HbA1c variability as an independent risk factor for diabetic retinopathy in type 1 diabetes: a German/Austrian multicenter analysis on 35,891 patients

PLoS One. 2014 Mar 7;9(3):e91137. doi: 10.1371/journal.pone.0091137. eCollection 2014.


Objective: This study aimed to analyze the effect of HbA1c variability on the occurrence of diabetic retinopathy in type 1 diabetes patients.

Patients and methods: 35,891 patients with childhood, adolescent or adult onset of type 1 diabetes from a large multicentre survey, the German/Austrian prospective documentation system (DPV), were analysed. Cox proportional hazard models were used to examine whether intra-individual HbA1c variability expressed as variation coefficient is an independent risk factor for the occurrence of diabetic retinopathy.

Results: Kaplan-Meier curves stratified by median HbA1c and variation coefficient revealed that retinopathy-free survival probability is lower when both median HbA1c and HbA1c variability are above the 50th percentile. Cox regression models confirmed this finding: After adjustment for age at diabetes onset, gender and median HbA1c, HbA1c variability was independently associated with the occurrence of diabetic retinopathy. Time-covariate interactions used to model non-proportionality indicated an effect decreasing with duration of diabetes for both median HbA1c and HbA1c variability. Predictive accuracy increased significantly when adding HbA1c variability to the Cox regression model.

Conclusions: In patients with type 1 diabetes, HbA1c variability adds to the risk of diabetic retinopathy independently of average metabolic control.

Publication types

  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Austria
  • Diabetes Mellitus, Type 1 / blood*
  • Diabetes Mellitus, Type 1 / complications*
  • Diabetic Retinopathy / blood*
  • Diabetic Retinopathy / complications*
  • Female
  • Germany
  • Glycated Hemoglobin A / metabolism*
  • Humans
  • Kaplan-Meier Estimate
  • Male
  • Proportional Hazards Models
  • Risk Factors


  • Glycated Hemoglobin A

Grant support

This study was financially supported by the Kompetenznetz Diabetes mellitus (Competence Network for Diabetes mellitus), which is funded by the Federal Ministry of Education and Research (FKZ 01GI1106), Dr.-Bürger-Büsing-Foundation and European Foundation for the Study of Diabetes (EFSD). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.