Patients with diabetes mellitus (DM) and those who are on hemodialysis (HD) may be particularly vulnerable to infections, but there is a dearth of clinical data on the relationship between glycemic control and infections in patients with DM on HD. We used data from the U.S. Renal Data System and the electronic health records from a large U.S. dialysis provider (DaVita, Inc.) merged at the patient level. We included adult Medicare-insured patients with DM aged ≥18 years who initiated in-center maintenance HD treatment from 20to 2011 and survived >90 days. The exposure was time-averaged HbA1c and quarterly mean HbA1c values were categorized as follows: <5.5%, 5.5-<6.5% (reference), 6.5-<7.5%, 7.5-<8.5%, and ≥8.5%. We used Medicare claims to ascertain infection-related hospitalizations and the ESRD Death Notification (CMS-2746) to identify death from infections. The primary outcome was the composite of infection-related death or hospitalization with all-cause death and transplant treated as competing risks using the Kaplan-Meier multiple imputation (MI) method. Missing data were handled through MI. We used extended-Cox models to estimate multivariable-adjusted hazard ratios (HR) and 95% CI for the associations between time-averaged HbA1c and the outcome, adjusting for baseline demographics and quarterly updated comorbidities from claims, central venous catheter use, and time-averaged vital signs and laboratory results. Among 33,753 eligible patients, 9415 infection-related hospitalizations occurred and 6deaths were linked to infection. Compared with patients with HbA1c 5.5-<6.5%, the adjusted HRs for infection-related death or hospitalization were 1.03 (CI, 0.96, 1.10), 1.03 (CI, 0.97, 1.09), 1.02 (0.95, 1.09), and 1.02 (CI, 0.95, 1.09) for patients with HbA1c <5.5%, 6.5-<7.5%, 7.5-<8.5%, and ≥8.5%, respectively (P-trend=0.97).
In summary, time-averaged HbA1c was not associated with the risk of a composite outcome of infection-related mortality or hospitalization.
J.J. Rhee: None. Y. Zheng: None. M. Montez-Rath: None. W. Winkelmayer: Advisory Panel; Self; Akebia Therapeutics, Amgen Inc., Bayer AG, FibroGen, Inc., AMAG Pharmaceuticals, Vifor Fresenius Medical Care Renal Phama, Relypsa Inc..