.5%, with mortality particularly elevated at high HbA1c >9% (HR = 2.13 [95% CI 1.10-4.10]).

CONCLUSION

Patients with DM in the GCC have high comorbidity burden and mortality rates despite a relatively young mean age. In GCC countries, a holistic strategy for improving diabetes care and outcomes for HD patients is needed at the primary, secondary, and tertiary levels.

Predictive value of the glycated albumin versus glycosylated hemoglobin in follow-up of glucose homeostasis in hemodialysis-maintained type-2 diabetic patients

Objectives. Markers for glucose control in hemodialysis patients (HDP) are debated. Glycosylated hemoglobin (HbA1c%) relies on the stable red blood cell survival. Albumin turnover is faster than hemoglobin. Glycated albumin (GA%) may be used as an index of short-term glycemic control. The predictive value of GA% versus HbA1c% in monitoring the glucose homeostasis in type-2 diabetic HDP is studied. Methods. Forty type-2 diabetic HDP and 20 healthy non diabetic subjects matched age and sex as a control group were included. Calculation of body mass index and Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) and urea reduction ratio were done. Glycosylated hemoglobin, glycated albumin, fasting blood glucose, insulin, total lipid, kidney and liver functions tests, hepatitis markers, electrolytes, complete blood count, and international normalized ratio were performed. Patients were followed up after 6 months. Results. The study showed that GA% is more sensitive than HbA1c%, but less specific in the follow-up of the glucose homeostasis in type-2 diabetic HDP. Diagnostic accuracy is higher in HbA1c% than in GA%. HOMA-IR is superior regarding the sensitivity and the diagnostic accuracy. Conclusion. The present data show that GA% is more sensitive than HbA1c% and has more diagnostic accuracy in the follow-up of the glucose homeostasis in type-2 diabetic HDP.

Glycemic Control and its Predictors among Adult Diabetic Patients attending Mettu Karl Referral Hospital, Southwest Ethiopia: A Prospective Observational Study

INTRODUCTION

The current estimate is that 463 million people worldwide have diabetes. In 2017, an estimated 5 million (9.9%) deaths worldwide among adults were caused by diabetes. The burden of disease associated with uncontrolled diabetes is substantial in terms of mortality and cardiovascular disease. The aim of this study was to assess glycemic control level and its predictors among adult patients with diabetes.

METHODS

A prospective observational study was conducted among patients with diabetes during follow-up at an ambulatory clinic of Mettu Karl referral hospital from 15 April to 09 August 2019. The consecutive sampling method was used to collect data, following which the data were entered into Epidata manager version 4.4.2 and exported to the SPSS version 24.0 statistical software package for analysis. Logistic regression analysis was performed to identify predictors of poor glycemic control. Variables whose significance level was < 0.05 (p value) were considered to be predictors of poor glycemic control.

RESULTS

A total of 330 diabetic patients were included in the study, among whom 240 (72.7%) had poor glycemic control. The predictors of poor glycemic control in the multivariate logistic regression analysis were overweight [adjusted odds ratio (AOR) 4.07; 95% confidence interval (CI) 1.60, 10.36; p = 0.003], obesity (AOR 4.39; 95% CI 1.59, 12.14; p = 0.004), higher estimated glomerular filtration rate (eGFR) (AOR 2.34; 95% CI 1.23, 4.44; p = 0.010), type 1 diabetes (AOR 3.22; 95% CI 1.58, 6.55; p = 0.001), poor diet adherence (AOR 6.95; 95% CI 3.63, 13.32; p < 0.001) and non-adherence to medications (AOR 5.82; 95% CI 2.77, 12.26; p < 0.001).

CONCLUSION

Almost three-quarters of the study population of diabetic patients had poorly controlled blood sugar. Overweight, obesity, higher eGFR, type 1 diabetics, poor adherence to diet recommendation and non-adherence to medications were independent predictors of poor glycemic control. Educational strategies should focus on improving adherence to the recommended diet and medication(s), achieving weight control and optimizing glycemic control.

Glycemic Control and Infections Among US Hemodialysis Patients With Diabetes Mellitus

Introduction

Patients with diabetes mellitus (DM) on hemodialysis (HD) may be particularly vulnerable to infections.

