title: Epidemiology and outcomes of hypoglycemia in patients with advanced diabetic kidney disease on dialysis: A national cohort study.
abstract: BACKGROUND
  Patients with advanced diabetic kidney disease (DKD) behave differently to diabetic patients without kidney disease. We aimed to investigate the associations of hypoglycemia and outcomes after initiation of dialysis in patients with advanced DKD on dialysis.
  
  
  METHODS
  Using National Health Insurance Research Database, 20,845 advanced DKD patients beginning long-term dialysis between 2002 and 2006 were enrolled. We investigated the incidence of severe hypoglycemia episodes before initiation of dialysis. Patients were followed from date of first dialysis to death, end of dialysis, or 2008. Main outcomes measured were all-cause mortality, myocardial infarction (MI), and subsequent severe hypoglycemic episodes after dialysis.
  
  
  RESULTS
  19.18% patients had at least one hypoglycemia episode during 1-year period before initiation of dialysis. Advanced DKD patients with higher adapted Diabetes Complications Severity Index (aDCSI) scores were associated with more frequent hypoglycemia (P for trend < 0.001). Mortality and subsequent severe hypoglycemia after dialysis both increased with number of hypoglycemic episodes. Compared to those who had no hypoglycemic episodes, those who had one had a 15% higher risk of death and a 2.3-fold higher risk of subsequent severe hypoglycemia. Those with two or more episodes had a 19% higher risk of death and a 3.9-fold higher risk of subsequent severe hypoglycemia. However, previous severe hypoglycemia was not correlated with risk of MI after dialysis.
  
  
  CONCLUSIONS
  The rate of severe hypoglycemia was high in advanced DKD patients. Patients with higher aDCSI scores tended to have more hypoglycemic episodes. Hypoglycemic episodes were associated with subsequent hypoglycemia and mortality after initiation of dialysis. We studied the associations and further study is needed to establish cause. In addition, more attention is needed for hypoglycemia prevention in advanced DKD patients, especially for those at risk patients.
authors.affiliation: Department of Nephrology, Chi-Mei Medical Center, Tainan, Taiwan.
authors.forename: Yeh-Wen
authors.initials: YW
authors.lastname: Chu
authors.affiliation: Department of Nephrology, An Nan Hospital, China Medical University, Tainan, Taiwan.
authors.forename: Hsuan-Ming
authors.initials: HM
authors.lastname: Lin
authors.affiliation: Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan.
authors.forename: Jhi-Joung
authors.initials: JJ
authors.lastname: Wang
authors.affiliation: Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan.
authors.forename: Shih-Feng
authors.initials: SF
authors.lastname: Weng
authors.affiliation: Department of Nephrology, Taipei Veterans General Hospital, Taipei, Taiwan.
authors.forename: Chih-Ching
authors.initials: CC
authors.lastname: Lin
authors.affiliation: Department of Nephrology, Chi-Mei Medical Center, Tainan, Taiwan.
authors.forename: Chih-Chiang
authors.initials: CC
authors.lastname: Chien
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000208:ethnology; D015331:Cohort Studies; D015897:Comorbidity; D003928:Diabetic Nephropathies / Q000453:epidemiology* / Q000208:ethnology / Q000628:therapy; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology / Q000208:ethnology; D006801:Humans; D007003:Hypoglycemia / Q000453:epidemiology* / Q000208:ethnology; D053208:Kaplan-Meier Estimate; D007676:Kidney Failure, Chronic / Q000453:epidemiology* / Q000208:ethnology / Q000628:therapy; D008107:Liver Diseases / Q000453:epidemiology / Q000208:ethnology; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000453:epidemiology / Q000208:ethnology; D017063:Outcome Assessment, Health Care / Q000379:methods / Q000706:statistics & numerical data*; D016016:Proportional Hazards Models; D006435:Renal Dialysis; D013624:Taiwan / Q000453:epidemiology; D055815:Young Adult