High Glycemic Levels Have ‘Legacy Effect’ Even After Diabetic Patients Start Dialysis

By Annette M. Boyle

LONG BEACH, CA—In recent years, the American Diabetes Association and other organizations have recognized that very low glycemic rates do not provide a cardiovascular benefit and might instead increase mortality risk in the majority of patients. The studies that identified those counterintuitive results did not include diabetic patients with chronic kidney disease, however.

The new research is related to dialysis patients. In this photo, Air Force Mary Bolinger has dialysis equipment in her recreational vehicle as part of a program at the VA Pittsburgh Health System. VA photo

Diabetes not only increases the risk of end stage renal disease (ESRD), it increases mortality rates among those who develop kidney failure. Would historically high glycemic rates continue to affect patients after they transition to dialysis?

Connie Rhee, MD, MSc

Researchers led by Connie Rhee, MD, MSc, and Kam Kalantar-Zadeh, MD, MPH, PhD, both of the Tibpor Rubin VA Long Beach Healthcare System and the University of California-Irvine, recently found that the effects of high glycemic levels persisted much longer than expected. Their study was published in the August issue of Diabetes Care.1

“The avoidance of high glycemic levels in patients with diabetic kidney disease may have lasting benefit in reducing morbidity and mortality even after developing irreversible end-organ damage which required transitioning to dialysis therapy, as if there were a potential ‘metabolic memory’ or ‘legacy effect,’” Rhee told U.S. Medicine.

Understanding the impact of glycemic levels on diabetic patients with chronic kidney disease (CKD) could significantly affect VA care. Between 12,000 and 13,000 veterans transition to maintenance dialysis therapy each year. About 5,000 of those veterans develop end-stage renal disease as a complication of diabetes, she noted.

The study found that diabetic patients with chronic kidney disease who had mean HbA1c levels above 8% in the year before they transitioned to dialysis—the prelude period—had higher mortality rates in the year after they developed ESRD than those who had HbA1c levels between 6% and 7%. Patients with mean A1c between 8% and 9% in the prelude period had a 19% increase in the risk of death in the first year on dialysis, while those with A1c above 9% saw a 50% increase in mortality risk. Mean random glucose levels of 200 mg/dL or greater increased post-ESRD adjusted mortality risk 34% compared to the reference range of 100 mg/dL to 125 mg/dL.

Kam Kalantar-Zadeh, MD, MPH, PhD

The primary takeaway is “that a better control of diabetes in these veterans with advanced chronic kidney disease had far reaching impact even after they transitioned to dialysis,” Kalantar-Zadeh told U.S. Medicine.

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