Methods

We used merged data from the United States Renal Data System and electronic health records data from a large US dialysis provider to retrospectively examine the association between glycemic control and infections in these patients. Adult patients with DM aged ≥18 years who initiated in-center maintenance HD treatment from 2006 to 2011 and survived >90 days were included. Quarterly mean time-averaged hemoglobin A1c (HbA1c) values were categorized into <5.5%, 5.5 to <6.5%, 6.5 to <7.5%, 7.5 to <8.5%, and ≥8.5%. We used Medicare claims to ascertain infection-related outcomes and the ESRD Death Notification to identify death from infectious cause. We used Cox proportional hazards models to estimate multivariable-adjusted hazard ratios and 95% confidence intervals (CIs) for the associations between time-averaged HbA1c categories and infectious events.

Results

In a cohort of 33,753 eligible patients, those with higher HbA1c levels had higher rates of diabetic foot infections and skin and soft tissue infections, with patients with HbA1c ≥8.5% having 23% (95% CI, 5%, 45%) and 22% (95% CI, 5%, 42%) higher rates, respectively, compared with HbA1c 5.5 to <6.5%. Patients in the lower HbA1c categories had higher rates of infection-related and all-cause mortality (P-for-trend <0.001).

Conclusion

This study highlights the need for greater attention to foot evaluation and skin and soft tissue infections among patients on HD with less than optimal diabetes control.

Fluid overload is associated with use of a higher number of antihypertensive drugs in hemodialysis patients

INTRODUCTION

Hypertension is multifactorial, highly prevalent in the hemodialysis (HD) population and its adequate control requires, in addition to adequate volume management, often the use of multiple antihypertensive drugs. We aimed to describe the use of antihypertensive agents in a group of HD patients and to evaluate the factors associated with the use of multiple classes (≥3) of antihypertensives.

METHODS

We analyzed the baseline data from the HDFit study. Clinically stable patients with HD vintage between 3 and 24 months without any severe mobility limitation were recruited from sites throughout southern Brazil. Fluid status was measured pre-dialysis with the Body Composition Monitor (BCM; Fresenius, Germany). Fluid overload (FO) was considered when the overhydration index (OH) was greater than 7% of extracellular water (OH/ECW > 7%) and overweight was defined as a body mass index (BMI) greater than 25 kg/m² . Prescriptions of antihypertensive drugs were obtained from participants' reports and medical records. Logistic regression was employed to determine factors associated with excessive use of antihypertensive medication (≥3 classes).

FINDINGS

Of 195 studied patients, 171 with complete data were included (70% male, 53 ± 15 years old, 57% of them with FO). Pre-dialysis systolic blood pressure (SBP) was 150 ± 24 mmHg and patients used a median of 2 (1-3) antihypertensive drugs. Vasodilators (20%) were of lowest prevalence, use of other classes varied from 40% to 53%. Sixty-two (36%) subjects used ≥3 classes and presented a higher prevalence of diabetes and FO, lower prevalence of overweight, and higher SBP. In a logistic regression model age, BMI <25 kg/m² , and OH/ECW > 7% were associated with excessive drug use.

DISCUSSION

More than one-third of participants used ≥3 classes of antihypertensive drugs, and it was associated with older age, BMI <25 kg/m² and FO. Strategies that better manage FO may aid better blood pressure control and avoid the use of multiple antihypertensive medications.

Diabetes-related knowledge in diabetic haemodialysis patients: a cross-sectional study from Palestine

Background

Diabetes mellitus is the leading cause of end-stage renal disease. Monitoring and controlling normal blood sugar levels play a critical role in slowing the progression of micro- and macrovascular complications of diabetes. This study was conducted to measure glycaemic control and diabetes-related knowledge in diabetic patients on maintenance haemodialysis and to assess any relationship between these two variables.

Methods

This cross-sectional study was conducted at six dialysis centres in the north of the West Bank. Blood samples were collected to measure glycated haemoglobin (HbA1c) levels, while the Michigan Diabetic Knowledge Test (MDKT) was employed as a measure tool of diabetes-related knowledge. Patients were also asked to fill in a questionnaire in order to determine their sociodemographic characteristics. Finally, univariate analyses were used to measure the associations between the clinical and sociodemographic data, and diabetes knowledge and glycaemic control.

