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Yu J, Hua H, Yin M. U-shaped association between HbA1c and all-cause mortality in CVD patients with diabetes. Sci Rep 2024; 14:28386. [PMID: 39551840 PMCID: PMC11570596 DOI: 10.1038/s41598-024-80116-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 11/14/2024] [Indexed: 11/19/2024] Open
Abstract
In this analysis, the association of baseline glycated hemoglobin (HbA1c) levels with all-cause mortality in cardiovascular disease (CVD) patients with diabetes was investigated using data from NHANES 1999-2014. Under examination were 845 CVD patients who had diabetes and were followed for a median follow-up of 7.3 years, and an all-cause mortality rate of 22.60% was observed. To examine the association between HbA1c and mortality, multivariable Cox proportional hazard models using spline models determined the non-linear association. HbA1c as a continuous variable was not associated with mortality. However, a significant association was observed when HbA1c was classified according to quartiles. Particularly, after adjustment for potential confounders, in comparison to participants with HbA1c levels below 6.2%, patients with HbA1c levels of 6.2-6.8% and 6.9-7.6% had lower risks of all-cause mortality (hazard ratio: 0.49, 95% CI: 0.30-0.80 and hazard ratio: 0.64, 95% CI: 0.39-1.03, respectively). Using restricted cubic splines, further testing confirmed the lack of a linear association and instead suggested a U-shaped relationship between HbA1c and mortality, with an optimal HbA1c target value of 6.9%. A 1-unit increase in HbA1c with HbA1c less than or equal to 6.9% was predictive of a 55% reduction in all-cause mortality compared to HbA1c levels above 6.9%, which exhibited an elevation in risk. All told, these data suggest that the relationship between HbA1c and all-cause mortality in CVD patients with diabetes is non-linear and U-shaped, and therefore may suggest that individualization of glycemic control may be beneficial for this patient population.
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Affiliation(s)
- Jianhong Yu
- Department of Clinical Laboratory, Zigong First People's Hospital, Zigong, China
| | - Haodong Hua
- Department of Clinical Laboratory, Zigong First People's Hospital, Zigong, China
| | - Minggang Yin
- Department of Clinical Laboratory, Zigong First People's Hospital, Zigong, China.
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Agarwal H, Kapoor G, Sethi P, Ghosh T, Pandey S, Sehgal T, Meena VP, Ranjan P, Vikram NK. Anemia and its association with glycemia and transaminitis in patients with type 2 diabetes mellitus: A cross-sectional pilot study. J Family Med Prim Care 2024; 13:2972-2978. [PMID: 39228604 PMCID: PMC11368274 DOI: 10.4103/jfmpc.jfmpc_1601_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/14/2024] [Accepted: 01/24/2024] [Indexed: 09/05/2024] Open
Abstract
Background and Aims Anemia impairs glucose homeostasis, affects glycemic control, and predisposes to complications in diabetics. It correlates with oxidative stress and increases the risk of developing microvascular and macrovascular complications. However, it is an underrecognized comorbidity in diabetics. This study was conducted to assess the prevalence of anemia in diabetic patients and compare the metabolic profiles of anemic and non-anemic diabetics. Methods This is a cross-sectional study, conducted among type 2 diabetes (T2DM) patients, at the outpatient clinic. Patients with chronic kidney disease (CKD), known hematological disorders, and chronic inflammatory disorders were excluded. Results Of the 97 patients, 37 (38.14%) were found to be anemic (hemoglobin (Hb): male <13 g/dl, female <12 g/dl). The mean values of fasting blood sugar (FBS) in low and normal mean corpuscular volume (MCV) patients were 265.9 ± 43.7 mg/dl and 157.2 ± 7.2 mg/dl, respectively (P = 0.0026), and those of postprandial blood sugar (PPBS) were 370.3 ± 58.4 mg/dl and 226.3 ± 10.1 mg/dl, respectively (P = 0.0015). It was found that 6 (22.2%) of 27 patients with raised alanine aminotransferase (ALT) had anemia against 27 (45.8%) of 59 patients with normal ALT (P = 0.03). The mean Hb levels in patients with raised and normal ALT were 13.31 ± 2.3 gm% and 12.2 ± 2.0 gm% (P = 0.03), respectively. Conclusions Blood sugar may have a direct relationship with MCV in T2DM patients. Hb tends to relate to hepatic enzymes likely due to altered dietary patterns in anemics. Further larger studies on the effect of iron supplementation and dietary habits on glycemic control and hepatic steatosis are warranted.
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Affiliation(s)
- Harsh Agarwal
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Gautam Kapoor
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prayas Sethi
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Tamoghna Ghosh
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shivam Pandey
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Tushar Sehgal
- Department of Lab Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ved P. Meena
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Piyush Ranjan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naval K. Vikram
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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Liang Y, Luo S, Bell S, Mo JMY, He B, Zhou Y, Bai X, Au Yeung SL. Do iron homeostasis biomarkers mediate the associations of liability to type 2 diabetes and glycemic traits in liver steatosis and cirrhosis: a two-step Mendelian randomization study. BMC Med 2024; 22:270. [PMID: 38926684 PMCID: PMC11210020 DOI: 10.1186/s12916-024-03486-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 06/13/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Previous studies, including Mendelian randomization (MR), have demonstrated type 2 diabetes (T2D) and glycemic traits are associated with increased risk of metabolic dysfunction-associated steatotic liver disease (MASLD). However, few studies have explored the underlying pathway, such as the role of iron homeostasis. METHODS We used a two-step MR approach to investigate the associations of genetic liability to T2D, glycemic traits, iron biomarkers, and liver diseases. We analyzed summary statistics from various genome-wide association studies of T2D (n = 933,970), glycemic traits (n ≤ 209,605), iron biomarkers (n ≤ 246,139), MASLD (n ≤ 972,707), and related biomarkers (alanine aminotransferase (ALT) and proton density fat fraction (PDFF)). Our primary analysis was based on inverse-variance weighting, followed by several sensitivity analyses. We also conducted mediation analyses and explored the role of liver iron in post hoc analysis. RESULTS Genetic liability to T2D and elevated fasting insulin (FI) likely increased risk of liver steatosis (ORliability to T2D: 1.14 per doubling in the prevalence, 95% CI: 1.10, 1.19; ORFI: 3.31 per log pmol/l, 95% CI: 1.92, 5.72) and related biomarkers. Liability to T2D also likely increased the risk of developing liver cirrhosis. Genetically elevated ferritin, serum iron, and liver iron were associated with higher risk of liver steatosis (ORferritin: 1.25 per SD, 95% CI 1.07, 1.46; ORliver iron: 1.15 per SD, 95% CI: 1.05, 1.26) and liver cirrhosis (ORserum iron: 1.31, 95% CI: 1.06, 1.63; ORliver iron: 1.34, 95% CI: 1.07, 1.68). Ferritin partially mediated the association between FI and liver steatosis (proportion mediated: 7%, 95% CI: 2-12%). CONCLUSIONS Our study provides credible evidence on the causal role of T2D and elevated insulin in liver steatosis and cirrhosis risk and indicates ferritin may play a mediating role in this association.
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Affiliation(s)
- Ying Liang
- School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Shan Luo
- School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Steven Bell
- Precision Breast Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, UK
- Cancer Research UK Cambridge Institute, Li Ka Shing Centre, University of Cambridge, Cambridge, UK
| | - Jacky Man Yuen Mo
- School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Baoting He
- School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yangzhong Zhou
- Department of Rheumatology, Peking Union Medical College Hospital, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China
| | - Xiaoyin Bai
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Shiu Lun Au Yeung
- School of Public Health, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
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Zhang Z, Yang L, Cao H. Terminal trajectory of HbA 1c for 10 years supports the HbA 1c paradox: a longitudinal study using Health and Retirement Study data. Front Endocrinol (Lausanne) 2024; 15:1383516. [PMID: 38711985 PMCID: PMC11070457 DOI: 10.3389/fendo.2024.1383516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/02/2024] [Indexed: 05/08/2024] Open
Abstract
Objectives We aimed to assess the potential time-varying associations between HbA1c and mortality, as well as the terminal trajectory of HbA1c in the elderly to reveal the underlying mechanisms. Design The design is a longitudinal study using data from the Health and Retirement Study. Setting and participants Data were from the Health and Retirement Study. A total of 10,408 participants aged ≥50 years with available HbA1c measurements at baseline (2006/2008) were included. Methods Longitudinal HbA1c measured at 2010/2012 and 2014/2016 were collected. HbA1c values measured three times for their associations with all-cause mortality were assessed using Cox regression and restricted cubic splines. HbA1c terminal trajectories over 10 years before death were analyzed using linear mixed-effect models with a backward time scale. Results Women constitute 59.6% of the participants with a mean age of 69 years, with 3,070 decedents during the follow-up (8.9 years). The mortality rate during follow-up was 29.5%. Increased mortality risk became insignificant for the highest quartile of HbA1c compared to the third quartile (aHR 1.148, 1.302, and 1.069 for a follow-up of 8.9, 6.5, and 3.2 years, respectively) with a shorter follow-up, while it became higher for the lowest quartile of HbA1c (aHR 0.986, 1.068, and 1.439 for a follow-up of 8.9, 6.5, and 3.2 years, respectively). Accordingly, for both decedents with and without diabetes, an initial increase in HbA1c was followed by an accelerating terminal decline starting 5-6 years before death. Conclusions and implications The time-varying association between HbA1c and mortality mapped to the terminal trajectory in HbA1c. High and low HbA1c may have different clinical relationships with mortality. The HbA1c paradox may be partially explained by reverse causation, namely, early manifestation of death.
