Glycemic Control In Hemodialysis Patients Research Articles

Xanthine oxidoreductase activity is associated with serum uric acid and glycemic control in hemodialysis patients

Xanthine oxidoreductase activity (XOR-a) plays an important role as a pivotal source of reactive oxygen species. In the present study, we investigated factors associated with plasma XOR-a in 163 hemodialysis patients (age 67.3 ± 10.9 years; 89 males and 74 females), using a newly established, highly-sensitive assay based on [13C2,15N2] xanthine and liquid chromatography/triple quadrupole mass spectrometry. Plasma glucose and serum uric acid levels correlated significantly and positively with plasma XOR-a. In multiple regression analyses, the presence of type 2 diabetes mellitus (T2DM) and plasma glucose were associated significantly, independently, and positively with plasma XOR-a. While serum uric acid correlated significantly and positively with plasma XOR-a in hemodialysis patients without T2DM, plasma glucose and serum glycated albumin, a new marker of glycemic control in diabetic hemodialysis patients, correlated significantly and positively with plasma XOR-a in those with T2DM. Multivariate analyses in those with T2DM revealed that plasma glucose and serum glycated albumin were associated significantly and independently with plasma XOR-a, and that serum uric acid was associated significantly and independently with XOR-a in those without T2DM. Our results suggested that glycemic control in hemodialysis patients may be important in regard to a decrease in ROS induced by XOR.

HbA1c reliability in patients with diabetes on regular hemodialysis before and after erythropoietin therapy

Abstract Purpose The purpose of this study was to determine the effect of erythropoietin (EPO) treatment on HbA1c levels in diabetic patients on regular hemodialysis and to assess the reliability of HbA1c as a marker for glycemic control in such patients. Methods The study included 41 patients on regular hemodialysis who were EPO naive: 31 with diabetes mellitus and 10 nondiabetic controls. Baseline HBA1c and fasting blood glucose levels were measured and repeated after a 3-month course of EPO. Results HbA1c decreased significantly after EPO therapy (P =0.01) and was associated with a significant decline in fasting blood glucose levels (P = 0.001), with a significant negative correlation with hemoglobin (r = −0.185, P =0.03). HbA1c showed significant correlation with fasting blood glucose in diabetic patients before EPO therapy (r =0.82, P < 0.0001). This correlation was found to be independent of other laboratory parameters. No correlation was found between HbA1c and fasting blood glucose levels after 3 months of EPO treatment. Conclusion HbA1c is not a reliable marker for glycemic control in hemodialysis patients, especially for those on EPO therapy.

Glycated albumin versus glycated hemoglobin as glycemic indicator in hemodialysis patients with diabetes mellitus: Variables that influence

The significance of glycated albumin (GA) compared with casual plasma glucose (PG) and glycated hemoglobin (HbA1c) was evaluated as an indicator of the glycemic control state in hemodialysis (HD) patients with diabetes. In HD patients with diabetes (n = 25), the mean PG, GA and HbA1c levels were 192.9 + 23 mg/dL, 278.8 + 43 μmol/L and 5.9 + 0.5%, respectively, which were higher by 43.9%, 67.04% and 18%, respectively, compared with HD patients without diabetes (n = 25). HbA1c levels were significantly lower than simultaneous PG and GA values in those patients in comparison with the three parameters in patients who had diabetes without renal dysfunction (n = 25). A significant negative correlation was found between GA and serum albumin (r = 0.21, P <0.05) in HD patients with diabetes, whereas HbA1c correlated positively and negatively with hemoglobin (r = 0.11, P <0.01) and weekly dose of erythropoietin injection (r = -0.19, P < 0.01), respectively. Although PG and GA did not differ significantly between HD patients with diabetes and with and without erythropoietin injection, HbA1c levels were significantly higher in patients without erythropoietin. Categorization of glycemic control into arbitrary quartiles by GA level led to better glycemic control in a significantly higher proportion of HD patients with diabetes than those assessed by HA1c. Multiple regression analysis demonstrated that hemoglobin in addition to PG emerged as an independent factor associated with HbA1c in HD patients with diabetes, while PG, body mass index and albumin were an independent factor associated with GA. it is suggested that GA provides a significantly better measure to estimate glycemic control in HD patients with diabetes and that the assessment of glycemic control by HbA1c in these patients might lead to likely underestimation as a result of the increasing proportion of young erythrocyte by the use of erythropoietin.

