American Journal of Kidney Diseases
Volume 50, Issue 1 , Pages 166-167, July 2007

In Reply

For the National Kidney Foundation KDOQI Diabetes and Chronic Kidney Disease Work Group

Article Outline

 

In Reply:

We wish to thank Drs Halevy and Vemireddy for their interest in the KDOQI diabetes and chronic kidney disease guidelines,1 but we disagree with their conclusions regarding glycemic management in diabetic dialysis patients. Although an association between HbA1c levels and survival was not found in the Fresenius dialysis cohort,2 more recent observations from a larger cohort found that lower HbA1c conferred a survival advantage, after adjusting for indices of nutrition and anemia.3 Survival, however, is not the only criterion for keeping HbA1c levels near normal. Data supporting intensive glycemic control for preventing or decreasing other microvascular complications of diabetes are ample and strong.4 We concur with the editorial accompanying the Fresenius study that recommends optimal glycemic control in hemodialyzed patients in the absence of evidence for futility or unmanageable risks.5 The risks and management of hypoglycemia in acute and chronic care settings are reviewed extensively in the KDOQI guidelines, which clearly indicate that therapeutic targets may vary depending on comorbid conditions.1 Although patients with “severe” comorbid conditions may require less intensive goals, neither the ADA nor Veterans Administration guidelines specify end-stage renal disease as a comorbid condition requiring a higher HbA1c target, and the ADA does not endorse a particular “higher” target.4, 6 Importantly, therapeutic targets and clinical performance measures are not necessarily interchangeable. Policymakers should consider population-specific benefits and risks to determine appropriate clinical performance measures. In the meantime, the KDOQI guidelines advocate for excellent diabetes care even when preservation of kidney function is no longer possible.

Letters to the Editor may be in response to an article that appeared in AJKD no more than 6 months previously, or may concern a topic of interest to current nephrology. The body of the letter should be as concise as possible and in general should not exceed 250 words. Up to 10 references and 1 figure or table may be included. There is no guarantee that letters will be published. Letters are subject to editing and abridgment without notice.

Letters should be submitted via AJKD’s online manuscript handling site, www.editorialmanager.com/ajkd. More information, including details about how to contact the editorial staff for assistance, is available in the journal’s Information for Authors.

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References 

  1. National Kidney Foundation. KDOQI clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Am J Kidney Dis. 2007;49(suppl 2):S1–S180
  2. Williams ME, Lacson E, Teng M, Ofsthun N, Lazarus JM. Hemodialyzed type I and type II diabetic patients in the US: Characteristics, glycemic control, and survival. Kidney Int. 2006;70:1503–1509
  3. Kalantar-Zadeh K, Kopple JD, Regidor DL, et al. Hemoglobin A1c and survival in maintenance hemodialysis patients. Diabetes Care. 2007;30:1049–1055
  4. American Diabetes Association. Clinical Practice Recommendations: Standards of Medical Care in Diabetes – 2007. Diabetes Care. 2007;30(suppl 1):S4–S41
  5. Feldt-Rasmussen B. Is there a need to optimize glycemic control in hemodialyzed patients?. Kidney Int. 2006;70:1392–1394
  6. Pogach LM, Brietzke SA, Cowan CL, Conlin P, Walder DJ, Sawin CT VA/DoD Diabetes Guideline Development Group. Development of evidence-based clinical practice guidelines for diabetes. Diabetes Care. 2004;27(suppl 2):B82–B89

PII: S0272-6386(07)00831-1

doi:10.1053/j.ajkd.2007.05.005

Refers to article:

  • Is a Target Hemoglobin A1c Below 7% Safe in Dialysis Patients?

    Daniel Halevy, Madhavi Vemireddy
    American Journal of Kidney Diseases July 2007 (Vol. 50, Issue 1, Page 166)

American Journal of Kidney Diseases
Volume 50, Issue 1 , Pages 166-167, July 2007

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