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Affiliation(s)
- Zeyi Zhang
- Department of Surgical Intensive Care Unit, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Longshan Yang
- Department of General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Heng Cao
- Department of Surgical Intensive Care Unit, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Longitudinal proteomics study of serum changes after allogeneic HSCT reveals potential markers of metabolic complications related to aGvHD. Sci Rep 2022; 12:14002. [PMID: 35977993 PMCID: PMC9385631 DOI: 10.1038/s41598-022-18221-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 08/08/2022] [Indexed: 01/19/2023] Open
Abstract
Even though hematopoietic stem cell transplantation (HSCT) allows successful treatment for many malignant and non-malignant disorders, its curative potential remains limited by severe side effects, including infections and other transplant-related complications such as graft-versus-host disease (GvHD). This study examined changes in serum proteome via high-performance two-dimensional gel electrophoresis (2-DE) during HSCT to search for diagnostic biomarkers for post-HSCT complications. Longitudinal proteomic analysis revealed proteins related to metabolic complications and hemolytic anemia. Retinol-binding protein 4 (RBP4), a reliable marker of insulin resistance, was identified, and is possibly associated with the onset mechanism of acute graft-versus-host disease (aGvHD) and/or skin GvHD. Although the cause of insulin resistance is not fully understood, it is thought to be associated with adipocytes inflammation induced by RBP4, iron overload and hemolytic anemia after HSCT, as observed in this study. The present study has demonstrated that insulin resistance and metabolic complications could be immediate complications after transplantation and are associated with aGvHD. The biomarkers revealed in this study are promising tools to be used for improving the early diagnosis of HSCT-associated complications, especially aGvHD, possibly even before clinical manifestations.
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Song BM, Lee JH, Woo HD, Cho MJ, Kim SS. Association between haemoglobin A1c and all-cause and cause-specific mortality in middle-aged and older Koreans: a prospective cohort study. Nutr Metab (Lond) 2022; 19:46. [PMID: 35836264 PMCID: PMC9284843 DOI: 10.1186/s12986-022-00682-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 06/30/2022] [Indexed: 11/21/2022] Open
Abstract
Background This study aimed to examine associations between haemoglobin A1c (HbA1c) levels over time and all-cause and cause-specific mortality in middle-aged and older Koreans. Methods Using 16 years of follow-up data from the Korean Genome and Epidemiology Study, we analysed 9294 individuals aged 40–69 years with no history of cardiovascular disease (CVD) or cancer. Participants were divided into a known diabetes group and five groups categorized by HbA1c levels (< 5.0%, 5.0–5.4%, 5.5–5.9%, 6.0–6.4%, and ≥ 6.5%). Hazard ratios (HRs) for all-cause and cause-specific mortality associated with HbA1c levels were calculated using a conventional and a time-dependent Cox proportional hazards model. Restricted cubic spline models were fitted to investigate the relationship between continuous HbA1c levels and mortality among people without known diabetes. Subgroup analyses were performed for age, sex, smoking, hypertension, liver diseases, and red blood cell counts. Results During a median follow-up period of 15.7 years, there were 944 deaths, including 185 deaths from CVD, 359 from cancer, and 125 from all external causes. Compared with participants with HbA1c levels of 5.5–5.9%, multivariate-adjusted HRs and 95% confidence intervals for all-cause death of participants with levels < 5.0%, 5.0–5.4%, 6.0–6.4%, and ≥ 6.5% and participants with known diabetes were 1.84 (1.35–2.51), 1.13 (0.95–1.34), 1.30 (1.04–1.62), 1.37 (0.97–1.93), and 2.03 (1.70–2.44), respectively. The risk of cancer mortality was significantly increased in HbA1c < 5.0% (HR, 2.21; 95% CI 1.42–3.44) and known diabetes (HR, 1.60; 95% CI 1.18–2.15). When we performed diverse subgroup analyses, low HbA1c levels at baseline were strongly associated with mortality in participants with liver diseases. Conclusions We found U-shaped associations between HbA1c levels at baseline and over time and all-cause mortality in middle-aged and older Koreans. Additionally, the risk of cancer mortality increased both in low and high HbA1c groups, but CVD mortality increased only in high HbA1c group. In particular, people with liver diseases and low HbA1c levels had a high risk of all-cause mortality. Therefore, more careful management of these groups is suggested to identify any deteriorating health conditions. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s12986-022-00682-4.
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Affiliation(s)
- Bo Mi Song
- Division of Population Health Research, Department of Precision Medicine, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Chungcheongbuk-do, South Korea
| | - Jung Hyun Lee
- Division of Population Health Research, Department of Precision Medicine, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Chungcheongbuk-do, South Korea
| | - Hae Dong Woo
- Division of Population Health Research, Department of Precision Medicine, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Chungcheongbuk-do, South Korea
| | - Mi Jin Cho
- Division of Population Health Research, Department of Precision Medicine, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Chungcheongbuk-do, South Korea
| | - Sung Soo Kim
- Department of Chronic Disease Convergence Research, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju, Chungcheongbuk-do, South Korea.
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Balintescu A, Lind M, Franko MA, Oldner A, Cronhjort M, Svensson AM, Eliasson B, Mårtensson J. Glycemic Control and Risk of Sepsis and Subsequent Mortality in Type 2 Diabetes. Diabetes Care 2022; 45:127-133. [PMID: 34716212 DOI: 10.2337/dc21-1050] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 10/02/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the nature of the relationship between HbA1c and sepsis among individuals with type 2 diabetes, and to assess the association between sepsis and all-cause mortality in such patients. RESEARCH DESIGN AND METHODS We included 502,871 individuals with type 2 diabetes recorded in the Swedish National Diabetes Register and used multivariable Cox regression and restricted cubic spline analyses to assess the association between time-updated HbA1c values and sepsis occurrence between 1 January 2005 and 31 December 2015. The association between sepsis and death was examined using multivariable Cox regression analysis. RESULTS Overall, 14,534 (2.9%) patients developed sepsis during the study period. On multivariable Cox regression analysis, compared with an HbA1c of 48-52 mmol/mol (6.5-6.9%), the adjusted hazard ratio for sepsis was 1.15 (95% CI 1.07-1.24) for HbA1c <43 mmol/mol (6.1%), 0.93 (0.87-0.99) for HbA1c 53-62 mmol/mol (7.0-7.8%), 1.05 (0.97-1.13) for HbA1c 63-72 mmol/mol (7.9-8.7%), 1.14 (1.04-1.25) for HbA1c 73-82 mmol/mol (8.8-9.7%), and 1.52 (1.37-1.68) for HbA1c >82 mmol/mol (9.7%). In the cubic spline model, a reduction of the adjusted risk was observed within the lower HbA1c range until 53 mmol/mol (7.0%), with a hazard ratio of 0.78 (0.73-0.82) per SD; it increased thereafter (P for nonlinearity <0.001). As compared with patients without sepsis, the adjusted hazard ratio for death among patients with sepsis was 4.16 (4.03-4.30). CONCLUSIONS In a nationwide cohort of individuals with type 2 diabetes, we found a U-shaped association between HbA1c and sepsis and a fourfold increased risk of death among those developing sepsis.
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Affiliation(s)
- Anca Balintescu
- 1Section of Anaesthesia and Intensive Care, Department of Clinical Science and Education, South General Hospital, Karolinska Institute, Stockholm, Sweden
| | - Marcus Lind
- 2Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.,3Department of Medicine, NU Hospital Group, Uddevalla, Sweden
| | - Mikael Andersson Franko
- 1Section of Anaesthesia and Intensive Care, Department of Clinical Science and Education, South General Hospital, Karolinska Institute, Stockholm, Sweden
| | - Anders Oldner
- 4Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,5Section of Anaesthesia and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Maria Cronhjort
- 1Section of Anaesthesia and Intensive Care, Department of Clinical Science and Education, South General Hospital, Karolinska Institute, Stockholm, Sweden
| | - Ann-Marie Svensson
- 2Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.,6Swedish National Diabetes Register, Västra Götalandsregionen, Gothenburg, Sweden
| | - Björn Eliasson
- 2Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Johan Mårtensson
- 4Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,5Section of Anaesthesia and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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Di Luzio R, Dusi R, Barbanti FA, Calogero P, Marchesini G, Bianchi G. Prognostic Value of Stress Hyperglycemia in Patients Admitted to Medical/Geriatric Departments for Acute Medical Illness. Diabetes Ther 2022; 13:145-159. [PMID: 34859364 PMCID: PMC8638797 DOI: 10.1007/s13300-021-01183-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/17/2021] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Hyperglycemia is common in patients admitted to Italian medical/geriatric units and is associated with a poorer outcome. We tested the significance of diabetes and stress-induced hyperglycemia in clinical outcome. MATERIALS AND METHODS Three hundred seventy-eight consecutive patients with hyperglycemia at entry (≥ 126 mg/dl) (206 without known diabetes) were included, with a wide range of underlying diseases requiring hospital admission and independent of the presence of diabetes. Relative hyperglycemia was calculated as admission glucose divided by average glucose, estimated based of glycosylated hemoglobin. Values ≥ 1.20 were considered indicative of stress hyperglycemia (SHR). The association of SHR with outcome variables (all-cause complications, infections, non-infectious events, deaths) was tested by logistic regression analysis, adjusted for sex, BMI, age-adjusted comorbidities (Charlson index) and known diabetes. RESULTS During hospital stay, one or more events were registered in 96 patients (25.4%); 44 patients died in hospital, and fatality rate was borderline higher in patients without diabetes (14.6% vs. 8.1% in diabetes; P = 0.052) and nearly three times higher in patients with stress hyperglycemia (15.0%) vs. those with SHR < 1.2 (P = 0.005). Stress hyperglycemia-more common in the absence of diabetes (71% vs. 58%)-and age were the only independent prognostic factors for death. At multivariable analysis, the risks of death (OR 4.31, 95% CI 1.25-14.81), of all complications (OR 5.90, 95% CI 2.22-15.71) and of newly developed systemic infections (OR 5.67, 95% CI 1.61-19.92) were associated with stress hyperglycemia in subjects without diabetes, as was the risk in non-insulin-treated cases (OR 4.02, 95% CI 1.16-13.92; OR 5.47, 95% CI 2.21-13.52; OR 5.15, 95% CI 1.70-15.62, respectively). CONCLUSION The study confirms the prognostic value of stress-related hyperglycemia in patients requiring hospital admission to a geriatric/medical unit for a variety of acute medical conditions, contributing to adverse outcomes not limited to events commonly associated with hyperglycemia (e.g., infections).