Correlation between glycated hemoglobin and mean plasma glucose in hemodialysis patients

Since the half-life of red blood cells (RBCs) is shorter in hemodialysis patients, the value of glycated hemoglobin (HbA1c) as a marker of glycemic control in patients with diabetes on hemodialysis has recently been questioned. It is thought that it is not a good marker of mean plasma glucose (MPG) over a 3-month duration. In our current study, we evaluate whether monthly HbA1c values is a better marker of glycemic control than HbA1c every 3 months. We performed a cross-sectional analysis of a retrospective cohort of 152 patients with diabetes who presented to two hemodialysis units in NYC. Patients had weekly predialysis glucose levels checked over the last 3 months, and HbA1c values were checked every 3 months. Data collection spanned a 6-month time frame from August 2008 to January 2009. We found no difference in the correlation between HBA1c/mean plasma glucose (MPG) over the last month (MPG1m) and HbA1c/mean plasma glucose (MPG) over the last 3 months (MPG3m; r = 0.57 and r = 0.53, respectively; P = 0.212). Using multivariate analysis, reticulocyte count and weekly erythropoietin dose were found to independently and inversely effect the correlations HbA1c/MPG1m and HbA1c/MPG3m. The value of HbA1c in hemodialysis for monitoring glycemic control is limited in the setting of a high reticulocyte count (>2%) and a high weekly erythropoietin dose. Checking HbA1c monthly versus every 3 months is not a better approximation of glycemic control in hemodialysis patients.

Association of glycated albumin, but not glycated hemoglobin, with calcaneus quantitative ultrasound in male hemodialysis patients with type 2 diabetes mellitus

Sustained high glucose impairs bone metabolism in patients with type 2 diabetes mellitus (T2DM). In this study, the relationship between glycemic control and bone metabolism was examined in male hemodialysis (HD) patients with T2DM. To avoid the effect of menstruation and the menstrual cycle, obesity, and glycosuria-induced hypercalciuria on bone metabolism, male anuric nonobese HD patients with T2DM (n = 42) were enrolled. Calcaneus stiffness index (SI) was determined using ultrasound after HD session. Casual plasma glucose (PG), glycated hemoglobin (HbA 1c), and glycated albumin (GA) were measured before the HD session. In simple regression analysis, log PG ( r = −0.333, P < .05) and log GA ( r = −0.350, P < .05), but not log HbA 1c ( r = −0.134, P = .3985), exhibited significant and negative correlations with calcaneus SI. In multiple regression analysis including log BMI, log cCa × Pi product, and log PG, log PG was associated significantly in a negative manner with calcaneus SI, in addition to log cCa × Pi product. When log PG was replaced with log GA or log HbA 1c, log GA, but not log HbA 1c, emerged as a significant factor associated. The mechanism as to why HbA 1c failed to associate could be explained by its false reduction by erythropoietin injection. The present study supported the notion of GA as an appropriate indicator for glycemic control in HD patients with T2DM. Furthermore, it is suggested that poor glycemic control might be a significant factor toward decreasing calcaneus SI in T2DM HD patients.

Poor Glycemic Control is a Significant Predictor of Cardiovascular Events in Chronic Hemodialysis Patients With Diabetes

