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The influence of glycemic control on the prognosis of Japanese patients undergoing percutaneous transluminal angioplasty for critical limb ischemia.

Takahara M, Kaneto H, Iida O, Gorogawa S, Katakami N, Matsuoka TA, Ikeda M, Shimomura I - Diabetes Care (2010)

Bottom Line: The presence of diabetes in the whole population and A1C level in the diabetic population had no influence on morality; rather, mortality was associated with age (P = 0.007), impaired activities of daily living (P < 0.001), hemodialysis (P < 0.001), and albumin level (P = 0.010).The adjusted hazard ratio of diabetes with A1C ≥ 6.8% was 2.907 (95% CI 1.606-5.264) (P < 0.001).Prognostic indicators seem somewhat different between survival and limb salvage in the population.

View Article: PubMed Central - PubMed

Affiliation: Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.

ABSTRACT

Objective: To reveal the influence of preoperative factors on the prognosis of patients undergoing percutaneous transluminal angioplasty (PTA) for critical limb ischemia (CLI).

Research design and methods: We recruited 278 Japanese patients who underwent PTA for CLI between 2003 and 2009. The outcome measures were mortality and major amputation. Cox proportional hazards regression analyses were performed.

Results: The prevalence of diabetes was 71%, and A1C was 7.0 ± 1.4%. The follow-up period was 90 ± 72 weeks, and 48 patients underwent major amputations and 89 died. The presence of diabetes in the whole population and A1C level in the diabetic population had no influence on morality; rather, mortality was associated with age (P = 0.007), impaired activities of daily living (P < 0.001), hemodialysis (P < 0.001), and albumin level (P = 0.010). In contrast, the presence of diabetes and A1C level had significant association with major amputation (P = 0.012 and P = 0.007, respectively). The quartile analysis showed that diabetic subjects with an A1C ≥ 6.8%, but not <6.8%, had a significantly higher risk of major amputation than nondiabetic subjects. The adjusted hazard ratio of diabetes with A1C ≥ 6.8% was 2.907 (95% CI 1.606-5.264) (P < 0.001).

Conclusions: Diabetes with poor glycemic control is associated with major amputation, but not mortality, in CLI patients undergoing PTA. Prognostic indicators seem somewhat different between survival and limb salvage in the population.

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Related in: MedlinePlus

The association of poor glycemic control and other variables with major amputation. A: The adjusted HRs for major amputation according to glycemic control. Data are the adjusted HRs and 95% CIs of each A1C quartile of the diabetic group relative to the nondiabetic group in the stepwise multivariate model. They were adjusted for impaired activity of daily living, Fontaine stage IV, infection, and receiving hemodialysis. The quartiles of A1C were as follows: Q1: ≤5.9%, Q2: 6.0–6.7%, Q3: 6.8–7.6%, and Q4: ≥7.7%. B: Kaplan-Meier estimates of major amputation according to the number of risk factors (P < 0.001, log-rank test). Risk factors considered here are the following three variables: diabetes with A1C ≥6.8%, the presence of infection, and receiving hemodialysis, all of which had independent associations in the stepwise multivariate Cox proportional hazards regression model. DM, diabetes.
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Figure 2: The association of poor glycemic control and other variables with major amputation. A: The adjusted HRs for major amputation according to glycemic control. Data are the adjusted HRs and 95% CIs of each A1C quartile of the diabetic group relative to the nondiabetic group in the stepwise multivariate model. They were adjusted for impaired activity of daily living, Fontaine stage IV, infection, and receiving hemodialysis. The quartiles of A1C were as follows: Q1: ≤5.9%, Q2: 6.0–6.7%, Q3: 6.8–7.6%, and Q4: ≥7.7%. B: Kaplan-Meier estimates of major amputation according to the number of risk factors (P < 0.001, log-rank test). Risk factors considered here are the following three variables: diabetes with A1C ≥6.8%, the presence of infection, and receiving hemodialysis, all of which had independent associations in the stepwise multivariate Cox proportional hazards regression model. DM, diabetes.

Mentions: We further analyzed the influence of the presence of diabetes on major amputation according to their A1C level; each A1C quartile of the diabetic group, defined above, was compared with the nondiabetic group in a stepwise multivariate model. As shown in Fig. 2A, the two higher A1C quartiles of the diabetic group (that is, the diabetic group with A1C ≥6.8%) had a significantly higher risk than the nondiabetic group, whereas the two lower A1C quartiles (that is, A1C <6.8%) did not. Based on these findings, we reanalyzed with substitution of diabetes with A1C ≥6.8% for the presence of diabetes in the original multivariate model shown in Table 2. The result was that diabetes with A1C ≥6.8%, infection, and hemodialysis were significantly associated with major amputation; their adjusted HRs were 2.907 (95% CI 1.606–5.264) (P < 0.001), 2.375 (1.198–4.711) (P = 0.014), and 3.530 (1.772–7.029) (P < 0.001), respectively (online appendix Table B). Note that these three variables were independent of one another and therefore were expected to have additive influences on major amputation. In fact, a Kaplan-Meier model showed that those with the accumulation of these prognostic factors had an increased risk of major amputation (Fig. 2B). When they had all of these three risk factors, their prognosis was extremely poor. Their estimated median time to limb loss was only 23 weeks, which would be rarely different from natural course of nonrevascularized CLI patients (1).


