Anemia modifies the prognostic value of glycated hemoglobin in patients with diabetic chronic kidney disease

A common complication of chronic kidney disease (CKD), anemia can influence glycated hemoglobin (HbA1c) levels. In diabetic patients, anemia occurs earlier and with higher severity over the course of CKD stages. To elucidate the effect of hemoglobin (Hb) on the predictive value of HbA1c, we enrolled 1558 diabetic patients with stages 3-4 CKD, categorized according to baseline Hb and HbA1c quartiles. Linear regression revealed that higher HbA1c correlated significantly with higher Hb in the Hb < 10 g/dL group (beta = 0.146, P = 0.004). A fully-adjusted Cox regression model revealed worse clinical outcomes in patients with higher HbA1c quartiles in the Hb >= 10 g/dL group. Hazard ratios for end-stage renal disease (ESRD), all-cause mortality, and composite endpoint (cardiovascular events and all-cause mortality) in patients with Hb >= 10 g/dL and the highest HbA1c quartile were 1.92 (95% confidence interval [CI], 1.17 - 3.15), 1.76 (95% CI, 1.02 - 3.03), and 1.54 (95% CI, 1.03 - 2.31), respectively. By contrast, HbA1c was not associated with clinical outcomes in the Hb < 10 g/dL group. In conclusion, in stages 3-4 diabetic CKD, higher HbA1c is associated with a higher risk of poor clinical outcomes in patients with Hb >= 10 g/dL.