We investigated the impact of glycemic control on the emergence of cardiovascular disease (CVD) in diabetic patients who were on maintenance hemodialysis in a prospective observational study. One hundred and thirty-four diabetic hemodialysis patients (63 +/- 10 years-old, hemodialysis duration of 4.5 +/- 3.9 years) at a single dialysis center were enrolled. The cohort was observed prospectively for 5 years, and the emergence of fatal and non-fatal CVD was recorded. Patients were categorized into two groups; good (mean hemoglobin (Hb) A1C <7.0%, N = 65) and poor HbA1C (mean HbA1C > or = 7.0%, N = 69). The relationship between glycemic control and CVD emergence was evaluated by Kaplan-Meier estimation and Cox proportional hazard models. During the follow-up period, 50 CVD events were observed. The cumulative CVD incidence in the poor HbA1C group was significantly higher than that of the good HbA1C group, as determined by Kaplan-Meier estimation (P = 0.0250, log-rank test). After adjustment for gender, age, duration of dialysis, and past history of CVD, a multivariate Cox proportional hazard model showed that poor HbA1C was a significant predictor of CVD events (hazards ratio [HR] 1.828 [95% CI, 1.008-3.314], P = 0.0470). When ischemic heart disease, cerebral infarction, and arteriosclerosis obliterans were determined as an endpoint, both HbA1C levels and the poor HbA1C group were significant predictors for the emergence of CVD (HR 1.269 per 1% HbA1C [95%CI, 1.022-1.574], P = 0.0307,and HR 2.816 [95% CI, 1.377-5.759], P = 0.0046, respectively). In diabetic hemodialysis patients, poor glycemic control is a significant, independent predictor of the emergence of CVD, indicating the importance of careful management of glycemic control in hemodialysis patients.

Glycated hemoglobin or glycated albumin for assessment of glycemic control in hemodialysis patients with diabetes?

This commentary discusses the findings of a study by Peacock et al., who measured levels of glycated hemoglobin (HbA(1c)) and glycated albumin in patients with diabetes who either were or were not on hemodialysis in an effort to determine which marker is the better indicator of glycemic control. They found that HbA(1c) and glycated albumin levels are both independently associated with serum glucose level. However, HbA(1c) level--unlike glycated albumin level--was also influenced by hemodialysis, hemoglobin level, and erythropoietin dose. Although we agree that glycated albumin level could be a better indicator of glycemic control than HbA(1c) level in patients on hemodialysis who have diabetes and anuria, this conclusion might not be applicable to patients with massive proteinuria or to those on peritoneal dialysis. Further studies are required to confirm the target glycated albumin level that is necessary to ensure a good prognosis for patients with diabetes who are on hemodialysis because no clear consensus has yet been reached. In addition, more data are needed to determine at which stage of kidney disease measurement of glycated albumin levels becomes preferable to assessment of HbA(1c) level.

Glycated albumin as an improved indicator of glycemic control in hemodialysis patients with type 2 diabetes based on fasting plasma glucose and oral glucose tolerance test

Aims To compare glycated albumin (GA) with glycated hemoglobin (HbA1c) as an indicator of glycemic control in hemodialysis patients with diabetes mellitus (DM), based on relationships with plasma glucose (PG) after overnight fasting and during 75 g oral glucose tolerance test (OGTT). Methods GA, HbA1c, plasma glucose during 75 g OGTT, and serum pentosidine were determined in DM hemodialysis patients ( n = 23, male/female 9/14). Results Significant positive correlations were found for GA and HbA1c with fasting PG (GA, r = .660, p = 0.0006; HbAlc r = 0.665, p = 0.0004), and with PG at 30, 60 and 120 min after initiation of 75 g OGTT (GA, r = 0.584, p = 0.0035; r = 0.624, p = 0.0015; r = 0.510, p = 0.0129, respectively; HbA1c, r = 0.669, p = 0.0004; r = 0.624, p = 0.0011; r = 0.509, p = 0.0112, respectively). The area under the curve for PG during 75 g OGTT showed strong correlations with GA ( r = 0.625, p = 0.0008) and HbA1c ( r = 0.671, p = 0.0003). GA and HbA1c also correlated positively with serum pentosidine, demonstrating that GA provides a no less significant assay than HbA1c as a reflection of glycemic control in DM hemodialysis patients. However, HbA1c was apparently reduced in DM hemodialysis patients, as reflected by an increase in the GA/HbA1c ratio to 3.58 ± 0.62 (mean ± SD), suggesting underestimation of glycemic control by HbA1c. Conclusion GA and HbA1c exhibited similar correlations with PG during a 75 g OGTT. The dependence of GA, in contrast to HbA1c, on PG does not differ in DM hemodialysis patients from that reported for subjects with normal renal function, suggesting GA as a better marker of glycemic control in DM hemodialysis patients.

