Glycemic Control and Mortality in Diabetic Patients Undergoing Hemodialysis: Much More to Learn

interval [CI], 1.09-1.19) and 1.29 (95% CI, 1.23-1.35), respectively,adjustedforage,sex,diabetestype,timeon HD therapy, and hemoglobin concentration. Relationships with HbA1c levels were similar for incident and prevalentHDpatients,definedasdialysisfor90orfewer days or more than 90 days, respectively. Low HbA1c levels (#6.4% [#46 mmol/mol]) also were associated with significantly increased mortality, but only for incident patients (HR, 1.29; 95% CI, 1.23-1.35). The authors conclude that their analysis supports the adoption of an HbA1c target , 8.5% (,69 mmol/mol) for diabetic patients treated with HD. More cautious conclusions may be warranted because we need to be wary of assuming that reducing HbA1c level has a clinical benefit on mortality and CVDbasedonassociationdataonly.TheUKPDS(UK Prospective Diabetes Study) showed a linear relationshipbetweenachievedHbA1clevelandCVDinpeople with newly diagnosed type 2 diabetes without kidney failure such that a 1% (11-mmol/mol) reduction in updated mean HbA1c level was associated with a 14% (95% CI, 8%-21%) reduction in risk of myocardial infarction. 7 Although derived from a randomized controlled trial of intensive versus conventional hypoglycemic therapy, this analysis was performed in only 79% of the trial population. Notably, subsequent large clinical trials evaluating the impact of intensive glycemiccontroloncardiovascularoutcomesinpeople with type 2 diabetes along with meta-analyses of these studieshavebeenperformedandhavefailedtoconfirm a significant CVD benefit. 8-10 One study demonstrated greater mortality from acute myocardial infarction for those in the intensive treatment arm. 11