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Affiliation(s)
- Raffaella Di Luzio
- Unit of Internal Medicine and Diabetology, Local Health Unit, Modena, Italy
- IRCCS-Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Rachele Dusi
- IRCCS-Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Pietro Calogero
- IRCCS-Sant'Orsola-Malpighi Hospital, Bologna, Italy
- Department of Hospital and Community Medicine, Malpighi Hospital, Bologna, Italy
| | - Giulio Marchesini
- Department of Medical and Surgical Sciences, Alma Mater University, 9, Via Massarenti, 40138, Bologna, Italy
| | - Giampaolo Bianchi
- IRCCS-Sant'Orsola-Malpighi Hospital, Bologna, Italy.
- Department of Medical and Surgical Sciences, Alma Mater University, 9, Via Massarenti, 40138, Bologna, Italy.
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Inoue K, Nianogo R, Telesca D, Goto A, Khachadourian V, Tsugawa Y, Sugiyama T, Mayeda ER, Ritz B. Low HbA1c levels and all-cause or cardiovascular mortality among people without diabetes: the US National Health and Nutrition Examination Survey 1999-2015. Int J Epidemiol 2021; 50:1373-1383. [PMID: 33378417 DOI: 10.1093/ije/dyaa263] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE It is unclear whether relatively low glycated haemoglobin (HbA1c) levels are beneficial or harmful for the long-term health outcomes among people without diabetes. We aimed to investigate the association between low HbA1c levels and mortality among the US general population. METHODS This study includes a nationally representative sample of 39 453 US adults from the National Health and Nutrition Examination Surveys 1999-2014, linked to mortality data through 2015. We employed the parametric g-formula with pooled logistic regression models and the ensemble machine learning algorithms to estimate the time-varying risk of all-cause and cardiovascular mortality by HbA1c categories (low, 4.0 to <5.0%; mid-level, 5.0 to <5.7%; prediabetes, 5.7 to <6.5%; and diabetes, ≥6.5% or taking antidiabetic medication), adjusting for 72 potential confounders including demographic characteristics, lifestyle, biomarkers, comorbidities and medications. RESULTS Over a median follow-up of 7.5 years, 5118 (13%) all-cause deaths, and 1116 (3%) cardiovascular deaths were observed. Logistic regression models and machine learning algorithms showed nearly identical predictive performance of death and risk estimates. Compared with mid-level HbA1c, low HbA1c was associated with a 30% (95% CI, 16 to 48) and a 12% (95% CI, 3 to 22) increased risk of all-cause mortality at 5 years and 10 years of follow-up, respectively. We found no evidence that low HbA1c levels were associated with cardiovascular mortality risk. The diabetes group, but not the prediabetes group, also showed an increased risk of all-cause mortality. CONCLUSIONS Using the US national database and adjusting for an extensive set of potential confounders with flexible modelling, we found that adults with low HbA1c were at increased risk of all-cause mortality. Further evaluation and careful monitoring of low HbA1c levels need to be considered.
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Affiliation(s)
- Kosuke Inoue
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Roch Nianogo
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Donatello Telesca
- Department of Biostatistics, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Atsushi Goto
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Vahe Khachadourian
- Gerald & Patricia Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Takehiro Sugiyama
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Elizabeth Rose Mayeda
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Beate Ritz
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA, USA.,Department of Environmental Health Sciences, UCLA Fielding School of Public Health, Los Angeles, CA, USA.,Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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Evaluation of the prevalence of inappropriate hba1c examination requests at the General Hospital of Dokter Saiful Anwar Malang. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-021-00996-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Metabolic Dysfunction in Spinal Muscular Atrophy. Int J Mol Sci 2021; 22:ijms22115913. [PMID: 34072857 PMCID: PMC8198411 DOI: 10.3390/ijms22115913] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/25/2021] [Accepted: 05/29/2021] [Indexed: 12/11/2022] Open
Abstract
Spinal muscular atrophy (SMA) is an autosomal recessive genetic disorder leading to paralysis, muscle atrophy, and death. Significant advances in antisense oligonucleotide treatment and gene therapy have made it possible for SMA patients to benefit from improvements in many aspects of the once devastating natural history of the disease. How the depletion of survival motor neuron (SMN) protein, the product of the gene implicated in the disease, leads to the consequent pathogenic changes remains unresolved. Over the past few years, evidence toward a potential contribution of gastrointestinal, metabolic, and endocrine defects to disease phenotype has surfaced. These findings ranged from disrupted body composition, gastrointestinal tract, fatty acid, glucose, amino acid, and hormonal regulation. Together, these changes could have a meaningful clinical impact on disease traits. However, it is currently unclear whether these findings are secondary to widespread denervation or unique to the SMA phenotype. This review provides an in-depth account of metabolism-related research available to date, with a discussion of unique features compared to other motor neuron and related disorders.
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Rooney MR, Tang O, Pankow JS, Selvin E. Glycaemic markers and all-cause mortality in older adults with and without diabetes: the Atherosclerosis Risk in Communities (ARIC) study. Diabetologia 2021; 64:339-348. [PMID: 32990802 PMCID: PMC7855037 DOI: 10.1007/s00125-020-05285-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022]
Abstract
AIMS/HYPOTHESIS There is controversy regarding the performance of HbA1c in old age. We evaluated the prognostic value of HbA1c and other glycaemic markers (fructosamine, glycated albumin, fasting glucose) with mortality risk in older adults (66-90 years). METHODS This was a prospective analysis of 5636 participants (31% with diagnosed diabetes, mean age 76, 58% female, 21% black) in the Atherosclerosis Risk in Communities (ARIC) study, baseline 2011-2013. We used Cox regression to examine associations of glycaemic markers (modelled in categories) with mortality risk, stratified by diagnosed diabetes status. RESULTS During a median of 6 years of follow-up, 983 deaths occurred. Among older adults with diabetes, 30% had low HbA1c (<42 mmol/mol [<6.0%]) and 10% had high HbA1c (≥64 mmol/mol [≥8.0%]); low (HR 1.32 [95% CI 1.04, 1.68]) and high (HR 1.86 [95% CI 1.32, 2.62]) HbA1c were associated with mortality risk vs HbA1c 42-52 mmol/mol (6.0-6.9%) after demographic adjustment. Low fructosamine and glycated albumin were not associated with mortality risk. Both low and high fasting glucose were associated with mortality risk. After further adjustment for lifestyle and clinical risk factors, high HbA1c (HR 1.81 [95% CI 1.28, 2.56]), fructosamine (HR 1.96 [95% CI 1.43-2.69]), glycated albumin (HR 1.81 [95% CI 1.33-2.47]) and fasting glucose (HR 1.81 [95% CI 1.24, 2.66]) were associated with mortality risk. Low HbA1c and fasting glucose were no longer significantly associated with mortality risk. Among participants without diabetes, associations of glycaemic markers with mortality risk were less robust. CONCLUSIONS/INTERPRETATION Elevated HbA1c, fructosamine, glycated albumin and fasting glucose were associated with risk of mortality in older adults with diabetes. Low HbA1c and fasting glucose may be markers of poor prognosis but are possibly confounded by health status. Our findings support the clinical use of HbA1c in older adults with diabetes. Graphical abstract.
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Affiliation(s)
- Mary R Rooney
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
| | - Olive Tang
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - James S Pankow
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Elizabeth Selvin
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
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Yip TCF, Wong VWS, Chan HLY, Tse YK, Hui VWK, Liang LY, Lee HW, Lui GCY, Kong APS, Wong GLH. Thiazolidinediones reduce the risk of hepatocellular carcinoma and hepatic events in diabetic patients with chronic hepatitis B. J Viral Hepat 2020; 27:904-914. [PMID: 32340077 DOI: 10.1111/jvh.13307] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/27/2020] [Accepted: 04/05/2020] [Indexed: 12/22/2022]
Abstract
Thiazolidinediones (TZDs) improve glycaemic control and ameliorate liver steatosis, inflammation and fibrosis in patients with fatty liver disease. We aimed to study the impact of TZD and glycaemic control on the risk of hepatocellular carcinoma (HCC) and hepatic events in diabetic patients with chronic hepatitis B (CHB). We performed a retrospective cohort study on diabetic patients with CHB in 2000-2017 using a territory-wide electronic healthcare database in Hong Kong. Diabetes mellitus was identified by use of any antidiabetic medication, haemoglobin A1c (HbA1c ) ≥6.5%, fasting glucose ≥7 mmol/L in two measurements or ≥11.1 mmol/L in one measurement and/or diagnosis codes. Use of antidiabetic medications was modelled as time-dependent covariates. Of 28 999 diabetic patients with CHB, 3963 (13.7%) developed liver-related events (a composite endpoint of HCC and hepatic events) at a median (interquartile range) follow-up of 7.1 (3.7-11.8) years; 1153 patients received TZD during follow-up. After adjusted for important confounders, TZD use was associated with a reduced risk of liver-related events (adjusted hazard ratio [aHR] 0.46, 95% confidence interval [CI] 0.24-0.88; P = .019). Similar trends were observed in HCC (aHR 0.57) and hepatic events (aHR 0.35) separately. Compared to HbA1c of 6.5% at baseline, patients with HbA1c ≥7% had an increased risk of liver-related events; the risk further increased in 5795 (20.0%) patients with HbA1c ≥9% at baseline (aHR 1.14, 95% CI 1.04-1.26; P = .006). TZD use is associated with a lower risk of liver-related events in diabetic patients with CHB. Liver-related events are more common in patients with high HbA1c levels.
