title: Glycated hemoglobin and risk of death in diabetic patients treated with hemodialysis: a meta-analysis.
abstract: BACKGROUND
  Studies investigating the association between glycated hemoglobin (HbA1c) level and mortality risk in diabetic patients receiving hemodialysis have shown conflicting results.
  
  
  METHODS
  We conducted a systematic review and meta-analysis using MEDLINE, EMBASE, Web of Science, and the Cochrane Library.
  
  
  METHODS
  Diabetic patients on maintenance hemodialysis therapy.
  
  
  METHODS
  Observational studies or randomized controlled trials investigating the association between HbA1c values and mortality risk. Study authors were asked to provide anonymized individual patient data or reanalyze results according to a standard template.
  
  
  METHODS
  Single measurement or mean HbA1c values. Mean HbA1c values were calculated using all individual-patient HbA1c values during the follow-up period of contributing studies.
  
  
  RESULTS
  HR for mortality risk.
  
  
  RESULTS
  10 studies (83,684 participants) were included: 9 observational studies and one secondary analysis of a randomized trial. After adjustment for confounders, patients with baseline HbA1c levels ≥ 8.5% (≥ 69 mmol/mol) had increased mortality (7 studies; HR, 1.14; 95% CI, 1.09-1.19) compared with patients with HbA1c levels of 6.5%-7.4% (48-57mmol/mol). Likewise, patients with a mean HbA1c value ≥ 8.5% also had a higher adjusted risk of mortality (6 studies; HR,1.29; 95% CI, 1.23-1.35). There was a small but nonsignificant increase in mortality associated with mean HbA1c levels ≤ 5.4% (≤ 36 mmol/mol; 6 studies; HR, 1.09; 95% CI, 0.89-1.34). Sensitivity analyses in incident (≤ 90 days of hemodialysis) and prevalent patients (>90 days of hemodialysis) showed a similar pattern. In incident patients, mean HbA1c levels ≤ 5.4% also were associated with increased mortality risk (4 studies; HR, 1.29; 95% CI, 1.23-1.35).
  
  
  CONCLUSIONS
  Observational study data and inability to adjust for diabetes type in all studies.
  
  
  CONCLUSIONS
  Despite concerns about the utility of HbA1c measurement in hemodialysis patients, high levels (≥ 8.5%) are associated with increased mortality risk. Very low HbA1c levels (≤ 5.4%) also may be associated with increased mortality risk.
authors: Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland; Regional Nephrology Unit, Belfast City Hospital, Belfast, Northern Ireland. Electronic address: chill05@qub.ac.uk.
authors: Christopher J
authors: CJ
authors: Hill
authors: Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland; Regional Nephrology Unit, Belfast City Hospital, Belfast, Northern Ireland.
authors: Alexander P
authors: AP
authors: Maxwell
authors: Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland.
authors: Christopher R
authors: CR
authors: Cardwell
authors: Wake Forest School of Medicine, Winston-Salem, NC.
authors: Barry I
authors: BI
authors: Freedman
authors: University of Alberta, Edmonton, Alberta, Canada.
authors: Marcello
authors: M
authors: Tonelli
authors: Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan.
authors: Masanori
authors: M
authors: Emoto
authors: Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan.
authors: Masaaki
authors: M
authors: Inaba
authors: Department of Endocrinology, Tenri Hospital, Nara, Japan.
authors: Yasuaki
authors: Y
authors: Hayashino
authors: Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan; Fukushima Medical University Center for Innovation in Clinical Research, Fukushima, Japan.
authors: Shunichi
authors: S
authors: Fukuhara
authors: Department of Nephrology, Tokyo Medical University, Tokyo, Japan.
authors: Tomonari
authors: T
authors: Okada
authors: Department of Medicine, Division of Nephrology, University Hospital, Würzburg, Germany.
authors: Christiane
authors: C
authors: Drechsler
authors: Department of Medicine, Division of Nephrology, University Hospital, Würzburg, Germany.
authors: Christoph
authors: C
authors: Wanner
authors: United Kingdom Renal Registry, Southmead Hospital, Bristol, United Kingdom.
authors: Anna
authors: A
authors: Casula
authors: Addenbrooke's Hospital, Cambridge, United Kingdom.
authors: Amanda I
authors: AI
authors: Adler
authors: Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Innsbruck Medical University, Innsbruck, Austria.
authors: Claudia
authors: C
authors: Lamina
authors: Division of Genetic Epidemiology, Department of Medical Genetics, Molecular and Clinical Pharmacology, Innsbruck Medical University, Innsbruck, Austria.
authors: Florian
authors: F
authors: Kronenberg
authors: Division of Nephrology and Hypertension, University of California, Irvine, CA.
authors: Elani
authors: E
authors: Streja
authors: Division of Nephrology and Hypertension, University of California, Irvine, CA.
authors: Kamyar
authors: K
authors: Kalantar-Zadeh
authors: Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland; Regional Nephrology Unit, Belfast City Hospital, Belfast, Northern Ireland; Department of Medicine, Division of Nephrology, University Hospital, Würzburg, Germany.
authors: Damian G
authors: DG
authors: Fogarty
mesh_terms: D003928:Diabetic Nephropathies / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D006442:Glycated Hemoglobin / Q000032:analysis*; D006801:Humans; D009026:Mortality; D064887:Observational Studies as Topic; D011237:Predictive Value of Tests; D016032:Randomized Controlled Trials as Topic; D006435:Renal Dialysis / Q000379:methods / Q000401:mortality / Q000706:statistics & numerical data; D018570:Risk Assessment; D016019:Survival Analysis
chemical_list: D006442:Glycated Hemoglobin
keywords: HbA1c; diabetes mellitus; hemodialysis; survival