Poor glycemic control in diabetes and the risk of incident chronic kidney disease even in the absence of albuminuria and retinopathy: Atherosclerosis Risk in Communities (ARIC) Study.
BACKGROUND
Diabetic nephropathy is the leading cause of kidney failure in the United States. The extent to which an elevated glycated hemoglobin (HbA(1c)) concentration is associated with increased risk of chronic kidney disease (CKD) in the absence of albuminuria and retinopathy, the hallmarks of diabetic nephropathy, is uncertain.


METHODS
Glycated hemoglobin concentration was measured in 1871 adults with diabetes mellitus followed up for 11 years in the Atherosclerosis Risk in Communities (ARIC) Study. Incident CKD was defined as an estimated glomerular filtration rate less than 60 mL/min/1.73 m(2) after 6 years of follow-up or a kidney disease-related hospitalization. We categorized HbA(1c) concentrations into 4 clinically relevant categories. Albuminuria and retinopathy were measured midway through follow-up.


RESULTS
Higher HbA(1c) concentrations were strongly associated with risk of CKD in models adjusted for demographic data, baseline glomerular filtration rate, and cardiovascular risk factors. Compared with HbA(1c) concentrations less than 6%, HbA(1c) concentrations of 6% to 7%, 7% to 8%, and greater than 8% were associated with adjusted relative hazard ratios (95% confidence intervals) of 1.4 (0.97-1.91), 2.5 (1.70-3.66), and 3.7 (2.76-4.90), respectively. Risk of CKD was higher in individuals with albuminuria and retinopathy, and the association between HbA(1c) concentration and incident CKD was observed even in participants without either abnormality: adjusted relative hazards, 1.46 (95% confidence intervals, 0.80-2.65), 1.17 (0.43-3.19), and 3.51 (1.67-7.40), respectively; P(trend) = .004.


CONCLUSIONS
We observed a positive association between HbA(1c) concentration and incident CKD that was strong, graded, independent of traditional risk factors, and present even in the absence of albuminuria and retinopathy. Hyperglycemia is an important indicator of risk of both diabetic nephropathy with albuminuria or retinopathy and of less specific forms of CKD.
Bash
Lori D
LD
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. lbash@jhsph.edu
Selvin
Elizabeth
E
Steffes
Michael
M
Coresh
Josef
J
Astor
Brad C
BC
D000419:Albuminuria; D002908:Chronic Disease; D003928:Diabetic Nephropathies / Q000097:blood*; D003930:Diabetic Retinopathy; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis*; D006801:Humans; D007674:Kidney Diseases / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors
D006442:Glycated Hemoglobin