Editorial Hemoglobin A1c in Hemodialysis Patients: Should One Size Fit All?

Currently recommended hemoglobin A1c (HbA1c) targets in ESRD patients are identical to those for the general population; an issue of considerable debate. In this issue, Williams and colleagues provide observational data on the association of HbA1c with mortality among nearly 25,000 hemodialysis patients in the United States. Statistically significant findings were observed only among subjects with HbA1c levels>11 % in final models in individuals with type 2 diabetes. For the first time, this study separately evaluates individuals with type 1 diabetes, among whom associations of HbA1c with mortality were stronger than among those with type 2 diabetes. This editorial considers this study in the context of existing literature and suggests directions for future research. In the absence of randomized trial data, it may be preferable to individualize HbA1c targets rather than targeting less than 7 % in all patients. Clin J Am Soc Nephrol 5: ●●●–●●●, 2010. doi: 10.2215/CJN.04410510 D iabetes mellitus remains the leading cause of ESRD inthe United States (1). On average, four in ten patientsencountered on dialysis rounds will have diabetes mellitus (1), among whom hemoglobin A1c (HbA1c) levels are often measured quarterly. Management of HbA1c values is therefore an extremely common clinical scenario in contempo-rary nephrology practice, with considerable risk of harm if treated too aggressively or not aggressively enough. Currently