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Affiliation(s)
- Terry Cheuk-Fung Yip
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vincent Wai-Sun Wong
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Henry Lik-Yuen Chan
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yee-Kit Tse
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Vicki Wing-Ki Hui
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lilian Yan Liang
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Hye Won Lee
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Grace Chung-Yan Lui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Alice Pik-Shan Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Grace Lai-Hung Wong
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China
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Li FR, Zhang XR, Zhong WF, Li ZH, Gao X, Kraus VB, Lv YB, Zou MC, Chen GC, Chen PL, Zhang MY, Kur AKA, Shi XM, Wu XB, Mao C. Glycated Hemoglobin and All-Cause and Cause-Specific Mortality Among Adults With and Without Diabetes. J Clin Endocrinol Metab 2019; 104:3345-3354. [PMID: 30896760 PMCID: PMC7328059 DOI: 10.1210/jc.2018-02536] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/15/2019] [Indexed: 12/25/2022]
Abstract
CONTEXT The patterns of associations between glycated Hb (HbA1c) and mortality are still unclear. OBJECTIVE To explore the extent to which ranges of HbA1c levels are associated with the risk of mortality among participants with and without diabetes. DESIGN, SETTING, AND PATIENTS This was a nationwide, community-based prospective cohort study. Included were 15,869 participants (median age 64 years) of the Health and Retirement Study, with available HbA1c data and without a history of cancer. Cox proportional hazards regression models were used to estimate hazard ratios with 95% CIs for mortality. RESULTS A total of 2133 participants died during a median follow-up of 5.8 years. In participants with diabetes, those with an HbA1c level of 6.5% were at the lowest risk of all-cause mortality. When HbA1c level was <5.6% or >7.4%, the increased all-cause mortality risk became statistically significant as compared with an HbA1c level of 6.5%. As for participants without diabetes, those with an HbA1c level of 5.4% were at the lowest risk of all-cause mortality. When the HbA1c level was <5.0%, the increased all-cause mortality risk became statistically significant as compared with an HbA1c level of 5.4%. However, we did not observe a statistically significant elevated risk of all-cause mortality above an HbA1c level of 5.4%. CONCLUSIONS A U-shaped and reverse J-shaped association for all-cause mortality was found among participants with and without diabetes. The corresponding optimal ranges for overall survival are predicted to be 5.6% and 7.4% and 5.0% and 6.5%, respectively.
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Affiliation(s)
- Fu-Rong Li
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Xi-Ru Zhang
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Wen-Fang Zhong
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Zhi-Hao Li
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Xiang Gao
- Nutritional Epidemiology Laboratory, The Pennsylvania State University, Philadelphia, Pennsylvania
| | - Virginia Byers Kraus
- Duke Molecular Physiology Institute and Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Yue-Bin Lv
- National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Meng-Chen Zou
- Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Guo-Chong Chen
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Pei-Liang Chen
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Min-Yi Zhang
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Akech Kuol Akech Kur
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Xiao-Ming Shi
- National Institute of Environmental Health, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Xian-Bo Wu
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
- Correspondence and Reprint Requests: Chen Mao, PhD, or Xian-Bo Wu, PhD, Department of Epidemiology, School of Public Health, Southern Medical University, 510000 Guangzhou, Guangdong, China. E-mail: or
| | - Chen Mao
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
- Correspondence and Reprint Requests: Chen Mao, PhD, or Xian-Bo Wu, PhD, Department of Epidemiology, School of Public Health, Southern Medical University, 510000 Guangzhou, Guangdong, China. E-mail: or
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Deguise M, Baranello G, Mastella C, Beauvais A, Michaud J, Leone A, De Amicis R, Battezzati A, Dunham C, Selby K, Warman Chardon J, McMillan HJ, Huang Y, Courtney NL, Mole AJ, Kubinski S, Claus P, Murray LM, Bowerman M, Gillingwater TH, Bertoli S, Parson SH, Kothary R. Abnormal fatty acid metabolism is a core component of spinal muscular atrophy. Ann Clin Transl Neurol 2019; 6:1519-1532. [PMID: 31402618 PMCID: PMC6689695 DOI: 10.1002/acn3.50855] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Spinal muscular atrophy (SMA) is an inherited neuromuscular disorder leading to paralysis and subsequent death in young children. Initially considered a motor neuron disease, extra-neuronal involvement is increasingly recognized. The primary goal of this study was to investigate alterations in lipid metabolism in SMA patients and mouse models of the disease. METHODS We analyzed clinical data collected from a large cohort of pediatric SMA type I-III patients as well as SMA type I liver necropsy data. In parallel, we performed histology, lipid analysis, and transcript profiling in mouse models of SMA. RESULTS We identify an increased susceptibility to developing dyslipidemia in a cohort of 72 SMA patients and liver steatosis in pathological samples. Similarly, fatty acid metabolic abnormalities were present in all SMA mouse models studied. Specifically, Smn2B/- mice displayed elevated hepatic triglycerides and dyslipidemia, resembling non-alcoholic fatty liver disease (NAFLD). Interestingly, this phenotype appeared prior to denervation. INTERPRETATION This work highlights metabolic abnormalities as an important feature of SMA, suggesting implementation of nutritional and screening guidelines in patients, as such defects are likely to increase metabolic distress and cardiovascular risk. This study emphasizes the need for a systemic therapeutic approach to ensure maximal benefits for all SMA patients throughout their life.
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Affiliation(s)
- Marc‐Olivier Deguise
- Regenerative Medicine ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
- Department of Cellular and Molecular MedicineUniversity of OttawaOttawaOntarioCanada
- Centre for Neuromuscular DiseaseUniversity of OttawaOttawaOntarioCanadaK1H 8M5
| | - Giovanni Baranello
- UO Neurologia dello SviluppoFondazione IRCCS Istituto Neurologico Carlo BestaMilanItaly
- The Dubowitz Neuromuscular CentreNIHR BRC University College London Great Ormond Street Institute of Child Health & Great Ormond Street HospitalLondonUnited Kingdom
| | - Chiara Mastella
- SAPRE‐UONPIA, Fondazione IRCCS Cà' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Ariane Beauvais
- Regenerative Medicine ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Jean Michaud
- Department of Pathology and Laboratory Medicine, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada
| | - Alessandro Leone
- International Center for the Assessment of Nutritional Status (ICANS), Department of Food, Environmental and Nutritional Sciences (DeFENS)University of MilanMilanItaly
| | - Ramona De Amicis
- International Center for the Assessment of Nutritional Status (ICANS), Department of Food, Environmental and Nutritional Sciences (DeFENS)University of MilanMilanItaly
| | - Alberto Battezzati
- International Center for the Assessment of Nutritional Status (ICANS), Department of Food, Environmental and Nutritional Sciences (DeFENS)University of MilanMilanItaly
| | - Christopher Dunham
- Division of Anatomic PathologyChildren's and Women's Health Centre of B.CVancouverBritish ColumbiaCanada
| | - Kathryn Selby
- Division of Neurology, Department of PediatricsBC Children's HospitalVancouverBritish ColumbiaCanada
| | - Jodi Warman Chardon
- Department of Cellular and Molecular MedicineUniversity of OttawaOttawaOntarioCanada
- Centre for Neuromuscular DiseaseUniversity of OttawaOttawaOntarioCanadaK1H 8M5
- Neuroscience Program, Ottawa Hospital Research InstituteOttawaOntarioCanada
- Department of PediatricsChildren's Hospital of Eastern OntarioOttawaOntarioCanada
- Department of MedicineUniversity of OttawaOttawaOntarioCanada
| | - Hugh J. McMillan
- Children's Hospital of Eastern Ontario Research InstituteUniversity of OttawaOttawaOntarioCanada
| | - Yu‐Ting Huang
- Euan MacDonald Centre for Motor Neurone Disease ResearchUniversity of EdinburghEdinburghUnited Kingdom
- College of Medicine & Veterinary MedicineUniversity of EdinburghEdinburghUnited Kingdom
| | - Natalie L. Courtney
- Euan MacDonald Centre for Motor Neurone Disease ResearchUniversity of EdinburghEdinburghUnited Kingdom
- College of Medicine & Veterinary MedicineUniversity of EdinburghEdinburghUnited Kingdom
- Centre for Discovery Brain ScienceUniversity of EdinburghEdinburghUnited Kingdom
| | - Alannah J. Mole
- Euan MacDonald Centre for Motor Neurone Disease ResearchUniversity of EdinburghEdinburghUnited Kingdom
- College of Medicine & Veterinary MedicineUniversity of EdinburghEdinburghUnited Kingdom
- Centre for Discovery Brain ScienceUniversity of EdinburghEdinburghUnited Kingdom
| | - Sabrina Kubinski
- Institute of Neuroanatomy and Cell BiologyHannover Medical SchoolHannoverGermany
- Center of Systems NeuroscienceHannoverGermany
| | - Peter Claus
- Institute of Neuroanatomy and Cell BiologyHannover Medical SchoolHannoverGermany
- Center of Systems NeuroscienceHannoverGermany
| | - Lyndsay M. Murray
- Euan MacDonald Centre for Motor Neurone Disease ResearchUniversity of EdinburghEdinburghUnited Kingdom
- College of Medicine & Veterinary MedicineUniversity of EdinburghEdinburghUnited Kingdom
