From the Guidelines
Diabetes mellitus is associated with an increased mortality rate in patients undergoing dialysis in India, with both high and low HbA1c levels contributing to this risk. The most recent and highest quality study, published in 2024 in Diabetologia 1, found that both high HbA1c levels (≥69.4 mmol/mol [≥8.5%]) and very low HbA1c levels (≤35.5 mmol/mol [≤5.4%]) are associated with an increased mortality risk in people undergoing haemodialysis. This is further supported by a study published in Endocrine Reviews in 2020 1, which reported a U-shaped association between HbA1c levels and risk of death, with higher mortality for levels less than 6% and 9% or higher, in hemodialysis patients with type 1 diabetes or type 2 diabetes.
Key factors contributing to the increased mortality risk in diabetic patients on dialysis in India include:
- Severe cardiovascular complications
- Poorer blood sugar control during dialysis
- Increased infection risks
- More challenging vascular access issues
- Delayed diagnosis or limited healthcare access, leading to advanced stages of kidney disease at the start of dialysis
To improve survival rates, the following strategies are essential:
- Strict glycemic control, typically maintaining HbA1c between 7-8%
- Careful monitoring of cardiovascular parameters
- Proper infection prevention
- Earlier referral to nephrology care
- Addressing the economic burden of managing both diabetes and end-stage renal disease simultaneously, particularly in resource-limited settings across India.
From the Research
Association between Diabetes Mellitus and Mortality in Dialysis Patients
- Diabetes mellitus (DM) is a significant risk factor for cardiovascular events and mortality in dialysis patients 2, 3, 4.
- Diabetic patients on dialysis have a high burden of morbidity and mortality, particularly from cardiovascular disease, and a higher societal and economic cost compared to non-diabetic subjects on dialysis 2.
- The evidence for improving glycaemic control in patients on dialysis having an impact on mortality or morbidity is sparse 2.
Glycemic Variability and Mortality
- Higher glycemic variability is associated with increased mortality risk among patients with diabetes receiving hemodialysis 5.
- A prospective cohort study found that the highest coefficient of variation quartile was independently associated with increased risk of all-cause mortality (HR 1.887,95% CI 1.407-2.531, P < 0.001) 5.
Management of Diabetes in Dialysis Patients
- The management of diabetes in dialysis patients is complex and requires a multi-disciplinary team involving endocrinologists and nephrologists to achieve targets and reduce morbidity and mortality 6.
- The treatment of diabetes in patients maintained on dialysis is challenging, and many blood glucose-lowering medications are renally metabolized and excreted, hence requiring dose adjustment or avoidance in dialysis patients 6.
Diabetes and Mortality in Hemodialysis Patients
- Diabetes was found to be a significant and independent contributor to the presence of sarcopenic obesity in chronic hemodialysis patients 4.
- Diabetes was shown to be a significant predictor of all-cause mortality, independent of the presence of obesity, sarcopenia, and sarcopenic obesity groups in hemodialysis patients 4.