The influence of glycemic control on the prognosis of Japanese patients undergoing percutaneous transluminal angioplasty for critical limb ischemia.

Takahara M, Kaneto H, Iida O, Gorogawa S, Katakami N, Matsuoka TA, Ikeda M, Shimomura I - Diabetes Care (2010)

The association of poor glycemic control and other variables with major amputation. A: The adjusted HRs for major amputation according to glycemic control. Data are the adjusted HRs and 95% CIs of each A1C quartile of the diabetic group relative to the nondiabetic group in the stepwise multivariate model. They were adjusted for impaired activity of daily living, Fontaine stage IV, infection, and receiving hemodialysis. The quartiles of A1C were as follows: Q1: ≤5.9%, Q2: 6.0–6.7%, Q3: 6.8–7.6%, and Q4: ≥7.7%. B: Kaplan-Meier estimates of major amputation according to the number of risk factors (P < 0.001, log-rank test). Risk factors considered here are the following three variables: diabetes with A1C ≥6.8%, the presence of infection, and receiving hemodialysis, all of which had independent associations in the stepwise multivariate Cox proportional hazards regression model. DM, diabetes.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2992184&req=5

Figure 2: The association of poor glycemic control and other variables with major amputation. A: The adjusted HRs for major amputation according to glycemic control. Data are the adjusted HRs and 95% CIs of each A1C quartile of the diabetic group relative to the nondiabetic group in the stepwise multivariate model. They were adjusted for impaired activity of daily living, Fontaine stage IV, infection, and receiving hemodialysis. The quartiles of A1C were as follows: Q1: ≤5.9%, Q2: 6.0–6.7%, Q3: 6.8–7.6%, and Q4: ≥7.7%. B: Kaplan-Meier estimates of major amputation according to the number of risk factors (P < 0.001, log-rank test). Risk factors considered here are the following three variables: diabetes with A1C ≥6.8%, the presence of infection, and receiving hemodialysis, all of which had independent associations in the stepwise multivariate Cox proportional hazards regression model. DM, diabetes.
Mentions: We further analyzed the influence of the presence of diabetes on major amputation according to their A1C level; each A1C quartile of the diabetic group, defined above, was compared with the nondiabetic group in a stepwise multivariate model. As shown in Fig. 2A, the two higher A1C quartiles of the diabetic group (that is, the diabetic group with A1C ≥6.8%) had a significantly higher risk than the nondiabetic group, whereas the two lower A1C quartiles (that is, A1C <6.8%) did not. Based on these findings, we reanalyzed with substitution of diabetes with A1C ≥6.8% for the presence of diabetes in the original multivariate model shown in Table 2. The result was that diabetes with A1C ≥6.8%, infection, and hemodialysis were significantly associated with major amputation; their adjusted HRs were 2.907 (95% CI 1.606–5.264) (P < 0.001), 2.375 (1.198–4.711) (P = 0.014), and 3.530 (1.772–7.029) (P < 0.001), respectively (online appendix Table B). Note that these three variables were independent of one another and therefore were expected to have additive influences on major amputation. In fact, a Kaplan-Meier model showed that those with the accumulation of these prognostic factors had an increased risk of major amputation (Fig. 2B). When they had all of these three risk factors, their prognosis was extremely poor. Their estimated median time to limb loss was only 23 weeks, which would be rarely different from natural course of nonrevascularized CLI patients (1).

Bottom Line: The presence of diabetes in the whole population and A1C level in the diabetic population had no influence on morality; rather, mortality was associated with age (P = 0.007), impaired activities of daily living (P < 0.001), hemodialysis (P < 0.001), and albumin level (P = 0.010).The adjusted hazard ratio of diabetes with A1C ≥ 6.8% was 2.907 (95% CI 1.606-5.264) (P < 0.001).Prognostic indicators seem somewhat different between survival and limb salvage in the population.

View Article: PubMed Central - PubMed

Affiliation: Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan.

ABSTRACT

Objective: To reveal the influence of preoperative factors on the prognosis of patients undergoing percutaneous transluminal angioplasty (PTA) for critical limb ischemia (CLI).

Research design and methods: We recruited 278 Japanese patients who underwent PTA for CLI between 2003 and 2009. The outcome measures were mortality and major amputation. Cox proportional hazards regression analyses were performed.

Results: The prevalence of diabetes was 71%, and A1C was 7.0 ± 1.4%. The follow-up period was 90 ± 72 weeks, and 48 patients underwent major amputations and 89 died. The presence of diabetes in the whole population and A1C level in the diabetic population had no influence on morality; rather, mortality was associated with age (P = 0.007), impaired activities of daily living (P < 0.001), hemodialysis (P < 0.001), and albumin level (P = 0.010). In contrast, the presence of diabetes and A1C level had significant association with major amputation (P = 0.012 and P = 0.007, respectively). The quartile analysis showed that diabetic subjects with an A1C ≥ 6.8%, but not <6.8%, had a significantly higher risk of major amputation than nondiabetic subjects. The adjusted hazard ratio of diabetes with A1C ≥ 6.8% was 2.907 (95% CI 1.606-5.264) (P < 0.001).

Conclusions: Diabetes with poor glycemic control is associated with major amputation, but not mortality, in CLI patients undergoing PTA. Prognostic indicators seem somewhat different between survival and limb salvage in the population.

Show MeSH
Related in: MedlinePlus