- Centre for Discovery Brain ScienceUniversity of EdinburghEdinburghUnited Kingdom
| | - Melissa Bowerman
- School of MedicineKeele UniversityStaffordshireUnited Kingdom
- Institute for Science and Technology in MedicineStoke‐on‐TrentUnited Kingdom
- Wolfson Centre for Inherited Neuromuscular DiseaseRJAH Orthopaedic HospitalOswestryUnited Kingdom
| | - Thomas H. Gillingwater
- Euan MacDonald Centre for Motor Neurone Disease ResearchUniversity of EdinburghEdinburghUnited Kingdom
- College of Medicine & Veterinary MedicineUniversity of EdinburghEdinburghUnited Kingdom
| | - Simona Bertoli
- International Center for the Assessment of Nutritional Status (ICANS), Department of Food, Environmental and Nutritional Sciences (DeFENS)University of MilanMilanItaly
| | - Simon H. Parson
- Euan MacDonald Centre for Motor Neurone Disease ResearchUniversity of EdinburghEdinburghUnited Kingdom
- Institute of Medical SciencesUniversity of AberdeenAberdeenUnited Kingdom
| | - Rashmi Kothary
- Regenerative Medicine ProgramOttawa Hospital Research InstituteOttawaOntarioCanada
- Department of Cellular and Molecular MedicineUniversity of OttawaOttawaOntarioCanada
- Centre for Neuromuscular DiseaseUniversity of OttawaOttawaOntarioCanadaK1H 8M5
- Department of MedicineUniversity of OttawaOttawaOntarioCanada
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Liao HW, Saver J, Yeh HC, Chen CHS, Wu YL, Lee M, Ovbiagele B. Low fasting glucose and future risks of major adverse outcomes in people without baseline diabetes or cardiovascular disease: a systematic review and meta-analysis. BMJ Open 2019; 9:e026010. [PMID: 31266835 PMCID: PMC6609056 DOI: 10.1136/bmjopen-2018-026010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To investigate the link between low fasting blood glucose levels and all-cause mortality and cardiovascular outcomes among people without baseline diabetes or cardiovascular disease. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed and Embase (1966-February 2019). SELECTION CRITERIA Prospective cohort studies were included for meta-analysis if they reported adjusted HRs with 95% CIs for associations between risk of all-cause mortality, stroke, major cardiovascular events, coronary heart disease and low fasting glucose levels (<4.6 mmol/L and/or 4.0 mmol/L, respectively) versus normal fasting glucose levels. DATA EXTRACTION AND STATISTICAL ANALYSIS Two independent reviewers extracted data from eligible studies. Heterogeneity was assessed by p value of χ2 tests and I2. We assessed four characteristics for each included study based on items developed by the US Preventive Task Force, as well as the modified checklist used in previous studies. RESULTS Eleven articles (consisting of 129 prospective cohort studies) with 2 674 882 participants without diabetes and cardiovascular disease at baseline were included in this meta-analysis. Pooled results from the random effects model showed increased risks of all-cause mortality (HR: 1.56; 95% CI 1.09 to 2.23), total stroke (HR: 1.08, 95% CI 1.03 to 1.13) and ischaemic stroke (HR: 1.06, 95% CI 1.01 to 1.10), and major cardiovascular events (HR: 1.05, 95% CI 1.03 to 1.07) among people with a fasting glucose <4.0 mmol/L, as compared with people with normal fasting glucose. The less stringent low fasting glucose level, <4.6 mmol/L, was not associated with increased risk of any endpoints. DISCUSSION AND CONCLUSIONS Among people without baseline diabetes or cardiovascular disease, a fasting blood glucose level of <4.0 mmol/L is associated with increased risk of all-cause mortality, major cardiovascular events and stroke.
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Affiliation(s)
- Hung-Wei Liao
- Department of Nephrology, Chinru Clinic, Taipei, Taiwan
| | - Jeffrey Saver
- Department of Neurology, University of California System, Los Angeles, California, USA
| | - Hsin-Chieh Yeh
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Yi-Ling Wu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan
| | - Meng Lee
- Department of Neurology, Chang Gung University, Kwei-Shan, Taoyuan, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California System, San Francisco, California, USA
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Nadelson J, Satapathy SK, Nair S. Glycated Hemoglobin Levels in Patients with Decompensated Cirrhosis. Int J Endocrinol 2016; 2016:8390210. [PMID: 27882051 PMCID: PMC5110874 DOI: 10.1155/2016/8390210] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/27/2016] [Accepted: 09/18/2016] [Indexed: 12/15/2022] Open
Abstract
Introduction. Aim of this study is to determine if HbA1c levels are a reliable predictor of glycemic control in patients with decompensated cirrhosis. Methods. 200 unique patients referred for liver transplantation at University of Tennessee/Methodist University Transplant Institute with a HbA1c result were included. Three glucose levels prior to the "measured" A1c (MA1c) were input into an HbA1c calculator from the American Diabetes Association website to determine the "calculated" A1c (CA1c). The differences between MA1c and CA1c levels were computed. Patients were divided into three groups: group A, difference of <0.5; group B, 0.51-1.5; and group C, >1.5. Results. 97 (49%) patients had hemoglobin A1c of less than 5%. Discordance between calculated and measured HbA1c of >0.5% was seen in 47% (n = 94). Higher level of discordance of greater than >1.5 was in 12% of patients (n = 24). Hemoglobin was an independent predictor for higher discordance (odds ratio 0.77 95%, CI 0.60-0.99, and p value 0.04). HbA1c was an independent predictor of occurrence of HCC (OR 2.69 955, CI 1.38-5.43, and p value 0.008). Conclusion. HbA1c is not a reliable predictor of glycemic control in patients with decompensated cirrhosis, especially in those with severe anemia.
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Affiliation(s)
- Jeffrey Nadelson
- Division of Gastroenterology and Hepatology, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Sanjaya K. Satapathy
- Methodist Transplant Institute, Division of Surgery, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Satheesh Nair
- Methodist Transplant Institute, Division of Surgery, University of Tennessee Health Sciences Center, Memphis, TN, USA
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18
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Wang P. What Clinical Laboratorians Should Do in Response to Extremely Low Hemoglobin A1c Results. Lab Med 2016; 48:89-92. [PMID: 27614470 DOI: 10.1093/labmed/lmw050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Extremely low hemoglobin A1c (HbA1c) results below reference range are rare, and the causes and clinical implications associated with low HbA1c results are not well understood among clinical laboratorians. A case of extremely low HbA1c results was reported, in which liver cirrhosis, subacute hemorrhage and recent transfusion all contributed to the low result. This case illustrates when HbA1c should not be used as a clinically relevant diabetes marker. However, low or extremely low HbA1c (<5.0% or <4.0%) may occur in apparently healthy individuals. When this occurs, it is an independent risk factor associated with liver diseases, hospitalization, and all-cause mortality. From the clinical laboratory perspective, the clinical cause of extremely low HbA1c should be determined, and suggestions of different test utilization or increased health surveillance should be given to care providers.
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Affiliation(s)
- Ping Wang
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston TX, and Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York City, NY .,Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston TX, and Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, New York City, NY
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19
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Goto A, Noda M, Sawada N, Kato M, Hidaka A, Mizoue T, Shimazu T, Yamaji T, Iwasaki M, Sasazuki S, Inoue M, Kadowaki T, Tsugane S. High hemoglobin A1c levels within the non-diabetic range are associated with the risk of all cancers. Int J Cancer 2015; 138:1741-53. [PMID: 26547128 PMCID: PMC4737277 DOI: 10.1002/ijc.29917] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 10/26/2015] [Indexed: 12/12/2022]
Abstract
Previous studies have reported associations between diabetes and cancer risk. However, specific association of hemoglobin A1c (HbA1c) levels with cancer risk remains inconclusive. We followed 29,629 individuals (11,336 men; 18,293 women) aged 46-80 years who participated in the Japan Public Health Center-based prospective study who had HbA1c measurements available and were cancer-free at baseline. Cancer incidence was assessed by systemic surveys. We estimated hazard ratios (HRs) for cancer risk with adjustment for age sex, geographic area, body mass index, smoking status, physical activity, alcohol, coffee, vegetable and total energy consumption, and history of cardiovascular disease. After a median follow-up of 8.5 years, 1,955 individuals had developed cancer. Higher HbA1c levels within both the non-diabetic and diabetic ranges in individuals without known diabetes were associated with overall cancer risk. Compared with individuals without known diabetes and HbA1c levels of 5.0-5.4%, the HRs for all cancers were 1.27 (95% confidence interval, 1.07-1.52); 1.01 (0.90-1.14); 1.28 (1.09-1.49); and 1.43 (1.14-1.80) for individuals without known diabetes and HbA1c levels <5.0%, 5.5-5.9%, 6.0-6.4%, and ≥6.5%, respectively, and 1.23 (1.02-1.47) for individuals with known diabetes. The lowest HbA1c group had the highest risk of liver cancer, and HbA1c levels were linearly associated with the risk of all cancers after excluding liver cancer (P for linear trend, 0.004). In conclusion, our findings corroborate the notion that glycemic control in individuals with high HbA1c levels may be important not only to prevent diabetes but also to prevent cancer.