Results

A total of 147 haemodialysis patients with diabetes were included in this study. The mean age of the cohort was 60.12 (SD = 10.28). Males accounted for 51.7% of the cohort. The HbA1c levels (%) and MDKT scores were 6.89 ± 1.72 and 9.19 ± 1.7 (mean ± SD), respectively. 36.1% of the patients had poor glycemic control. The study showed that residency and household income were associated with diabetes knowledge (P < 0.05). However, the study did not show a significant association between diabetes-related knowledge and glycaemic control overall, nor did it show a significant association between the clinical and sociodemographic factors and glycaemic control (P > 0.05).

Conclusions

This study showed that patients living in refugee camps as well as those with low income had low diabetes-related knowledge and needed extra care. This study also revealed that a relatively high proportion of diabetic patients on maintenance haemodialysis suffered from poor glycemic control. Here, we recommend to put greater emphasis on better diabetes-related knowledge as a means to achieve better diabetes care with improved glycemic control for all haemodialysis patients

Diabetes Management in Older Adults With Chronic Kidney Disease

PURPOSE OF REVIEW

Older adults often live with chronic disease including diabetes and its complications. In this review, we examine the complexity and heterogeneity of older adults with diabetes and chronic kidney disease, explore the nuances in their diabetes-related monitoring, and discuss their best diabetes management.

RECENT FINDINGS

Although there remains an overall lack of studies in older adults with diabetes and chronic kidney disease, recent reports have highlighted their vulnerabilities. These individuals face an increased risk of cognitive impairment and dementia, frailty, dysglycemia, polypharmacy, declining kidney function, and acute kidney injury. Their diabetes management should focus upon safer antihyperglycemic medications, close monitoring, and care individualization. Older adults with diabetes and chronic kidney disease are a complex population who requires careful diabetes management and monitoring. Research efforts might focus on improving the care and outcomes of these patients.

Ganglion cell complex loss in patients with type 1 diabetes: A 36-month retrospective study

BACKGROUND:

To analyze changes over a 3-year period in ganglion cell complex (GCC) thickness in individuals with type 1 diabetes mellitus (T1DM) using spectral-domain optical coherence tomography (Optovue, Fremont, CA, USA).

METHODS:

Thirty-seven individuals from “Friends for Life Conference” with T1DM and a 3-year history of GCC thickness measurements were included in the study. Data analysis using SPSS 22 and Excel StatPlus was completed to note the subgroups that had a significant change.

RESULTS:

Significant decreases were noted in the following subgroups with slope in parenthesis.

Overall: GCC superior thickness OD (−0.48)

Male: GCC thickness OD (−0.86), GCC superior thickness OD (−0.735)

Body mass index (BMI) 25.0–29.9: GCC thickness OD (−0.48), GCC superior thickness OS (−0.915), GCC inferior thickness OD (−0.43)

Ages 10–20 years: GCC superior thickness OD (−0.635)

Duration of diabetes 10–20 years: GCC thickness OD (−1.055), GCC superior thickness OD (−0.99).

CONCLUSION:

GCC loss was noted in individuals who were males, those with BMIs of 25.0–29.9, and those who had diabetes for 10–20 years. Ganglion cell loss was also noted before the presence of any diabetic retinopathy, suggesting onset of neuronal loss before any vasculature changes.

Using electronic health record data for environmental and place based population health research: a systematic review

PURPOSE

We conducted a systematic review of literature published on January 2000-May 2017 that spatially linked electronic health record (EHR) data with environmental information for population health research.

METHODS

We abstracted information on the environmental and health outcome variables and the methods and data sources used.

RESULTS

The automated search yielded 669 articles; 128 articles are included in the full review. The number of articles increased by publication year; the majority (80%) were from the United States, and the mean sample size was approximately 160,000. Most articles used cross-sectional (44%) or longitudinal (40%) designs. Common outcomes were health care utilization (32%), cardiometabolic conditions/obesity (23%), and asthma/respiratory conditions (10%). Common environmental variables were sociodemographic measures (42%), proximity to medical facilities (15%), and built environment and land use (13%). The most common spatial identifiers were administrative units (59%), such as census tracts. Residential addresses were also commonly used to assign point locations, or to calculate distances or buffer areas.