Glycated Albumin Is a Better Glycemic Indicator than Glycated Hemoglobin Values in Hemodialysis Patients with Diabetes

The significance of glycated albumin (GA), compared with casual plasma glucose (PG) and glycated hemoglobin (HbA(1c)), was evaluated as an indicator of the glycemic control state in hemodialysis (HD) patients with diabetes. The mean PG, GA, and HbA(1c) levels were 164.5 +/- 55.7 mg/dl, 22.5 +/- 7.5%, and 5.85 +/- 1.26%, respectively, in HD patients with diabetes (n = 538), which were increased by 51.5, 31.6, and 17.7%, respectively, compared with HD patients without diabetes (n = 828). HbA(1c) levels were significantly lower than simultaneous PG and GA values in those patients in comparison with the relationship among the three parameters in patients who had diabetes without renal dysfunction (n = 365), as reflected by the significantly more shallow slope of regression line between HbA(1c) and PG or GA. A significant negative correlation was found between GA and serum albumin (r = -0.131, P = 0.002) in HD patients with diabetes, whereas HbA(1c) correlated positively and negatively with hemoglobin (r = 0.090, P = 0.036) and weekly dose of erythropoietin injection (r = -0.159, P < 0.001), respectively. Although PG and GA did not differ significantly between HD patients with diabetes and with and without erythropoietin injection, HbA(1c) levels were significantly higher in patients without erythropoietin. Categorization of glycemic control into arbitrary quartile by HbA(1c) level led to better glycemic control in a significantly higher proportions of HD patients with diabetes than those assessed by GA. Multiple regression analysis demonstrated that the weekly dose of erythropoietin, in addition to PG, emerged as an independent factor associated with HbA(1c) in HD patients with diabetes, although PG but not albumin was an independent factor associated with GA. In summary, it is suggested that GA provides a significantly better measure to estimate glycemic control in HD patients with diabetes and that the assessment of glycemic control by HbA(1c) in these patients might lead to underestimation likely as a result of the increasing proportion of young erythrocyte by the use of erythropoietin.

Adequacy of Glycemic Control in Hemodialysis Patients With Diabetes

We sought to measure the prevalence of inadequate glycemic control in prevalent hemodialysis patients with diabetes and to examine independent predictors of inadequate glycemic control in these patients. This is a cross-sectional study of prevalent hemodialysis patients with diabetes in southeastern Ontario (n = 100). Data were collected by chart review and interview. The outcome variable was inadequate glycemic control defined as HbA1c (A1C) >0.07. Other measured variables were diabetes type, diabetes duration, diabetes physician, blood glucose monitoring, diabetes medications, BMI, time on dialysis, and other demographic, clinical, and laboratory variables. Fifty-four patients had A1C >0.07. In bivariate analysis, these patients had a longer diabetes duration (23.6 vs. 14.7 years, P < 0.001), higher proportion with insulin use (81.5 vs. 58.7%, P = 0.012), higher proportion with microvascular complications (66.7 vs. 43.5%, P = 0.017), and lower erythropoietin (EPO) dose (7.0 vs. 11.9 x 10(3) units/week, P < 0.01) than patients with adequate glycemic control. There was no difference between the two groups in terms of macrovascular complications (59.3 vs. 65.2%, P = 0.54). In multiple logistic regression controlling for age and diabetes type, the diabetes duration (odds ratio 1.09 [95% CI 1.04-1.15], P < 0.001), EPO dose (0.90 [0.85-0.97], P < 0.01), and blood glucose monitoring (10.06 [1.03-98.74], P = 0.05) were the only significant independent predictors of A1C >0.07. A high proportion of hemodialysis patients with diabetes had inadequate glycemic control, particularly those with longstanding disease. Patients with inadequate glycemic control had a significantly higher burden of microvascular complications.