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Affiliation(s)
- Atsushi Goto
- Department of Diabetes Research, Diabetes Research Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan.,Department of Public Health, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Mitsuhiko Noda
- Department of Diabetes Research, Diabetes Research Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan.,Department of Endocrinology and Diabetes, Saitama Medical University, 38 Moro-hongo, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Norie Sawada
- Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Masayuki Kato
- Department of Diabetes Research, Diabetes Research Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Akihisa Hidaka
- Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Tetsuya Mizoue
- Department of Epidemiology and Prevention, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-Ku, Tokyo, 162-8655, Japan
| | - Taichi Shimazu
- Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Taiki Yamaji
- Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Motoki Iwasaki
- Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Shizuka Sasazuki
- Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
| | - Manami Inoue
- Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan.,AXA Department of Health and Human Security, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
| | - Takashi Kadowaki
- Department of Diabetes and Metabolic Diseases, Graduate School of Medicine, the University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan
| | - Shoichiro Tsugane
- Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, 5-1-1 Tsukiji, Chuo-Ku, Tokyo, 104-0045, Japan
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Hb and dyslipidaemia as predicting markers of serum alanine aminotransferase elevation in Chinese adolescents. Public Health Nutr 2015; 19:1067-73. [PMID: 26328752 DOI: 10.1017/s1368980015002293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Fe is an essential element for erythropoiesis and Hb synthesis. High Hb levels affect the blood's viscosity and are associated with cardiovascular dysfunction. The aim of the present study was to examine relationships of Hb and cardiometabolic abnormalities with the risk of alanine aminotransferase (ALT) elevation in adolescents. DESIGN A population-based, cross-sectional study. SETTING National Nutrition and Health Survey in Taiwan (2010-2011, adolescents). SUBJECTS Healthy adolescents aged 13-18 years. RESULTS In total, 1941 adolescents (963 boys and 978 girls) were entered in the study. The mean age was 15·3 (sd 0·1) years (boys, 15·3 (sd 0·1) years; girls, 15·2 (sd 0·1) years). ALT tertile cut-off points for boys were 11 and 16 U/l, and for girls were 9 and 12 U/l. Girls without dyslipidaemia and presenting in the highest quartile (Q1) of Hb (>13·6 g/dl) were 1·89 and 3·76 times more likely to have raised serum ALT (9 and >12 U/l, respectively) than the reference (lowest quartile of Hb (Q1), 12 U/l) than the reference (Q1 of Hb, 15·4 g/dl), who were 7·40 times more likely to have elevated serum ALT of >16 U/l than the reference (Q1 of Hb, <14·1 g/dl). CONCLUSIONS Our findings suggest that an increased Hb level is a predictor of elevated serum ALT in adolescent girls with dyslipidaemia. Our study also highlights the importance of further research to establish cut-off points for Hb and its utility in diagnosing and preventing the onset of dyslipidaemia in adolescents.
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Lautt WW, Ming Z, Legare DJ, Chowdhury KK, Hatch GM, Wang HH. Fatty Liver and Fatty Heart—Where do They Stand in the AMIS Syndrome? Healthcare (Basel) 2015; 3:666-82. [PMID: 27417789 PMCID: PMC4939563 DOI: 10.3390/healthcare3030666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 07/14/2015] [Accepted: 07/31/2015] [Indexed: 11/16/2022] Open
Abstract
Meal-induced insulin sensitization (MIS) refers to the augmented glucose uptake response to insulin following a meal. Absence of MIS (AMIS) causes significant decrease in post-meal glucose disposal leading to postprandial hyperglycemia, hyperinsulinemia, hyperlipidemia, adiposity, increased free radical stress, and a cluster of progressive metabolic, vascular, and cardiac dysfunctions referred to as the AMIS syndrome. We tested the hypothesis that fat accumulation in the liver and heart is part of the AMIS syndrome. Questions examined in the study: (1) Is prediabetic fat accumulation in the heart and liver a component of the AMIS syndrome? (2) Is fatty liver a cause or consequence of peripheral insulin resistance? (3) Is early cardiac dysfunction in the AMIS syndrome attributable to fat accumulation in the heart? and (4) Can the synergistic antioxidant cocktail SAMEC (S-adenosylmethionine, vitamin E, and vitamin C), known to benefit MIS, affect cardiac and hepatic triglyceride levels? Four animal models of AMIS were used in aged male Sprague-Dawley rats (52 weeks ± sucrose ± SAMEC), compared with young controls (nine weeks). Fat accumulation in the heart was not significant and therefore cannot account for the early cardiac dysfunction. Hepatic triglycerides increased only in the most severe AMIS model but the small changes correlated with the much more rapidly developing peripheral adiposity. Systemic adiposity represents an early stage, whereas accumulation of cardiac and hepatic triglycerides represents a late stage of the prediabetic AMIS syndrome. Fat accumulation in the liver is a consequence, not a cause, of AMIS. SAMEC protected against the sucrose effects on whole body adiposity and hepatic lipid accumulation.
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Affiliation(s)
- W Wayne Lautt
- Department of Pharmacology and Therapeutics, College of Medicine, Faculty of Health Sciences, University of Manitoba, A224-753 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada.
| | - Zhi Ming
- Department of Pharmacology and Therapeutics, College of Medicine, Faculty of Health Sciences, University of Manitoba, A224-753 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada.
| | - Dallas J Legare
- Department of Pharmacology and Therapeutics, College of Medicine, Faculty of Health Sciences, University of Manitoba, A224-753 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada.
| | - Kawshik K Chowdhury
- Department of Pharmacology and Therapeutics, College of Medicine, Faculty of Health Sciences, University of Manitoba, A224-753 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada.
| | - Grant M Hatch
- Department of Pharmacology and Therapeutics, College of Medicine, Faculty of Health Sciences, University of Manitoba, A224-753 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada.
| | - Hui Helen Wang
- Department of Pharmacology and Therapeutics, College of Medicine, Faculty of Health Sciences, University of Manitoba, A224-753 McDermot Avenue, Winnipeg, MB R3E 0T6, Canada.
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22
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Goto A, Noda M, Matsushita Y, Goto M, Kato M, Isogawa A, Takahashi Y, Kurotani K, Oba S, Nanri A, Mizoue T, Yamagishi K, Yatsuya H, Saito I, Kokubo Y, Sawada N, Inoue M, Iso H, Kadowaki T, Tsugane S. Hemoglobin a1c levels and the risk of cardiovascular disease in people without known diabetes: a population-based cohort study in Japan. Medicine (Baltimore) 2015; 94:e785. [PMID: 25929925 PMCID: PMC4603057 DOI: 10.1097/md.0000000000000785] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
High hemoglobin A1c (HbA1c) levels are strongly associated with an increased risk of cardiovascular disease (CVD) in people with and without diabetes. However, information regarding the relationship between low HbA1c levels and the risk of CVD among people without known diabetes is limited. The aim of this large-scale, prospective, population-based cohort study was to clarify the association between HbA1c levels and CVD risk among people without known diabetes.We followed-up 10,980 men and 18,079 women (46-80 years old and free of CVD and cancer at baseline) in the Japan Public Health Center-based Prospective Study. Using Cox models, we estimated the hazard ratios for CVD risk with adjustments for age, sex, geographic areas, body mass index, smoking status, sports and physical exercise, alcohol intake, systolic blood pressure, non-high-density lipoprotein cholesterol, and high-density lipoprotein cholesterol.During the median follow-up of 9.4 years, 935 CVD events (770 strokes and 165 coronary heart diseases) occurred. We observed a nonlinear association between HbA1c levels and CVD risk in participants without known diabetes. Compared with HbA1c levels of 5.0 to 5.4% (31-36 mmol/mol), the hazard ratios for CVD in participants without known diabetes were 1.50 (95% confidence interval: 1.15-1.95), 1.01 (0.85-1.20), 1.04 (0.82-1.32), and 1.77 (1.32-2.38) for HbA1c levels of <5.0% (<31 mmol/mol), 5.5 to 5.9% (37-41 mmol/mol), 6.0 to 6.4% (42-47 mmol/mol), and ≥6.5% (≥48 mmol/mol), respectively (P value for nonlinear trend: <0.001). In addition, the hazard ratio for CVD was 1.81 (1.43-2.29) in patients with known diabetes compared with participants with HbA1c levels of 5.0 to 5.4% and without known diabetes. This nonlinear relation persisted after excluding people with kidney dysfunction, liver dysfunction, anemia, body mass index <18.5 kg/m, or early events within 3 years of follow-up (P value for nonlinear trend: <0.01 for all tests).In conclusion, both low and high levels of HbA1c were associated with a higher risk of CVD in a Japanese general population without known diabetes.
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Affiliation(s)
- Atsushi Goto
- From the Departments of Diabetes Research, Diabetes Research Center, National Center for Global Health and Medicine, Tokyo, Japan (AG, MN, MG, MK); Department of Public Health, Tokyo Women's Medical University, Tokyo, Japan (AG); Departments of Clinical Research (YM) and Epidemiology and Prevention (KK, AN, TM), National Center for Global Health and Medicine, Tokyo, Japan; Department of Internal Medicine, Mitsui Memorial Hospital, Tokyo, Japan (AI); Division of Diabetes and Metabolism, Iwate Medical University School of Medicine, Iwate, Japan (YT); Department of Health Promotion, National Institute of Public Health, Saitama, Japan (SO); Department of Public Health Medicine, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan (KY); Department of Public Health, Fujita Health University, Aichi, Japan (HY); Department of Basic Nursing and Health Science, Ehime University Graduate School of Medicine, Ehime, Japan (IS); Department of Preventive Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan (YK); Epidemiology and Prevention Group, Research Center for Cancer Prevention and Screening, National Cancer Center, Tokyo, Japan (NS, ST); AXA Department of Health and Human Security (MI) and Diabetes and Metabolic Diseases (TK), Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Public Health, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Osaka, Japan (HI)
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23
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Rebnord EW, Pedersen ER, Strand E, Svingen GFT, Meyer K, Schartum-Hansen H, Løland KH, Seifert R, Ueland PM, Nilsen DWT, Nordrehaug JE, Nygård O. Glycated hemoglobin and long-term prognosis in patients with suspected stable angina pectoris without diabetes mellitus: a prospective cohort study. Atherosclerosis 2015; 240:115-20. [PMID: 25770690 DOI: 10.1016/j.atherosclerosis.2015.02.053] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 01/23/2015] [Accepted: 02/23/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Associations of glycated hemoglobin A1c (HbA1c) levels to incident coronary and cardiovascular events among non-diabetic patients with coronary artery disease are unclear. We investigated relations of HbA1c to long-term prognosis in such patients. METHODS A prospective cohort of 2519 patients undergoing elective coronary angiography for suspected stable angina pectoris (SAP) was divided into pre-defined categories according to HbA1c (%) levels (<5.0, 5.0-5.6 (reference), 5.7-6.4), and followed for median 4.9 years. The primary end-point was major coronary events (including non-fatal and fatal acute myocardial infarctions, and sudden cardiac death). Secondary end-points were death from cardiovascular disease (CVD) and all-cause mortality. Hazard ratios (HRs) (95% confidence intervals [CIs]) were obtained by Cox regression. RESULTS Median age at inclusion was 62 years, 73% were males, median HbA1c was 5.6% and random plasma-glucose 5.4 mmol/L. After multivariate adjustment, HbA1c levels within the pre-diabetic range were not associated with risk of major coronary events, HR (95% CI): 1.13 (0.79-1.62); P=0.49, death from CVD or all-cause mortality HR (95% CI): 0.95 (0.55-1.66) and 1.04 (0.70-1.53), respectively; P≥0.85. Similarly, there was no significant association between HbA1c values within the lowest category and risk of study outcomes, (P≥0.18). CONCLUSION In non-diabetic patients with suspected SAP, there was no overall association between HbA1c levels and prognosis, questioning an independent role of glycemia in the pathogenesis of atherosclerotic complications in these patients.