CONCLUSIONS

Future research should include more detailed descriptions of methods used to geocode addresses, focus on a broader array of health outcomes, and describe linkage methods. Studies should also explore using longitudinal residential address histories to evaluate associations between time-varying environmental variables and health outcomes.

Associations of Glycemic Control With Cardiovascular Outcomes Among US Hemodialysis Patients With Diabetes Mellitus

Background

There is a lack of data on the relationship between glycemic control and cardiovascular end points in hemodialysis patients with diabetes mellitus.

Methods and Results

We included adult Medicare‐insured patients with diabetes mellitus who initiated in‐center hemodialysis treatment from 2006 to 2008 and survived for >90 days. Quarterly mean time‐averaged glycated hemoglobin (HbA_1c) values were categorized into <48 mmol/mol (<6.5%) (reference), 48 to <58 mmol/mol (6.5% to <7.5%), 58 to <69 mmol/mol (7.5% to <8.5%), and ≥69 mmol/mol (≥8.5%). Medicare claims were used to identify outcomes of cardiovascular mortality, nonfatal myocardial infarction (MI), fatal or nonfatal MI, stroke, and peripheral arterial disease. We used Cox models as a function of time‐varying exposure to estimate multivariable adjusted hazard ratios and 95%CI for the associations between HbA_1c and time to study outcomes in a cohort of 16 387 eligible patients. Patients with HbA_1c 58 to <69 mmol/mol (7.5% to <8.5%) and ≥69 mmol/mol (≥8.5%) had 16% (CI, 2%, 32%) and 18% (CI, 1%, 37%) higher rates of cardiovascular mortality (P‐trend=0.01) and 16% (CI, 1%, 33%) and 15% (CI, 1%, 32%) higher rates of nonfatal MI (P‐trend=0.05), respectively, compared with those in the reference group. Patients with HbA_1c ≥69 mmol/mol (≥8.5%) had a 20% (CI, 2%, 41%) higher rate of fatal or nonfatal MI (P‐trend=0.02), compared with those in the reference group. HbA_1c was not associated with stroke, peripheral arterial disease, or all‐cause mortality.

Conclusions

Higher HbA_1c levels were significantly associated with higher rates of cardiovascular mortality and MI but not with stroke, peripheral arterial disease, or all‐cause mortality in this large cohort of hemodialysis patients with diabetes mellitus.

Prayer sign as a marker of increased ventilatory hours, length of intensive care unit and hospital stay in patients undergoing coronary artery bypass grafting surgery

Context:

Various predictors have been used to predict diabetic patients who are likely to have increased ventilatory hours and an increased length of stay (LOS) in the Intensive Care Unit (ICU) as well as in the hospital after undergoing coronary artery bypass grafting (CABG) surgery, for example, glycosylated hemoglobin (HbA1c). The authors propose a simple bed-side test, i.e., the prayer sign to predict increased ventilatory hours and increased length of ICU and hospital stay.

Aims:

The aim of the present study was to assess whether any association exists between a positive prayer sign and increased ventilatory hours, length of ICU and hospital stay after CABG surgery in diabetic patients.

Settings and Design:

This prospective observational study was conducted in a 650-bedded tertiary cardiac center.

Subjects and Methods:

A total of 501 diabetic patients were recruited in the study over a period of 1 year. Group P consisted of 121 patients with prayer sign positive, whereas Group N consisted of 380 patients with prayer sign negative. HbA1c levels, ventilatory hours, LOS in the postoperative ICU and hospital were compared.

Statistical Analysis Used:

Unpaired Student's t-test was used to compare the data.

Results:

The mean HbA1c levels in Group P were 8.01 ± 2.28% as compared to 6.52 ± 2.46% in Group N (P < 0.0001). The mean ventilatory hours in Group P were 9.52 ± 6.46 h, and in Group N were 7.42 ± 8.01 h (P = 0.013). Whereas, the mean length of ICU stay and hospital stay in Group P was 156.42 ± 32.66 h (6.51 ± 1.36 days) and 197.36 ± 32.46 h (8.22 ± 1.35 days), respectively, it was 121.12 ± 29.48 h (5.04 ± 1.22 days) and 178.52 ± 28.52 h (7.43 ± 1.18 days) in Group N (P < 0.0001).

Conclusions:

A positive prayer sign is a useful bedside test for predicting increased ventilatory hours and increased length of ICU and hospital stay after CABG surgery.