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Affiliation(s)
- Eirik Wilberg Rebnord
- Department of Heart Disease, Haukeland University Hospital, 5021 Bergen, Norway; Department of Clinical Science, University of Bergen, Mailbox 7804, 5021 Bergen, Norway.
| | - Eva Ringdal Pedersen
- Department of Clinical Science, University of Bergen, Mailbox 7804, 5021 Bergen, Norway.
| | - Elin Strand
- Department of Clinical Science, University of Bergen, Mailbox 7804, 5021 Bergen, Norway.
| | | | - Klaus Meyer
- BEVITAL, Laboratoriebygget, 9th Floor, Jonas Lies veg 87, 5021 Bergen, Norway.
| | - Hall Schartum-Hansen
- Department of Heart Disease, Haukeland University Hospital, 5021 Bergen, Norway.
| | | | - Reinhard Seifert
- Department of Clinical Science, University of Bergen, Mailbox 7804, 5021 Bergen, Norway.
| | - Per Magne Ueland
- Department of Clinical Science, University of Bergen, Mailbox 7804, 5021 Bergen, Norway; Laboratory of Clinical Biochemistry, Haukeland University Hospital, 5021 Bergen, Norway.
| | - Dennis W T Nilsen
- Department of Clinical Science, University of Bergen, Mailbox 7804, 5021 Bergen, Norway; Division of Cardiology, Stavanger University Hospital, 4011 Stavanger, Norway.
| | - Jan Erik Nordrehaug
- Department of Clinical Science, University of Bergen, Mailbox 7804, 5021 Bergen, Norway; Division of Cardiology, Stavanger University Hospital, 4011 Stavanger, Norway.
| | - Ottar Nygård
- Department of Heart Disease, Haukeland University Hospital, 5021 Bergen, Norway; Department of Clinical Science, University of Bergen, Mailbox 7804, 5021 Bergen, Norway; K. G. Jebsen Center for Diabetes Research, Department of Clinical Science, University of Bergen, Mailbox 7804, 5021 Bergen, Norway.
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Paprott R, Schaffrath Rosario A, Busch MA, Du Y, Thiele S, Scheidt-Nave C, Heidemann C. Association between hemoglobin A1c and all-cause mortality: results of the mortality follow-up of the German National Health Interview and Examination Survey 1998. Diabetes Care 2015; 38:249-56. [PMID: 25414153 DOI: 10.2337/dc14-1787] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study examined the association of HbA1c-defined glycemic status and continuous HbA1c with all-cause mortality. RESEARCH DESIGN AND METHODS The study population comprised 6,299 participants (aged 18-79 years) of the German National Health Interview and Examination Survey 1998, who were followed up for mortality for an average of 11.6 years. Glycemic status was defined as known diabetes (self-reported diagnosis or intake of antidiabetic medication) and based on HbA1c levels according to American Diabetes Association diagnostic criteria as undiagnosed diabetes (≥6.5% [≥48 mmol/mol]), prediabetes with very high (6.0-6.4% [42-46 mmol/mol]) or high diabetes risk (5.7-5.9% [39-41 mmol/mol]), and normoglycemia (<5.7% [<39 mmol/mol]). Associations between glycemic status and mortality were examined by Cox regression adjusting for age, sex, education, lifestyle factors, anthropometric measures, and history of chronic diseases (reference: normoglycemia). Spline models were fitted to investigate associations between continuous HbA1c and mortality among participants without known diabetes. RESULTS Excess mortality risk was observed for participants with known diabetes (hazard ratio 1.41 [95% CI 1.08-1.84]) and undiagnosed diabetes (1.63 [1.23-2.17]) but not for those with high (1.02 [0.80-1.30]) or very high diabetes risk (0.87 [0.67-1.13]). Spline models revealed a U-shaped association, with lowest risk at HbA1c levels 5.4-5.6% (36-38 mmol/mol) and a significantly increased risk at ≤5.0% (≤31 mmol/mol) and ≥6.4% (≥46 mmol/mol). CONCLUSIONS Unlike known and undiagnosed diabetes, HbA1c levels in the prediabetic range were not associated with an increased mortality risk. The observed U-shaped relationship adds to existing evidence that not only high but also low HbA1c levels might be associated with all-cause mortality.
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Affiliation(s)
- Rebecca Paprott
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | | | - Markus A Busch
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Yong Du
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Silke Thiele
- Department of Food Economics and Consumption Studies, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Christa Scheidt-Nave
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
| | - Christin Heidemann
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany
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25
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Onat A, Dönmez I, Karadeniz Y, Cakır H, Kaya A. Type-2 diabetes and coronary heart disease: common physiopathology, viewed from autoimmunity. Expert Rev Cardiovasc Ther 2015; 12:667-79. [PMID: 24846677 DOI: 10.1586/14779072.2014.910114] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Two highly prevalent diseases, Type-2 diabetes mellitus and coronary heart disease (CHD), share risk factors. Excess levels of LDL-cholesterol have been overemphasized to uniformly encompass the development of CHD, and the origin of insulin resistance underlying Type-2 diabetes has not been fully elucidated. Autoimmune response has been recognized to be responsible only of a small minority of diabetes. The increasing trend in the worldwide prevalence of diabetes and the risk factors for both diseases are reviewed, the independent mediation for CHD of (central) adiposity in both diseases and the 'hypertriglyceridemic waist' phenotype are outlined. Evidence is described that serum lipoprotein (Lp)(a) concentrations, not only in excess, but also in apparently 'reduced' levels, as a result of autoimmune response, underlie both disorders and are closely related to insulin resistance.
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Affiliation(s)
- Altan Onat
- Department of Cardiology, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey
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26
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Li CI, Chen HJ, Lai HC, Liu CS, Lin WY, Li TC, Lin CC. Hyperglycemia and chronic liver diseases on risk of hepatocellular carcinoma in Chinese patients with type 2 diabetes--National cohort of Taiwan Diabetes Study. Int J Cancer 2014; 136:2668-79. [PMID: 25387451 DOI: 10.1002/ijc.29321] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 10/29/2014] [Indexed: 12/22/2022]
Abstract
This study examined whether glycated hemoglobin A1C (HbA1C) and chronic liver diseases are associated with hepatocellular carcinoma (HCC) risk in Type 2 diabetic patients. A retrospective cohort study consisting of 51,705 patients with Type 2 diabetes aged 30 and over enrolled in the National Diabetes Care Management Program before 2004 was used in Cox proportional hazards models. HbA1C was independently associated with HCC incidence, and multivariate-adjusted hazard ratio (HR) of HCC was 1.20 (95% confidence interval, CI: 1.02-1.41) for patients with a level of HbA1c ≥ 9% compared with patients with a level of HbA1c <7% after multivariate adjustment. We observed a significant linear trend in HCC incidence with increasing HbA1c (p for trend = 0.02, HR = 1.07, 95% CI = 1.01-1.12 for every 1% increment in HbA1c). We observed significant HRs of HCC for patients with a level of HbA1c ≥ 9% with alcoholic liver damage, liver cirrhosis, HBV, HCV and any one of chronic liver diseases compared with patients with a level of HbA1c <9% and no counterpart comorbidity in the entire sample (HR = 8.63, 95% CI = 1.41-52.68; HR = 5.02, 95% CI = 3.10-8.12; HR = 2.53, 95% CI = 1.10-5.85; HR = 1.79, 95% CI = 1.01-3.17; and HR = 3.59, 95% CI = 2.56-5.02, respectively). Our results suggest significant joint associations of HbA1c ≥ 9% and chronic liver diseases. Lifestyle or treatment interventions such as maintaining a satisfactory glycemic control and chronic liver diseases may reduce the burden of HCC.
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Affiliation(s)
- Chia-Ing Li
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
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27
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Calanna S, Scicali R, Di Pino A, Knop FK, Piro S, Rabuazzo AM, Purrello F. Lipid and liver abnormalities in haemoglobin A1c-defined prediabetes and type 2 diabetes. Nutr Metab Cardiovasc Dis 2014; 24:670-676. [PMID: 24656139 DOI: 10.1016/j.numecd.2014.01.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 12/16/2013] [Accepted: 01/07/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS We aimed to investigate lipid abnormalities and liver steatosis in patients with HbA1c-defined prediabetes and type 2 diabetes compared to individuals with HbA1c-defined normoglycaemia. METHODS AND RESULTS Ninety-one subjects with prediabetes according to HbA1c, i.e. from 5.7 to 6.4% (39-46 mmol/mol), 50 newly diagnosed patients with HbA1c-defined type 2 diabetes (HbA1c ≥6.5% [≥48 mmol/mol]), and 67 controls with HbA1c lower than 5.7% (<39 mmol/mol), were studied. Fasting blood samples for lipid profiles, fatty liver index (FLI), bioimpedance analysis, ultrasound scan of the liver, and BARD (body mass index, aspartate aminotransferase/alanine aminotransferase ratio, diabetes) score for evaluation of liver fibrosis, were performed in all subjects. In comparison to controls, subjects with prediabetes were characterised by: lower apolipoprotein AI and HDL cholesterol levels, higher blood pressure, triglycerides levels and apolipoprotein B/apolipoprotein AI ratio, higher FLI, increased prevalence of and more severe hepatic steatosis, similar BARD score, and higher total body fat mass. In comparison to subjects with diabetes, subjects with prediabetes exhibited: similar blood pressure and apolipoprotein B/apolipoprotein AI ratio, similar FLI, reduced prevalence of and less severe hepatic steatosis, lower BARD score, increased percent fat and lower total body muscle mass. In comparison to controls, subjects with diabetes showed: lower apolipoprotein AI and HDL cholesterol levels, higher blood pressure and triglycerides levels, higher FLI, increased prevalence of and more severe hepatic steatosis, higher BARD score, and higher total body muscle mass. Moreover, HbA1c was correlated with BMI, HOMA-IR, triglycerides, HDL cholesterol, AST, and ALT. CONCLUSIONS Subjects with HbA1c-defined prediabetes and type 2 diabetes, respectively, are characterised by abnormalities in lipid profile and liver steatosis, thus exhibiting a severe risk profile for cardiovascular and liver diseases.
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Affiliation(s)
- S Calanna
- Department of Clinical and Molecular Biomedicine, University of Catania, Catania, Italy
| | - R Scicali
- Department of Clinical and Molecular Biomedicine, University of Catania, Catania, Italy
| | - A Di Pino
- Department of Clinical and Molecular Biomedicine, University of Catania, Catania, Italy
| | - F K Knop
- Diabetes Research Division, Department of Medicine, Gentofte Hospital, University of Copenhagen, Hellerup, Denmark; Department of Biomedical Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - S Piro
- Department of Clinical and Molecular Biomedicine, University of Catania, Catania, Italy
| | - A M Rabuazzo
- Department of Clinical and Molecular Biomedicine, University of Catania, Catania, Italy
| | - F Purrello
- Department of Clinical and Molecular Biomedicine, University of Catania, Catania, Italy.
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28
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Di Angelantonio E, Gao P, Khan H, Butterworth AS, Wormser D, Kaptoge S, Kondapally Seshasai SR, Thompson A, Sarwar N, Willeit P, Ridker PM, Barr ELM, Khaw KT, Psaty BM, Brenner H, Balkau B, Dekker JM, Lawlor DA, Daimon M, Willeit J, Njølstad I, Nissinen A, Brunner EJ, Kuller LH, Price JF, Sundström J, Knuiman MW, Feskens EJM, Verschuren WMM, Wald N, Bakker SJL, Whincup PH, Ford I, Goldbourt U, Gómez-de-la-Cámara A, Gallacher J, Simons LA, Rosengren A, Sutherland SE, Björkelund C, Blazer DG, Wassertheil-Smoller S, Onat A, Marín Ibañez A, Casiglia E, Jukema JW, Simpson LM, Giampaoli S, Nordestgaard BG, Selmer R, Wennberg P, Kauhanen J, Salonen JT, Dankner R, Barrett-Connor E, Kavousi M, Gudnason V, Evans D, Wallace RB, Cushman M, D'Agostino RB, Umans JG, Kiyohara Y, Nakagawa H, Sato S, Gillum RF, Folsom AR, van der Schouw YT, Moons KG, Griffin SJ, Sattar N, Wareham NJ, Selvin E, Thompson SG, Danesh J. Glycated hemoglobin measurement and prediction of cardiovascular disease. JAMA 2014; 311:1225-33. [PMID: 24668104 PMCID: PMC4386007 DOI: 10.1001/jama.2014.1873] [Citation(s) in RCA: 163] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The value of measuring levels of glycated hemoglobin (HbA1c) for the prediction of first cardiovascular events is uncertain. OBJECTIVE To determine whether adding information on HbA1c values to conventional cardiovascular risk factors is associated with improvement in prediction of cardiovascular disease (CVD) risk. DESIGN, SETTING, AND PARTICIPANTS Analysis of individual-participant data available from 73 prospective studies involving 294,998 participants without a known history of diabetes mellitus or CVD at the baseline assessment. MAIN OUTCOMES AND MEASURES Measures of risk discrimination for CVD outcomes (eg, C-index) and reclassification (eg, net reclassification improvement) of participants across predicted 10-year risk categories of low (<5%), intermediate (5% to <7.5%), and high (≥ 7.5%) risk. RESULTS During a median follow-up of 9.9 (interquartile range, 7.6-13.2) years, 20,840 incident fatal and nonfatal CVD outcomes (13,237 coronary heart disease and 7603 stroke outcomes) were recorded. In analyses adjusted for several conventional cardiovascular risk factors, there was an approximately J-shaped association between HbA1c values and CVD risk. The association between HbA1c values and CVD risk changed only slightly after adjustment for total cholesterol and triglyceride concentrations or estimated glomerular filtration rate, but this association attenuated somewhat after adjustment for concentrations of high-density lipoprotein cholesterol and C-reactive protein. The C-index for a CVD risk prediction model containing conventional cardiovascular risk factors alone was 0.7434 (95% CI, 0.7350 to 0.7517). The addition of information on HbA1c was associated with a C-index change of 0.0018 (0.0003 to 0.0033) and a net reclassification improvement of 0.42 (-0.63 to 1.48) for the categories of predicted 10-year CVD risk. The improvement provided by HbA1c assessment in prediction of CVD risk was equal to or better than estimated improvements for measurement of fasting, random, or postload plasma glucose levels. CONCLUSIONS AND RELEVANCE In a study of individuals without known CVD or diabetes, additional assessment of HbA1c values in the context of CVD risk assessment provided little incremental benefit for prediction of CVD risk.
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Affiliation(s)
| | - Pei Gao
- University of Cambridge, Cambridge, United Kingdom
| | - Hassan Khan
- University of Cambridge, Cambridge, United Kingdom
| | | | | | | | | | | | | | | | | | | | - Kay-Tee Khaw
- University of Cambridge, Cambridge, United Kingdom
| | - Bruce M Psaty
- University of Washington, Seattle6Group Health Research Institute, Seattle, Washington
| | | | - Beverley Balkau
- Inserm, Villejuif, France9University Paris-Sud, Villejuif, France
| | | | | | | | | | | | | | | | | | | | | | | | | | - W M M Verschuren
- National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Nicholas Wald
- Wolfson Institute of Preventive Medicine, London, United Kingdom
| | - Stephan J L Bakker
- University of Groningen, University Medical Center Groningen, the Netherlands
| | | | - Ian Ford
- University of Glasgow, Glasgow, United Kingdom
| | | | | | | | - Leon A Simons
- University of New South Wales, Kensington, Australia
| | - Annika Rosengren
- Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | - Dan G Blazer
- Duke University Medical Center, Durham, North Carolina
| | | | - Altan Onat
- University of Istanbul, Istanbul, Turkey
| | | | | | | | | | | | - Børge G Nordestgaard
- Herlev Hospital, Copenhagen University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Randi Selmer
- Norwegian Institute of Public Health, Oslo, Norway
| | | | | | | | - Rachel Dankner
- The Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel47Tel Aviv University, Tel Aviv, Israel48The Feinstein Institute for Medical Research, New York, New York
| | | | | | - Vilmundur Gudnason
- Icelandic Heart Association, Reyjavik, Iceland52University of Iceland, Reykjavik, Iceland
| | - Denis Evans
- Rush University Medical Center, Chicago, Illinois
| | | | | | | | - Jason G Umans
- Georgetown University Medical Centre, Washington, DC
| | | | | | - Shinichi Sato
- Osaka Medical Center for Health Science and Promotion/Chiba Prefectural Institute of Public Health, Osaka, Japan
| | | | | | - Yvonne T van der Schouw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Karel G Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | | | | | | | | | - John Danesh
- University of Cambridge, Cambridge, United Kingdom
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Abstract
OBJECTIVE To identify predictors of low hemoglobin A(1c) (HbA(1c)) (<5.0%) and to investigate the association of low HbA(1c) with cause-specific mortality and risk of liver disease hospitalization. RESEARCH DESIGN AND METHODS Prospective cohort study of 13,288 participants in the Atherosclerosis Risk in Communities Study. Logistic regression was used to identify cross-sectional correlates of low HbA(1c), and Cox proportional hazards models were used to estimate the association of low HbA(1c) with cause-specific mortality. RESULTS Compared with participants with HbA(1c) in the normal range (5.0 to <5.7%), participants with low HbA(1c) were younger, less likely to smoke, had lower BMI, lower white cell count and fibrinogen levels, and lower prevalence of hypercholesterolemia and history of coronary heart disease. However, this group was more likely to have anemia and had a higher mean corpuscular volume. In adjusted Cox models with HbA(1c) of 5.0 to <5.7% as the reference group, HbA(1c) <5.0% was associated with a significantly increased risk of all-cause mortality (hazard ratio [HR]: 1.32, 95% CI: 1.13-1.55) and of cancer death (1.47, 95% CI: 1.16-1.84). We also noted nonsignificant trends toward increased risk of death from cardiovascular causes (1.27, 95% CI: 0.93-1.75) and respiratory causes (1.42, 95% CI: 0.78-2.56). There was a J-shaped association between HbA(1c) and risk of liver disease hospitalization. CONCLUSIONS No single cause of death appeared to drive the association between low HbA(1c) and total mortality. These results add to evidence that low HbA(1c) values may be a generalized marker of mortality risk in the general population.
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Affiliation(s)
- Vikas Aggarwal
- Department of Medicine, Division of Cardiology, University of Colorado (Anschutz Medical Campus), Aurora, Colorado, USA
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